SOAP Note Patient Initials:           RA Pt. Encounter Number: 1 Date: 10/1/20 Age: 23 Sex: female Allergies:    NKA                                                                              Advanced Directives:      none SUBJECTIVE CC: “I have been having heavy periods for 4-5 months now. I feel tired and dizzy most days” HPI: 23-year-old came to the clinic today complaining of heavy menstrual periods happening for the past 4 to 5 months. Accompanying the heavy flow, patient states that she has moderate cramps. Pt describes the pain as stabbing and its 3 out of the 0-10 scale. Patient does not take any medications for the pain. The pain is decreased by applying warm compresses to the lower abdominal area. In addition, patient complains of feeling dizziness and tiredness most of the times. Current Medications: none PMH  Medication Intolerances: NONE  Chronic Illnesses/Major traumas: NONE Screening Hx/Immunizations Hx: Vaccinations up to date, most recent pap smear 12/19 – negative  Hospitalizations/Surgeries: None Family History:Father: Alive, No medical history Mother: Alive, Htn Social History: Patient is a full-time college student and part time employee at Publix as cashier. Pt lives at home with parents and denies having had a sexual partner for the past year. Patient denies the use of cigars, alcohol, or illegal drugs. ROS GeneralDenies recent weight loss, fever, change in appetite or headaches. She denies chills or night sweats. CardiovascularDenies palpitations, chest pain, orthopnea, and claudication. Reports episodes of hypotension. SkinDenies bruising, skin rash, or discoloration. Denies changes in moles or skin breakdown. RespiratoryDenies shortness of breath, abnormal sputum, cough, or wheezing. EyesDenies pain, redness, loss of vision, double or blurred vision GastrointestinalDenies abdominal pain, decreased appetite, nausea, or vomiting. Denies food intolerances and changes in stool EarsDenies ear pain, ear infections, or tinnitus Genitourinary/GynecologicalDenies dysuria, flank pain, and hematuria. Denies abnormal vaginal discharge or itching. Denies STI history. Reports heavy menstrual periods lasting 5 to 6 days, associated with cramping; every 28 days. OBSTETRIC/GYNECOLOGICAL Hx:Menarche:  11 years                       LMP: 09/15/20                       G 0 T 0 P 0 A 0 L 0               Birth Control/Type: NoneMenopause:  no                           Sexually Active: yes STD Hx:  None Nose/Mouth/ThroatDenies nasal pain, congestion, epistaxis, or postnasal drip. Denies pain in mouth, bleeding gums, or dry mouth. Denies pain in throat, hoarseness, difficulty or painful swallowing. MusculoskeletalDenies muscle pain or joint pain. Denies limited range of motion BreastDenies breast tenderness, discharge, redness, or lumps. NeurologicalDenies headache, dizziness, seizures, or memory loss. Heme/Lymph/EndoPt denies bruising PsychiatricDenies mood changes, irritability, or changes in concentration. Denies hav.

1. SOAP Note
Patient Initials: RA Pt. Encounter Number: 1
Date: 10/1/20 Age: 23 Sex: female
Allergies: NKA
Advanced Directives: none
SUBJECTIVE
CC: “I have been having heavy periods for 4-5 months now. I
feel tired and dizzy most days”
HPI: 23-year-old came to the clinic today complaining of heavy
menstrual periods happening for the past 4 to 5 months.
Accompanying the heavy flow, patient states that she has
moderate cramps. Pt describes the pain as stabbing and its 3 out
of the 0-10 scale. Patient does not take any medications for the
pain. The pain is decreased by applying warm compresses to the
lower abdominal area. In addition, patient complains of feeling
dizziness and tiredness most of the times.
Current Medications: none
PMH Medication Intolerances:
NONE Chronic Illnesses/Major traumas: NONE Screening
Hx/Immunizations Hx: Vaccinations up to date, most recent pap
smear 12/19 – negative Hospitalizations/Surgeries: None
Family History:Father: Alive, No medical history Mother:
Alive, Htn
Social History: Patient is a full-time college student and part

2. time employee at Publix as cashier. Pt lives at home with
parents and denies having had a sexual partner for the past year.
Patient denies the use of cigars, alcohol, or illegal drugs.
ROS
GeneralDenies recent weight loss, fever, change in appetite or
headaches. She denies chills or night sweats.
CardiovascularDenies palpitations, chest pain, orthopnea, and
claudication. Reports episodes of hypotension.
SkinDenies bruising, skin rash, or discoloration. Denies changes
in moles or skin breakdown. RespiratoryDenies shortness of
breath, abnormal sputum, cough, or wheezing.
EyesDenies pain, redness, loss of vision, double or blurred
vision GastrointestinalDenies abdominal pain, decreased
appetite, nausea, or vomiting. Denies food intolerances and
changes in stool
EarsDenies ear pain, ear infections, or tinnitus
Genitourinary/GynecologicalDenies dysuria, flank pain, and
hematuria. Denies abnormal vaginal discharge or itching.
Denies STI history. Reports heavy menstrual periods lasting 5
to 6 days, associated with cramping; every 28
days. OBSTETRIC/GYNECOLOGICAL Hx:Menarche: 11
years LMP: 09/15/20 G 0 T 0 P 0
A 0 L 0 Birth Control/Type:
NoneMenopause: no Sexually Active:
yes STD Hx: None
Nose/Mouth/ThroatDenies nasal pain, congestion, epistaxis, or
postnasal drip. Denies pain in mouth, bleeding gums, or dry
mouth. Denies pain in throat, hoarseness, difficulty or painful
swallowing. MusculoskeletalDenies muscle pain or joint pain.
Denies limited range of motion

3. BreastDenies breast tenderness, discharge, redness, or lumps.
NeurologicalDenies headache, dizziness, seizures, or memory
loss.
Heme/Lymph/EndoPt denies bruising PsychiatricDenies mood
changes, irritability, or changes in concentration. Denies having
depressive ideation.
OBJECTIVE
Weight 119 BMI 21.08 Temp 98.0 BP 106/60
Height 5’3” Pulse 99 Resp 20
PHYSICAL EXAMINATION
General AppearanceCooperative, Hispanic woman, appearing in
no distress, well-nourished and maintains appropriate eye
contact.
SkinNo skin lesions or discoloration noted.
HEENTHead normocephalic with normal hair distribution. No
lesions or masses noted. Eye: PERRLA intact, EOMs intact.
Fundoscopic exam unremarkable. Ears: Tympanic membrane
intact and pearly grey. Nasopharynx: no exudate, lesions,
erythema, or discoloration. Mouth: Good dentition. No lesions
or discoloration. Uvula midline, tonsils noted 1+.
CardiovascularS1, S2 with regular rate and rhythm. No carotid
bruits. Capillary refill 2 seconds. Pulses 3+ throughout.
RespiratorySymmetric chest wall. Respirations regular and
unlabored. Lungs clear to auscultation bilaterally.

4. GastrointestinalAbdomen soft and nontender. No mass or bruit
noted. Normoactive bowel sounds present x4
BreastNo lumps or masses. No nipple retraction or discharge.
No lymphadenopathy.
GenitourinaryNo bladder distention or CVA tenderness. On
pelvic examination, menstrual bleeding is noted.
MusculoskeletalFull ROM, muscle strength 5/5. No crepitus,
joint clicks or pain
NeurologicalCranial nerves intact. Motor and sensory intact.
PsychiatricAwake, alert, and oriented x 3, responsive to verbal
and tactile stimuli.
Lab Tests80025: BLOOD COUNT; COMPLETE CBC,
AUTOMATED & AUTOMATED DIFFERENTIAL WBC83540:
IRON83550: IRON BINDING CAPACITY82728:
FERRITIN84466: TRANSFERRIN76830: ECHOGRAPHY,
TRANSVAGINAL
Diagnosis
Primary Diagnosis- D50.9 Iron Deficiency Anemia: The
objective and the subjective information obtained support the
suspected diagnosis for Iron Deficiency Anemia (Kocaoz,
Cirpan, & Degirmencioglu, 2019). In addition, all the symptoms
manifested such as the fact that she is feeling more tired than
usual, abnormally heavy menses, associated with moderate to
severe abdominal cramps and a family history, contribute to
select this diagnosis as a final diagnosis.
Differential diagnoses:

5. D25.9 Leiomyoma of Uterus, Unspecified: Benign tumors also
known as fibroids. The tumors arise from the overgrowth of
tissue and muscle in the uterus. Common symptoms include
heavy menstruation and pelvic pain. This condition is unlikely
to be the main diagnosis because the patient is not complaining
of pelvic pressure (Sabry & Al-Hendy, 2019).
soap 4.docx
N80.1 Endometriosis of Ovary: Occurs when extra tissue
outgrows to the ovaries. Common symptoms include painful
periods, pain with intercourse, excessive bleeding and infertility
(Alimi, Loukas, & Tubbs, 2018).
C54.1 Malignant neoplasm of endometrium: A malignant
condition that occurs when the abnormal growth of cells appear
in the endometrium (Parasar, Ozcan, & Terry, 2017). The cells
can also spread to other organs. Vaginal bleeding and pain are
the most common first manifestations. In this case, this
condition is unlikely because the patient is having heavy
bleeding associated with menstruation (Porter, 2020).
PLAN including education Test:
CBC, Serum iron, Transferring saturation, Total Iron-binding
capacity, Serum Ferritin, Transvaginal UltrasoundMedications:
None at this time until lab work is evaluated. Birth Control
options discussed with patient at this time. Education: Patient
was educated on safe sex practices and self-breast examination.
Patient was educated to eat diet high in iron including red meat,
pork and poultry, seafood, beans, dark green leafy vegetables,
such as spinach, dried fruit, and raisins. Increase fluid
intake. Follow up in 2 days for results.
References

6. Alimi, Alimi, Y., Iwanaga, J., Loukas, M., & Tubbs, R. S.
(2018). The Clinical Anatomy of Endometriosis: A
Review. Cureus, 10(9), e3361.
https://doi.org/10.7759/cureus.3361
Kocaoz, S., Cirpan, R., & Degirmencioglu, A. Z. (2019). The
prevalence and impacts heavy menstrual bleeding on anemia,
fatigue and quality of life in women of reproductive
age. Pakistan journal of medical sciences, 35(2), 365–
370. https://doi.org/10.12669/pjms.35.2.644
Parasar, P., Ozcan, P., & Terry, K. L. (2017). Endometriosis:
Epidemiology, Diagnosis and Clinical Management. Current
obstetrics and gynecology reports, 6(1), 34–41.
https://doi.org/10.1007/s13669-017-0187-1
Porter S. (2020). Endometrial cancer. Seminars in oncology
nursing, 18(3), 200–206.
https://doi.org/10.1053/sonu.2002.34082
Sabry, M., & Al-Hendy, A. (2019). Medical treatment of uterine
leiomyoma. Reproductive sciences (Thousand Oaks,
Calif.), 19(4), 339–353.
https://doi.org/10.1177/1933719111432867