SOAP NOTE Name: J.D. Date: 03/26/2020 Time: 2:00 pm Age: 25 y/o Sex: F SUBJECTIVE CC:  ” I have a lot of pain on my left side, in my lower belly” HPI: J.D. is a 25-year-old white female that came to the office today complaining of pain in her lower abdomen. The patient has always had painful cramps with her periods but this time it is much worse being described as a 6 out of 10 and lasting up to 5 hours. The pain started 2 days ago. The pain is described as more painful cramps. It is debilitating and prevents the patient from performing most daily activities. It is localized in the lower abdominal area, and sometimes radiates down her legs, and to her lower back. The patient uses hot compresses to relieve the pain as Tylenol does not work. The patient also states that she has been feeling nauseous ever since the pain started. She also urinates more frequently and pain on urination. Denies fever, vomiting, or chills. Medications: 2 Tylenol as needed for her pain PMH (include-immunization status including Gardisil, GTPLA). Current or past illnesses: No current or past illnesses Immunizations: All vaccines updated including flu vaccine and Gardasil. Allergies: NKDA Medication Intolerances: None. Chronic Illnesses/Major traumas: None. Hospitalizations/Surgeries (include delivery of pregnancies here) No hospitalizations. G0P0 Family History Mother: 49 years old, no significant health problems Maternal Side: No significant health problems Father: 50 years old, hypertensive Paternal Side: no significant health problems Social History Patient works full-time as a research assistant at a local university. A full-time student seeking a master’s degree in biochemistry at a local university. Married. Sexually active only with husband. Always uses male condoms as contraceptive device. Does not use recreational drugs, tobacco, or electronic cigarettes. Devout follower of Christianity. Denomination: catholic. ROS General Patient denies fever or chills, no weight changes. Cardiovascular Denies chest pain, or discomfort. Denies palpitations, dyspnea, or orthopnea.  Skin: Denies presences of moles, rash, or itching. Respiratory: Denies dyspnea, cough, hemoptysis, or pleuritic pains. Eyes Denies problems or changes in her vision; denies double or blurred vision. Gastrointestinal Positive for nausea.Denies hemorrhoids, constipation, or diarrhea. No variation in bowel habits. Denies vomiting. Ears Denies difficulty or changes in his hearing. Denies tinnitus, or discharges. Genitourinary/Gynecological Menarche 11 years old. Regular menstrual periods starting around the 3rd week of every month. LMP: 03.

1. SOAP NOTE
Name: J.D.
Date: 03/26/2020
Time: 2:00 pm
Age: 25 y/o
Sex: F
SUBJECTIVE
CC:
” I have a lot of pain on my left side, in my lower belly”
HPI: J.D. is a 25-year-old white female that came to the office
today complaining of pain in her lower abdomen. The patient
has always had painful cramps with her periods but this time it
is much worse being described as a 6 out of 10 and lasting up to
5 hours. The pain started 2 days ago. The pain is described as
more painful cramps. It is debilitating and prevents the patient
from performing most daily activities. It is localized in the
lower abdominal area, and sometimes radiates down her legs,
and to her lower back. The patient uses hot compresses to
relieve the pain as Tylenol does not work. The patient also
states that she has been feeling nauseous ever since the pain
started. She also urinates more frequently and pain on urination.
Denies fever, vomiting, or chills.
Medications:
2 Tylenol as needed for her pain
PMH (include-immunization status including Gardisil, GTPLA).
Current or past illnesses: No current or past illnesses
Immunizations: All vaccines updated including flu vaccine and
Gardasil.
Allergies: NKDA
Medication Intolerances: None.
Chronic Illnesses/Major traumas: None.
Hospitalizations/Surgeries (include delivery of pregnancies
here)

2. No hospitalizations.
G0P0
Family History
Mother: 49 years old, no significant health problems
Maternal Side: No significant health problems
Father: 50 years old, hypertensive
Paternal Side: no significant health problems
Social History
Patient works full-time as a research assistant at a local
university. A full-time student seeking a master’s degree in
biochemistry at a local university. Married. Sexually active only
with husband. Always uses male condoms as contraceptive
device. Does not use recreational drugs, tobacco, or electronic
cigarettes. Devout follower of Christianity. Denomination:
catholic.
ROS
General Patient denies
fever or chills, no weight changes.
Cardiovascular
Denies chest pain, or discomfort. Denies palpitations, dyspnea,
or orthopnea.
Skin: Denies presences of moles, rash, or itching.
Respiratory: Denies dyspnea, cough, hemoptysis, or pleuritic
pains.
Eyes Denies
problems or changes in her vision; denies double or blurred
vision.
Gastrointestinal
Positive for nausea.Denies hemorrhoids, constipation, or
diarrhea. No variation in bowel habits. Denies vomiting.
Ears Denies
difficulty or changes in his hearing. Denies tinnitus, or
discharges.

3. Genitourinary/Gynecological Menarche
11 years old. Regular menstrual periods starting around the 3rd
week of every month. LMP: 03/24/2020, heavy flow. Last pap
11/2019 -negative. No history of STDs. Male condoms used as
contraceptive. Positive for lower abdominal pain. Positive for
heavy menstrual flow. Positive for increased urination. Positive
for pain on urination.
Nose/Mouth/Throat Denies nosebleeds,
nasal obstruction. No Bleeding gums, teeth or mouth pain, no
lesion in mouth or tongue, no dry mouth.
Musculoskeletal
Denies joint stiffness, limitation of movement, no history of
musculoskeletal or disk herniation.
Breast Denies
alteration of nipples, or discharge. Denies skin retractions.
Denies breast pain or changes. Denies lumps.
Neurological
Denies syncope or seizure. No dizziness or vertigo.
Heme/Lymph/Endo Denies bruising or
bleeding. No history of anemia, blood transfusions. Denies
exposure to toxic agents or radiation. No HIV history.
Psychiatric
Denies sadness, or anxiety. No sleeping problems.
OBJECTIVE - (if you are seeing a patient for an Episodic OV –
PE should relate to the CC)
Weight: 130 lb. BMI: 21.6
Temp: 98.6
BP: 128/72
Height: 5’5’’
Pulse: 91
Resp: 20
General Appearance: Patient is alert and oriented x 4. Well-
developed and nourished. She speaks clearly and appropriate.
Good personal hygiene.
Skin: Intact, clean, and moist. Well hydrated, no rashes or
lesions observed.

4. HEENT: Normocephalic, symmetric. Eyes: Sclera white,
conjunctiva pink. PERRLA. Ears: Bilateral canals patent. No
exudate. Nose: External aspect is normal. Lips and oral cavity
pink and moist. Thyroid has a normal size, no nodules or masses
noted.
Cardiovascular: S1, S2. Regular rate and rhythm, no murmurs,
no gallops. No thrill or palpable murmurs on palpation. No
edema.
Respiratory: Lungs clear to auscultation bilaterally anteriorly
and posteriorly, normal respiratory effort. No rales, no rhonchi,
no wheezes upon auscultation.
Gastrointestinal: Soft, tenderness present on deep palpation in
the lower abdomen, no masses, Bowel sounds presents in all
four quadrants. No ascites. No splenomegaly, no hepatomegaly.
No rebound, no guarding.
Breasts symmetric: Breast tender on palpation. No discharge, no
dimpling, wrinkling or discoloration of the skin; no skin
retraction, no lymphadenopathy in left axilla. Both breasts with
no masses or skin abnormalities. No palpable adenopathy in the
either axilla.
Genitourinary: Lower abdomen tenderness on deep palpation.
No CVA tenderness. Genitalia: External genitalia with pubic
hair in normal distribution; skin color is consistent with general
pigmentation. No vulvar lesions or masses noted. Bimanual
examination: Mobile cervix, not painful. No adnexal masses or
tenderness. Vaginal walls are smooth and pink; no lesions
noted. Ovaries are non-palpable.
Musculoskeletal: Normal gait and ROM. No joints and muscle
tenderness, no warmth, no erythema or inflammation.
Neurological: Speech normal, no sensory-perceptions disorders.
No altered mental status.
Psychiatric: Alert and oriented times 4. Patient is anxious, no
signs or symptoms of depression, no suicidal ideas, maintains
eye contact.
Lab Tests (list the results if you have them)
CBC

5. Urinalysis w/culture
STD screening – Chlamydia, Gonorrhea
Special Tests (done or ordered during the OV)
Pelvic ultrasound
Laparoscopy
Diagnosis – include the appropriate ICD – 10 Code for each
diagnosis used
Primary Diagnosis:
1-Endometriosis, unspecified (N80.9). Patient has nausea, pain
on urination, and unspecified tenderness in the lower abdomen.
No other gynecological signs are present. Endometriosis usually
does not present with any signs except tenderness sometimes
(Davila, 2018). The patient is sexually active but practices safe
sex with one partner.
Differential Diagnoses:
1- Torsion of ovary and ovarian pedicle (N83.51). Ovarian
torsion usually has a rapid onset. This patient described the pain
as beginning two days ago. It has nonspecific symptoms and is
often misdiagnosed as a gastrointestinal problem (Ding, Huang,
Hong, 2017). Ovarian torsion can present with abdominal
tenderness on palpation. Ovarian torsion also presents with
nausea in around 70% of patients (Ding, Huang, Hong, 2017).
2- Urinary tract infection, site not specified (N39.0): The
patient reports frequent urination and pain on urination as well.
UTI’s can also result in increased nausea and lower back pain
(Urinary Tract Infection, n.d.)
3- Unspecified acute appendicitis (K35.80): Appendicitis
causes onset of pain throughout the abdomen. It can cause lower
abdominal pain that radiates to other areas including the lower
back and legs. Additionally, appendicitis can cause nausea as
well. (Appendicitis, 2019).

6. Plan/Therapeutics (explain fully)
Plan:
Pharmacologic: Ibuprofen 800mg three times a day.
Non-pharmacological.
-Continue using hot compresses to alleviate the pain.
If the pain worsens come back to the office or go to the nearest
ER.
Follow up with patient in one week to review lab and imaging
results and formulate a more specific plan of action.
Referrals:
Referral to Gynecologist.
Education:
The patient is advised to continue using hot compresses, and to
take prescribed medications and to monitor the pain. Wash
genital areas before and after sexual encounters to promote
good hygiene and to prevent urinary tract infections. Continue
safe sex practices. She is also advised to rest and to not perform
any demanding activities. Increase fiber in the diet to prevent
constipation.
References
Appendicitis. (2019, March 18). Retrieved from
https://medlineplus.gov/appendicitis.html
Davila, W. (2018, July 25). Endometriosis. Retrieved March 27,
2020, from https://emedicine.medscape.com/article/271899-
overview
Ding, D.-C., Huang, C., & Hong, M.-K. (2017). A review of
ovary torsion. Tzu Chi Medical Journal, 29(3), 143. doi:
10.4103/tcmj.tcmj_55_17
Urinary tract infection (UTI). (2019, January 30). Retrieved
from https://www.mayoclinic.org/diseases-conditions/urinary-
tract-infection/symptoms-causes/syc-20353447
Evaluation of patient encounter:
I agreed with my preceptor that this patient has endometriosis.
Her symptoms are accurate for this diagnosis. She has s/s that

7. are characteristic of endometriosis.
4