SOAP NOTE Name:  DL Date: 9/30/2022 Time: 10:00 am Age: 28 years Sex: Female SUBJECTIVE CC:  “I have my period for 22 days; I have pelvic pain and also noted some dark vaginal bleeding since yesterday.” HPI: The patient states that she noted the darker bleeding yesterday. She has been having pelvic pain although she did not mention if it was severe, but some time she felt nauseous. She also states that she has been having her periods for the last 22 days although she noted the darker bleeding yesterday. She has been having pelvic pain. The patient took ibuprofen 400 mg to alleviate the pain. Medications: Ibuprofen 400 mg PO Q6H as needed for pain PMH: Allergies:  NKA Medication Intolerances: Patient reports no known medical intolerance. Immunizations: Immunization up to date Chronic Illnesses/Major traumas: None reported Hospitalizations/Surgeries no mention of any surgery or hospitalization. Family History: Both patents are alive. Only child. For the first-degree relatives there is no mention of malignancy.   Social History: Patient was born in Cuba, came to US with her current boyfriend 2 years ago. Patient lives with her boyfriend. The patient denies any smoking, drinking, or any use of recreational drugs. The patient explains that she has been maintaining a regular diet and goes to the gym 2 or 3 times per week and usually sleep 7-8 hours daily. There is also no drug or tabaco use history in his family. ROS General- the patient states that her periods are 22 days, she has pelvic pain and that yesterday she noticed dark vaginal bleeding. From yesterday. Cardiovascular She denies any chest pains, palpitations nor pressure. Skin  No changes on her skin Respiratory  No coughing nor shortness of breath. Eyes- she has no double vision, loss of vision, or blurred vision. Gastrointestinal  The patient denies any nausea, vomiting or diarrhea, constipation but she states that she has pelvic pain. Ears  No ear pain nor loss of hearing. Genitourinary/Gynecological  She denies pain when urinating, she has vaginal discharge where she has noticed dark vaginal bleeding. Nose/Mouth/Throat No mouth pain, mouth discharge, throat pain nor having issues when swallowing. Musculoskeletal No bones, muscles, and joints pain and she deny constraint to a range motion, swelling of joints. Breast Denies any discomfort or lumps. Neurological She denies dizziness, headache, ataxia, or syncope. Heme/Lymph/Endo Denies any swollen gland, vaginal bleeding, and no sweats. Psychiatric No depression, insomnia, mood swings, or anxiety. OBJECTIVE Weight: 167.0lbs ...

1. SOAP NOTE
Name: DL
Date: 9/30/2022
Time: 10:00 am
Age: 28 years
Sex: Female
SUBJECTIVE
CC:
“I have my period for 22 days; I have pelvic pain and also noted
some dark vaginal bleeding since yesterday.”
HPI: The patient states that she noted the darker bleeding
yesterday. She has been having pelvic pain although she did not
mention if it was severe, but some time she felt nauseous. She
also states that she has been having her periods for the last 22
days although she noted the darker bleeding yesterday. She has
been having pelvic pain. The patient took ibuprofen 400 mg to
alleviate the pain.
Medications: Ibuprofen 400 mg PO Q6H as needed for pain
PMH:
Allergies: NKA
Medication Intolerances: Patient reports no known medical
intolerance.

2. Immunizations: Immunization up to date
Chronic Illnesses/Major traumas: None reported
Hospitalizations/Surgeries no mention of any surgery or
hospitalization.
Family History:
Both patents are alive. Only child. For the first-degree relatives
there is no mention of malignancy.
Social History:
Patient was born in Cuba, came to US with her current
boyfriend 2 years ago. Patient lives with her boyfriend. The
patient denies any smoking, drinking, or any use of recreational
drugs. The patient explains that she has been maintaining a
regular diet and goes to the gym 2 or 3 times per week and
usually sleep 7-8 hours daily. There is also no drug or tabaco
use history in his family.
ROS
General- the patient states that her periods are 22 days, she has
pelvic pain and that yesterday she noticed dark vaginal
bleeding. From yesterday.
Cardiovascular
She denies any chest pains, palpitations nor pressure.
Skin
No changes on her skin
Respiratory
No coughing nor shortness of breath.

3. Eyes- she has no double vision, loss of vision, or blurred vision.
Gastrointestinal
The patient denies any nausea, vomiting or diarrhea,
constipation but she states that she has pelvic pain.
Ears
No ear pain nor loss of hearing.
Genitourinary/Gynecological
She denies pain when urinating, she has vaginal discharge
where she has noticed dark vaginal bleeding.
Nose/Mouth/Throat
No mouth pain, mouth discharge, throat pain nor having issues
when swallowing.
Musculoskeletal
No bones, muscles, and joints pain and she deny constraint to a
range motion, swelling of joints.
Breast
Denies any discomfort or lumps.
Neurological
She denies dizziness, headache, ataxia, or syncope.
Heme/Lymph/Endo
Denies any swollen gland, vaginal bleeding, and no sweats.
Psychiatric
No depression, insomnia, mood swings, or anxiety.
OBJECTIVE
Weight: 167.0lbs
Temp: 97.5F
BP: 115/77mgHg
Height: 5.8”

4. Pulse: 77 beats per minute
Resp: 17/min
General Appearance
The patient appears to be normal; she has no acute distress, and
she is well-nourished and well developed. She is oriented, alert,
and cooperative with the examination.
Skin
The skin of the patient is normal without cyanosis, clubbing or
bruises. No symptom of dehydration is seen from, warm to
touch, and the turgor of her skin is normal.
HEENT
Normocephalic, PERRLA, Pharynx is noted not to be having
any difficulties in swallowing, neck, thyroid non palpable, no
carotid bruits, TM intact bilaterally.
Cardiovascular
Patient has no murmurs, gallops, or clicks. The S1 and S2 are
present.
Respiratory
She has a normal respiratory effort, and her lungs are free to
auscultation bilaterally, and she has no rales or wheezing in her
lungs.
Gastrointestinal
Abdomen is flat with active bowel sounds in all four quadrants.
It is soft and non-tender, no masses or hepatosplenomegaly. No
CVA tenderness.
Breast

5. Normal, no lumps or discomfort.
Genitourinary:
She does not experience pain when urinating.
Musculoskeletal
No noted joint deformities. Positive ROM in all extremities.
Neurological
Cranial nerves intact. Stable gait.
Psychiatric- she is alert, oriented x3 as well as cooperative with
the examination.
Lab Tests (list the results if you have them)
Special Tests (done or ordered during the OV)
Pap Smear
Pelvic Exam
STD & HIV Screening/Counseling
Diagnosis – include the appropriate ICD – 10 Code for each
diagnosis used
Plan/Therapeutics (explain fully)
Evaluation of patient encounter:
I saw this patient with my preceptor. I participated in the
differential diagnosis selection.

6. Weakness: I need to participate more and feel more comfortable
on my own.
Strengths: I have improved my physical exam skill.
Reflection: I need to study more to feel more comfortable while
giving a diagnosis.
References
Carmelita Swiner. (2020, January 27).
Symptoms of cervical cancer. WebMD.
https://www.webmd.com/cancer/cervical-
cancer/understanding-cervical-cancer-symptoms
ShariBoeckstaens. (2020, November 11).
Signs and symptoms associated with uterine cancer in
pre-and postmenopausal women. ScienceDirect.com | Science,
health, and medical journals, full-text articles, and books.
https://www.sciencedirect.com/science/article/pii/S2405844020
322155
1
SOAP NOTE
Name: DB
Date: 1/13/2017
Time: 10:33AM
Age: 33
Sex: Female

7. SUBJECTIVE
CC:
“My back hurts”.
HPI: (Use OLDCART)
She reports feeling pain in her lower back that started yesterday
while at work. Last night she went to sleep as usual, when she
woke up this morning she was in a lot of pain and was very
stiff. The pain is described as a 7/10 on the pain scale, feels like
burning. Pt states pain is worse in the R lumbo-sacral area. Pain
radiated to her R buttock. It hurts her to stand up or to find a
comfortable position. Pain worsens after bending or lifting. Her
back hurts even at rest, but gets worse with movement. Taking
Tylenol 500mg 2 caplets with no relief of the pain. Denies hx of
UTI symptoms; Denies vaginal discharge or dyspareunia; denies
change in bladder or bowel habits; denies weight loss or fever.
Denies hx of previous back pain, injury or trauma. States she
works as a cashier at the grocery store where she stands most of
the day. Yesterday was her second day of working over time at
work and she thinks since she works standing up, this might
have cause for her to feel pain in her lower back. Denies muscle
weakness, paresthesia, loss of sensations, and no severe or
progressive neurological deficit in lower extremity.
Medications: (list with reason for med )
Tylenol Extra Strength 500 mg Caplets, 2 tabs q4-6 hr for back
pain with no relief
Metformin 500mg 1 PO QD for Type 2DM
Lisinopril 10mg 1 po QD for HTN
PMH
Allergies: NKDA, denies food allergies
Medication Intolerances: Denies
Chronic Illnesses/Major traumas: HTN (2016), Type 2 NIDDM
(2017)

8. Hospitalizations/Surgeries: Appendectomy (2001)
Family History
States her parents (mother 59, father 63), siblings (sister 34,
brother 27) and daughter- 4y/o are healthy and both sets of
grandparents are alive and live in Colombia (doesn’t know age
or if they have any medical problems).
Social History
General: Born and raised in Cali, Colombia, moved to the US
with her parents when she was 17 years old.
Marital status: Single Mom of a 4-yr/old girl. Ex-husband not
involved financially or physically in care of child.
Living situation: Parents live 100 miles away. One brother in
town; sees brother seldom. Mrs. B has a few close friends. Pt
sates she is in debt “way over head”. No health insurance
benefits. Considers herself a strong and independent woman.
Children: One 4-yr/old daughter who is healthy
Occupation: Works at a local grocery store as a cashier. She
stands most of the day in her job. Sees job only as a means of
providing income for her and her daughter.
Leisure Patterns: Pt states she doesn’t have time to “relax”.
Social habits: Denies smoking or alcohol consumption. Does not
exercise.

9. Spirituality: No church involvement but states that she believes
in God.
Nutrition: Pt states her appetite has increased owing to “stress”,
craves chocolate, eats what she wants, no special diet. Has not
experienced any changes on her weight.
Sleep Patterns: States that she usually gets about 7 hrs of sleep
every night.
ROS
General
States there have not been any changes in the past 5 years. He
has been wearing the same size of clothes for the past 5 years.
Denies weakness, fatigue, or fever.
Head: Denies headache, head injury, dizziness, or
lightheadedness.
Cardiovascular
States she was just recently diagnosed with HTN, takes
Lisinopril every night, states she checks her BP at least once a
week when she goes to the grocery store and it is always below
130/80. Denies any troubles with her heart, rheumatic fever, or
heart murmurs. Denies having chest pain or discomfort,
palpitations, dyspnea, orthopnea, paroxysmal nocturnal
dyspnea, or edema. Has never had EKG done.
Skin
Reports dryness of the skin, especially on his hands, legs and
feet. Denies rashes, lumps, sores, itching, and changes in color.
Denies changes in his nails or hair. Denies changes in size or
color of moles.
Respiratory

10. Denies cough, sputum, hemoptysis, dyspnea, wheezing, or
pleurisy. Has not had a Chest X Ray done. Denies having
asthma, bronchitis, emphysema, pneumonia, or tuberculosis.
Eyes
Denies any changes in her vision. Does not use glasses. Last eye
exam 2 years ago (Oct/15). Denies any pain, redness, excessive
tearing, double or blurred vision, spots, specks, flashing lights,
glaucoma or cataracts.
Gastrointestinal
Denies trouble swallowing, heartburn, changes in appetite, or
nausea. States she has bowel movements every other day
normally, the stools are small, brown and formed. Denies pain
or bleeding with defecation. No changes in bowel habits. Denies
black or tarry stools, hemorrhoids, constipation, or diarrhea.
Denies abdominal pain, food intolerance or excessive belching
or passing gas. Denies jaundice, live, or gallbladder trouble.
Denies Hepatitis. Does not remember if she has received Hep B
vaccine.
Ears
States she doesn’t have any hearing problems. Denies tinnitus,
vertigo, earaches, infection, or discharge. Denies use of hearing
aides.
Genitourinary/Gynecological
Goes to the bathroom 4 or 5 times a day. Denies polyuria,
nocturia, urgency, burning or pain during urination. Denies
hematuria, urinary infections, kidney or flank pain, kidney
stones, urethral colic, suprapubic pain, or incontinence. No
changes in bladder habits.
Menarche at age 13. States she gets her period approx. q 28
days and it lasts about 5 days. Flow heavier on the first 2 days.
Denies bleeding between periods. LMP: September 4th. Denies
PMS. Denies any vaginal discharge, dyspareunia, itching, sores,
lumps, or STDs. G1 P1, spontaneous vaginal delivery at 39
weeks. Denies any complications with her pregnancy. Denies
use of birth control methods. Not sexually active at the moment.

11. Has had one partner in the past 5 years. Denies exposure to HIV
infection or STDs.
Nose/Mouth/Throat
Pt states she gets occasional allergies and colds that cause her
to have stuffiness and discharge. Denies hay fever, nose
bleeding, or sinus trouble. Throat: States her teeth are yellow
and sometimes her gums would bleed. Denies use of dentures.
Last dental examination 2 yrs ago (Oct/15). Denies sore tongue,
frequent sore throats or hoarseness. Denies having dry mouth or
excessive thirst.
Neck: Denies swollen glands, goiter, lumps, pain, or stiffness in
the neck.
Musculoskeletal
Denies muscle weakness, paresthesia, loss of sensations, no
severe or progressive neurological deficit in lower extremity.
No Hx of cancer, or risk factors for spinal infection (no IV drug
abuse, UTI, Immune suppression). Pt reports feeling lower back
pain that started yesterday while at work that is worse in the R
lumbo-sacral area. Pain radiates to her R buttock. Pt states it
hurts to stand up or find a comfortable position. States her back
hurts even at rest, but pain gets worse when she moves. Pain
worsens after bending or lifting. Denies other muscle or joint
pain, stiffness, arthritis or hx of gout. Denies fever, chills, rash,
anorexia, weight loss or weakness.
Breast
Denies lumps, pain, discomfort or nipple discharge.
Neurological
Denies changes in mood, attention or speech. Denies changes in
orientation, memory, insight, or judgment. Denies headaches,
dizziness, vertigo, fainting, blackouts, seizures, weakness,
paralysis, numbness or loss of sensation, tingling or pins and
needles, tremors or other involuntary movements.
Heme/Lymph/Endo
Denies anemia, easy bruising or bleeding, and past transfusions.
Denies excessive thirst and hunger. Denies thyroid trouble, heat

12. or cold intolerance, excessive sweating, polyuria or changes in
shoe size. Denies weight changes or fever.
Periferal Vascular: Pt states she has a few spider veins that look
like bruises, she got them during the pregnancy. Denies leg
cramps, varicose veins, past clots in veins, swelling in calves,
legs or feet. Pt states there have not been any changes in the
color of her fingertips or toes during cold temperatures/weather.
Denies any swelling or tenderness.
Psychiatric
Denies nervousness, tension, mood changes, depression, or
memory changes.
OBJECTIVE
Weight 120lbs BMI 20
Temp 98 F
BP 114/74
Height 67”
Pulse 89
Resp 20
General Appearance
Skin warm and dry w/o discoloration or pallor, A/O x 3,
appropriate responses, cooperative, appears concerned w/o signs
of acute distress.
Skin
Skin is warm, pink and supple, no lesions noted.
HEENT
Normocephalic, PERRLA, EOMs intact, fundoscopic: red reflex
present, no nicking or hemorrhage. TM intact bilaterally, pearly
with + light reflex. Nares patent, neck supple. Pharynx:
swallows w/o difficulty, no erythema; Neck: thyroid non
palpable, no carotid bruits.

13. Cardiovascular
Carotid upstrokes are brisk, w/o bruits. The PMI is tapping, 7cm
lateral to the midsternal line in the 5th intercostal space. S1
louder than S2 on auscultation. No murmurs or extra sounds.
Extremities are warm and w/o edema. No varicosities or stasis
changes. Calves are supple and nontender. No femoral or
abdominal bruits. Brachial, radial, femoral, popliteal, dorsalis
pedis, and posterior tibial pulses are 2+ , brisk, and symmetric.
Respiratory
Thorax is symmetric with good expansion. Lungs resonant.
Breath sounds vesicular; no rales, wheezes, or ronchi.
Gastrointestinal
Abdomen is flat with active bowel sounds in all four quadrants.
It is soft and non-tender; no masses or hepatosplenomegaly. No
CVA tenderness.
Breast
Deferred
Genitourinary
Deferred
Musculoskeletal
No joint deformities. Positive ROM in hands, wrists, elbows,
shoulders, knees and ankles. Gait/Posture: Flexed forward at
15º, walked slowly with a wide based stance, and grimaced with
movement. Heel and toe walking intact. Spinal column: No
kyphosis, scoliosis or lordosis; unable to extend or rotate.
Lateral movement: bilaterally to 20º. All attempts at ROM
produced pain. Right paravertebral muscle spasm noted in
lumbar area. Straight leg raise (SLR) negative, Patrick test
negative, crossed SLR negative. No noted major motor
weakness on knee extension, ankle plantar flexors, evertors,
dorsiflexors. No CVA Tenderness.
Neurological
Cranial nerves II to XII intact. Good muscle bulk and tone.
Strength 5/5 throughout. Rapid alternating movements and point
to point movements are intact. Gait stable. Pinprick, light touch,
position sense, vibration, and stereognosis intact, Romberg

14. negative. Reflexes 2 + and symmetric with plantar reflexes
down going.
Psychiatric
Alert, relaxed and cooperative. Thought process is coherent.
Oriented to person, place and time.
Lab Tests
None ordered today.
Special Tests
None ordered today.
Diagnosis
Diagnosis:
1. Acute lumbosacral strain (M54.5)
Differentials:
1.
Acute lumbosacral pain (M54.5): Minimal
discomfort initially followed by increased pain and stiffness 12-
36 hrs later, SLR, crossed SLR, heel and toe walking were
intact. No muscular weakness or loss of sensation. DTRs were
equal and not depressed. Babinski negative. Spasm noted in
paravertebral muscles.
2.
Herniated lumbar disc (M51.2)
: Pain in buttocks.
3.
Sciatica (M54.3): Pain in back/buttocks.
4.
Possible vertebral Fx (S32.009A): Low back
pain.

15. Plan/Therapeutics
Plan:
Diagnostic: No tests needed at this time
Therapeutic: Pharmacological:
D/C OTC Tylenol. Start Ibuprofen 600mg 1 po q8h x 7 days
then PRN for pain. Robaxin 500mg 1 po QAM, 2 po QHS x 2
weeks then 1 po Q8H PRN for back pain.
Non-pharmacological:
Local application of ice may help initially to decrease pain,
apply cold pack for 20 minutes q2-3 hours while awake. After
2-3 days, either heat or ice may be applied. No bed rest
indicated. Take 3-7 days off work (her job would increase stress
on her back), or perform other duties until the symptoms abate.
Patient Education:
1. Avoid jerky, hurried movements when lifting
2. Lift with legs by straddling the load; bend knees to pick up
load; keep back straight (do not bend back)
3. Keep objects close to the body at navel level when lifting
4. Avoid twisting, bending, reaching while lifting
5. Avoid prolonged sitting
6. Change positions often while sitting
7. A soft support belt for the back, armrests to support some

16. body weight, a slight reclining chair may make sitting more
comfortable
8. Firm mattress/bed board, lying supine with hips and knees
flexed on pillows is beneficial when sleeping
9. May return to work in 4-8 days
10. As soon as she returns to regular activities (in 2 weeks),
aerobic conditioning exercises such as walking, swimming,
stationary biking, or even light jogging may be recommended to
avoid debilitation.
Referral: None
Follow-Up: Come back if the pain does not improve by 50%
in 24-48 hrs. Return to the office in 7-10 days. Return sooner if
neurological symptoms worsen or bowel/bladder dysfunction
occurs.
Evaluation of patient encounter:
I was able to assess the patient independently and then later
present the case to my preceptor by providing her with the
pertinent positive on the ROS and on the physical exam
findings. I participated in the Dx selection and in the treatment
plan.
Weaknesses: I must by managing my time. It took me almost 45
minutes to work on this case.
Strengths: I have improved my physical exam skills, I feel
confident and comfortable interacting with patients on my own.
Reflection: I feel like I am improving with collecting enough

17. information and with performing focused physical exams. I feel
like everything is starting to fall in the right place.
References:
Bickley, L. (2007). Bates’ Guide to Physical Examination &
History Taking (9th Edition), Lippincott, Williams and Wilkins
Publishers
National Guideline Clearinghouse. (2008). Management of
Acute Low Back Pain. Retrieved November 10, 2008 from
http://www.guideline.gov/summary/summary.aspx?doc_id=1249
1&nbr=006422&string=back+AND+pain
Uphold C, Graham M.
Clinical Guidelines in Family Practice. 4th ed.
Gainesville, Fl: Barmarrae Books Inc; 2003:370-376.