Running Head: ACUTE PROBLEM: SOAP 1

Acute Problem SOAP Note

Alyssa Matulich

University of Tennessee at Chattanooga

ACUTE PROBLEM SOAP 2

SUBJECTIVE:
PATIENT IDENTIFIERS: T.R., female, age 42, Caucasian. Works for Hamilton County in a Jail.
Last seen at Sequoyah Health Department Sept 17, 2018. Date of encounter 10/1/18 at 9:30 am.
Patient is a reliable historian.

CHIEF COMPLAINT (CC): Nexplanon check, increase in headaches, and lower back and abdominal
pain
HISTORY OF PRESENT ILLNESS (HPI): Pt here today for Nexplanon check that was place on Sept
17th. The patient has not had any spotting or bleeding since placement. Patient states that since
the placement she has experienced an increase in the number of headaches she has. The
headaches have lasted 1-2 days and are not relieved with medication like Tylenol or Excedrin.
The patient states that the headaches are across the front of her forehead above her eyebrows and
are a dull pulsating pressure. She states nothing has helped relieve the headaches and she just
deals with them because they aren’t terrible just annoying. There are no other associated
symptoms with the headaches like vertigo, aura, or nausea and vomiting. The patient is also
complaining of a consistent dull ache in her lower back that radiates to her front lower abdomen.
The pain started about a week ago. The patient states she has had some frequency, urgency but
denies pain with urination as well as pain with sex. Pt denies having vaginal discharge or foul
odor. Pt states that she had found that laying with a heating pad on her abdomen helps her get
more comfortable but does not help get rid of the pain. Denies fever, chills, nausea and vomiting.
Denies change in bowel habits, diarrhea, and constipation. Last STD tests were negative May
2018. Last pap was normal in May of 2018. Last sexual intercourse was 9/27/18 with condoms.
LMP 9/10/18. Pt states her periods usually last 5-7 days with moderate bleeding and she
typically uses 3-5 tampons per day. Pt states she experiences mild cramping, fatigue, and
headaches associated with her menstrual cycle. Pt states Tylenol usually relieves menstrual
symptoms. Pt denies excessive bleeding. Pt has never been pregnant and has no interest in being
pregnant. Pt preforms monthly breast exams and found a lump under right axilla that was
examined at last visit on 9/17/18. Pt had appointment with Mary Ellen Locher tomorrow for
ultrasound. Pt states the lump is non-tender and moveable but is a golf-ball sized mass. Pt denies
any other change in breast tissue, breast pain, and nipple discharge. Pt has had 2 sexual partners
in her lifetime and only one partner within the last six months, all partners being male.

PMH: Past surgery includes wisdom teeth removal 2016. No previous hospitalization. No history
of blood transfusions. No history of psychiatric disorders.
ALLERGIES & REACTIONS: NKA
PERSONAL HISTORY: Patient is a single, Caucasian, female. Currently employed with Hamilton
County and works night shift at a jail. Pt is currently a student at UTC. Pt lives at home with her
mom, dad, and sister and feels safe at home. Has access to food, water, and transportation.
Patient currently has insurance through Hamilton County.
ACUTE PROBLEM SOAP 3

SOCIAL HISTORY: Patient has never smoked cigarettes. Patient drinks alcohol occasionally stating
she may drink 4-5 drinks per month. Denies current illicit drug use. Healthy diet consisting of
meats, fruits, and vegetables. Patient notes that she exercises 3-4 times per week for 30-60
minutes. Her exercise consists of running on treadmill. Patient is currently sexually active with
one partner
HEALTH MAINTENANCE: Last pap smear in May of this year and came back WNL. Performs self-
breast exams monthly. BP check yearly, WNL. STD screening last in May 2018, WNL. HIV
screening not performed.
FAMILY HISTORY: Grandmother – diabetes Mother – hypertension. Sister- epilepsy Father-
hypertension
CURRENT MEDICATIONS & TREATMENTS: Nexplanon implant in Left arm.
REVIEW OF SYSTEMS:
GENERAL: Patient denies any fever, chills, malaise, increased fatigue, night sweats, or
weight changes.
Skin: Nexplanon site well healed. Denies tenderness or discharge at site
LYMPH: Patient denies any lymph node tenderness or enlargement in the neck or groin
areas. One golf ball sized mass under right axilla that is non-tender and moveable
BREASTS: Patient denies any breast pain, tenderness, lumps, or discharge.
GENITOURINARY: Patient denies vaginal discharge and foul odor. Patient has had lower
abdominal and back pain, urinary urgency and urinary frequency. Denies flank pain, pain
with urination, and pain with sex. Urine golden yellow and a little cloudy, no odor
present. Denies visible blood
FEMALE: LMP on 9/10/18, age at menarche 11, G0, P0, A0, L0. History of 2 sexual
partners. Last sexual intercourse 9/27 with condoms. Nexplanon placed Sept 17th in left
arm.
MUSCULOSKELETAL: Patient denies any muscle or joint pain, warmth or swelling. Denies
crepitus. Denies muscles weakness.
NEUROLOGIC: Patient denies any numbness or tingling in extremities. Denies fainting,
weakness, or loss of coordination. Denies vision or hearing loss
MENTAL STATUS: Patient denies any problems with concentration, sleeping, appetite,
socialization, or mood changes. Denies suicidal thoughts. Denies anxiety or nervousness.
OBJECTIVE:
Physical Examination
VS: T 98.2 F, P 79, R 22, BP 122/83, Ht 5’6”, Wt 172lbs
ACUTE PROBLEM SOAP 4

GENERAL APPEARANCE: Patient appears stated age, race, and gender. Sitting upright on exam
table.
Skin: warm and dry. Nexplanon implant site healed well. No redness, discharge or other signs of
infection at implant site. Nexplanon implant able to be palpated under surface of skin.
MENTAL STATUS AND NEURO: A&O X3. PEERLA. EEOM INTACT. Speech is clear and
organized. Responds to questions appropriately. Long term and short-term memory intact.
Pleasant and cooperative. Romberg negative. Patient able to shrug shoulders and turn head.
Patient able to smile and frown symmetrically. Tongue protrudes midline. Brachioradialis and
Achilles reflexes 2+. Negative Babinski.. Sensation intact bilaterally to pain and light touch.
CHEST/LUNGS: Lungs CTA with equal expansion, no adventitious breath sounds, no wheezing.
HEART: Heart RRR with no murmurs, rubs, or gallops.
ABDOMEN: Abdomen flat, bowel sounds WNL in all four quadrants, no tenderness on palpation,
no palpable masses.
FEMALE GENITALIA: External genitalia without lesions or redness. No Bartholin or Skene gland
enlargement. No vaginal discharge. No blood in vaginal canal. Vaginal walls rugated and red
with moderate amount of thin, white discharge. Cervix round, closed without discharge, no
vaginal or cervical lesions, no CMT. Uterus small, mobile, midline, and non-tender. No adnexal
masses or tenderness bilaterally.
MUSCULOSKELETAL: Upper and lower extremities with full ROM and strength 5/5. No joint
swelling, redness, or tenderness to palpation. Normal gait. Spine is aligned. No CVA tenderness.
ASSESSMENT:
Differentials for abdominal pain:
Urinary tract infection N39.0: A patient with a UTI may present with dysuria, frequency,
urgency, suprapubic pain/ache, back pain, fever, gross hematuria, vague abdominal discomfort.
The patient is complaining of pain with urination and blood on tissue, and lower abdominal
ache/pain. See UA results. This diagnosis is likely. (Hawkins, 2016)
Pyelonephritis O23.40- symptoms include fever, chills, back pain, CVA tenderness, and flank
pain, dysuria, urinary frequency and urgency and hematuria. This diagnosis is unlikely because
the patient does not seem sick/acutely ill. (Schuiling, 2011)
PID related to STI (Schuiling, 2011) :
Chlamydia A56.02: A female patient may present with dysuria and pelvic pain as well as
vaginal discharge, intermenstrual spotting, postcoital bleeding, mucopurulent discharge.
This patient is not complaining of any discharge. No cervical friability or tenderness.
Vaginal discharge is thin and white. Diagnosis not likely (Hawkins, 2016)
Gonorrhea A54.02: A pt may present with dysuria and lower abdominal discomfort but
may also have purulent and irritating vaginal discharge, fever, abnormal menstrual
ACUTE PROBLEM SOAP 5

bleeding, labial pain and swelling, and dyspareunia. Diagnosis not likely (Hawkins,
2016)
Kidney Stones- pain is the most common symptom and varies from mild and barely noticeable
ache to intense discomfort. The pain typically waxes and wanes in severity. The site of the stone
or obstruction determines the location of the pain. (Churan, 2018)
Appendicitis- abdominal pain is the most common symptom along with anorexia, right lower
quadrant pain, and nausea and vomiting. Patients may also have indigestion, flatulence, bowel
irregularity, diarrhea, and general malaise. This diagnosis is not likely. (Martin, 2018)
Differentials for Headache:
Migraine: unilateral, pulsatile headache that can last for a few hours or days and is associated
with nausea and vomiting and sensitivity to light or sound.

Problem list: UTI N39.0, Headache R51

CPT codes and ICD10:
Pregnancy test, negative- Z32.02
Established implant check Z30.46
Screening for STIs- Z113

UA- 5463
Urine pregnancy test 81205
Office Visit: 99385

PLAN:
Urinary Tract Infection:
- Diagnostics: UA- leukocytes, small blood, and nitrates present
- Macrobid 100mg PO twice a days for seven days
o Counseled pt to take with food and possible side effects
- Follow-up with doctor in one week or sooner if symptoms worsen
- Education: advise voiding before and after sex. Advise adequate lubrication for sex. Wipe
front to back. Drinking cranberry juice can help prevent UTI (prevent E. coli from
attaching to urinary tract). Increase water intake; at least 6-8 glasses per day). Decrease
bladder irritants which include caffeine, smoking and artificial sweeteners. Wear cotton
underwear and avoid tight fitting clothes.
- No referrals at this time. Follow up of symptoms do not resolve after treatment
- Reference: Guidelines for nurse practitioners in gynecologic settings
ACUTE PROBLEM SOAP 6

Birth Control and headaches

- Diagnostics- pregnancy test negative
- Educated patient on using condoms with sex as Nexplanon does not protect against STDs,
Nexplanon is a medication so make sure to tell other medical providers you have it. If pt
cannot feel the implant she should return to the office for evaluation. Side effect of
Nexplanon is headaches and should resolve in the next two months. If headaches worsen
or do not resolve return for follow up visit.

STI:
- Diagnostics- completed chlamydia and gonorrhea culture, wet mount- negative trich
o Declined HIV testing
- Educated patient on importance of using condoms to protect against STDs. Results should
be back within one week and will contact patient if she needs treatment
- If positive for chlamydia: azithromycin 1gram PO tab x 1dose for patient and her partner
- If positive for gonorrhea: ceftriaxone 250 mg IM in a single dose plus azithromycin 1 gm
orally in one dose
- Reference: Guidelines for nurse practitioners in gynecologic settings

Health Maintenance
- Continued yearly gynecological exam and breast exams necessary
- Repeat Pap in two years from May 2018
- Educated on continuing monthly breast exams
- Pt up to date on immunizations. Pt states she will receive flu vaccine from employer
when distributed.
- Referral made 9/17 to Mary Ellen Locher Breast Center for mammogram. No new
referrals at this time.
- Counseled patient on alcohol use. Alcoholic beverage intake should be limited to one per
day and binge drinking should be avoided.
ACUTE PROBLEM SOAP 7

References

Churan, G. (2018, September 21). Diagnosis and acute management of suspected nephrolithiasis

in adults.

Hawkins, J. W., Roberto-Nichols, D. M., & Stanley-Haney, J. L. (2016). Guidelines for nurse

practitioners in gynecologic settings (11th ed.). New York, NY: Springer Publishing

Company, LLC.

Martin, R. (2018, April 27). Acute appendicitis in adults: Clinical manifestations and differential

diagnosis.

Schuiling, K., & Likis, F. E. (2011). Womens gynecological health (3rd ed.). Sudbury: Jones &

Bartlett Learning.