SOAP Note Template

Subjective

First Name Elizabeth

Last Name Walker

Gender Female

Age 34

CC

Abdominal pain RLQ one hour with nausea. Reports pain is stabbing, sharp, strong, feels deep, rates pain 8 on scale 0-10.

HPI

History (including PMH, surgical, family, and social)

Elizabeth Walker is a 34-year-old married female who presents for evaluation of acute onset of RLQ abdominal pain with nausea for one hour. She characterizes the pain as sharp, constant, and worse with any movement. She reports associated nauseas, denies vomiting, fevers/chills, diarrhea, abnormal vaginal bleeding or discharge, lower urinary tract symptoms, or flank discomfort. PMH is notable for her currently undergoing hormonal stimulation fertility treatments (G0P0). The physician exam is significant for tachycardia, RLQ pain with guarding and rebound, as well as a tender right adnexal mass per pelvic examination. Other active problems: Infertility – takes HCG injections and FSH. Obstetric History: Gravida 0, Para 0, Abortus 0. Surgical History: 1. Tonsillectomy – @ age 14. Preventive: Flu immunization recommended yearly. BMI to 22.3 Seat belts – uses regularly. Texting while driving – never. Current on immunizations:1) up to date on Tdap. 2) up to date on influenza vaccination. Family History: Mother – 62 with HTN, alive and well. Father – 65 with diabetes, alive and well. Sister – 36 with two children, alive and well. Grandparents – deceased unknown causes. Social History: Tobacco – none. Alcohol – no. Recreational drugs – none. Married – monogamous. Education – college graduate. Job – elementary-school principal. Travel – none recently. Pets – none. Home safety – no guns in household.

ROS (general, skin, HEENT, neck, breasts, resp, CV, GI, peripheral vascular, urinary, genital/LMP, MSK, psych, neuro, hematologic, endocrine)

General: No evidence of fever, chills, fatigue, malaise, night sweats, excessive or unexplained weight gain or loss. Skin/Breasts: No rashes, bruising, jaundice, pruritis, acne, sores, ulcers, changes in moles, hair loss or brittleness, nails. No pain from her breasts. No lumps on bilat breasts. Does monthly self-breast exam. No discoloration near nipples or breasts. No nipple discharge. Periods are regular every 26-28 days. LMP three weeks ago. Uses three pads or tampons per day. HEENT/Neck: Denies vision changes, blurred vision; eye pain, discharge, itching, or redness. Denies ear pain, ear discharge, hearing difficulty, vertigo, nasal congestion, epistaxis, sinus pain or pressure, sore throat, swollen glands in neck, tooth pain. Cardiovascular: No complaints of chest pain/pressure, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, palpitations, ankle swelling. Resp: Denies shortness of breath, wheezing, cough/ sputum, hemoptysis, tightness in chest, pleuritic chest pain (pain with deep breath or cough). Abd/GI: C/o nausea and RLQ abdominal pain for last hour. No problems with appetite changes, dysphagia, vomiting, hematemesis, heartburn, diarrhea, constipation, melena. GU: No menstrual irregularities, amenorrhea, dysmenorrhea, dyspareunia. Denies dysuria, urinary frequency, nocturia, hematuria, incontinence, urgency, hesitancy, difficulty starting or stopping stream. MSK: No joint or muscle pains, joint stiffness and swelling, limitations in movement, functionality. Neuro: No problems with headaches, syncope, presyncope, dizziness, weakness, paralysis, numbness/tingling, or balance. Allergic/Immunologic: Denies food allergies, hives, or rashes. Lymphatic/Endocrine: Denies polyuria, polydipsia, polyphagia, tremor, heat or cold intolerance, hot flashes. Hematologic: Denies excess bruising or bleeding, swollen glands/lymphadenopathy. Psychological: No problems with mood changes, feeling depressed, manic behaviors, auditory or visual hallucinations, anxiety, insomnia, suicidal or homicidal ideations.

Allergies

Penicillin. NKFA.

Current Medications

FSH and HCG injections.

Objective

Vital Signs:

BP 106/70 mmHg – sitting.

RR 14 unlabored

Pain 8

Height 5’ 4”

Weight 130 lbs. (59.1kg)

BMI 22.3

Temp 98.6 oral

Pulse Ox 99% room air

Physical exam (general, HEENT, neck/lymph, breasts, chest/respiratory, CV, GI/abdomen, GU/rectal, back, MSK, skin, neuro, psych)

Weight: 130.0 pounds. Skin/Breasts: Atraumatic, good skin turgor, skin, and scalp normal, no evidence of suspicious pigmented lesions. Normal symmetrical breast contour bilat. No overt inflammatory signs. No previous incisions or trauma. Left and right breast with no abnormalities. No axillary adenopathy. No expressible nipple discharge. HEENT: Eyes: Sclera and conjunctiva normal. Pupils and irises size symmetrical and shows normal reaction to light and accommodation bilaterally. Ears: no external scars or lesions. Otoscopic exam normal with only minimal wax, no masses or foreign bodies, good light reflex bilaterally. Nose: External without abnormality. Normal nasal mucosa, septum, turbinate’s. Mouth: Good dental hygiene. Neck supple, no adenopathy, trachea midline, no carotid bruits, thyroid size 25 gm, no masses or tenderness. Cardiovascular: No JVD. No thrills, heaves, or lifts. PMI normal size and location. Heart RRR Normal S1 and S2, no murmurs appreciated. No carotid bruits, abdominal aorta normal size no bruits, pedal pulses present and symmetrical, no evidence of peripheral edema or varicosities. Respiratory: Normal chest shape, normal respiratory movement, no tenderness, and percussion normal. Auscultation found normal breath sounds throughout without wheezing, rales or ronchi. Abdomen/GI: Flat contour. No scars. Normal bowel sounds present. No hepatosplenomegaly. Severe tenderness to RLQ palpation below McBurney’s point, with associated guarding and rebound; no palpable mass. Mild tenderness to RUQ and LLQ palpations. No CVA tenderness. Liver edge felt below the coastal margin, span normal to percussion. Spleen normal size. GU/GYN: No lesions on external exam. Speculum exam: no blood or discharge present, cervix appears normal. Bimanual exam: right adnexal tenderness with palpable mass. No cervical motion tenderness. Normal genitalia, no evidence of infection. MSK: Normal ROM and muscle tone throughout. Muscle strength and flexibility throughout axial and appendicular skeleton normal. Motor 5/5 all extremities. Neurological: A & O x 4, good attention, memory, normal gait, CN 2-12 intact, reflexes 4/4 throughout. Normal cerebellar exam with finger to nose (FTN), rapid alternating movements (RAM), heal to shin (HTS) bilaterally. Allergic/Immunologic: No worrisome preauricular, posterior auricular, anterior cervical, posterior cervical, submandibular, supraclavicular lymph nodes. Lymphatic/Endocrine: Thyroid normal to palpation, 25 gm, no masses or tenderness. Hematologic: Normal capillary refill. No evidence of anemia.

Assessment

Problem List:

Right Ovarian Torsion

Differential diagnoses:

Differential Diagnoses	How Was This Diagnosis Ruled Out?
Ectopic pregnancy
Tubo-ovarian abscess
Ovarian cyst rupture
Appendicitis
Ovarian torsion

Plan

Include the following:

Medications to be prescribed (drug-dose directions)
Instructions to continue, discontinue, or start medications, including changes to routine medications.
Diagnostic tests in the proper order and reason for the order (e.g., CT abdomen and pelvis with and without contrast, Dx, LLQ abdominal pain)
Labs, including appropriate serum panels (e.g., BMP, CBC with diff., TSH, T4, UA, C&S)
Patient education pertinent to health condition
Follow-up plan
Referrals

Plan

Rationale and/or results

Pelvic Ultrasound

Results show an enlarged right ovary with no blood flow is diagnostic for ovarian torsion.

Right ovary 11cm x 4cm with small cyst. No blood flow to right ovary seen.

Left ovary 4cm overall size. No pathology identified.

CBC

Name	Value	Units	Reference Range
White blood cells (WBCs)	11200	mm3	4,000-10,000
Red Blood Cell Count (RBC)	4.9	million/µl	4.5-5.9(♂), 4.0-5.2(♀), adults
Hemoglobin (Hgb)	12.2	g/dl	14-18(♂), 12-16(♀), adults
Hematocrit (Hct)	38.4	%	42-54(♂), 37-47(♀), adults
Mean corpuscular volume (MCV)	91	fl	82-103, adults
Mean corpuscular hemoglobin (MCH)	28	µm3	26-34, adults
Mean corpuscular hemoglobin concentration (MCHC)	31	%	30-37, adults
Platelets (thrombocytes)	280	k/dL	150-399, adults
Red cell distribution width (RDW)	12.0	%	11.5-14.5, adults
Neutrophils	74	%	46-78, adult
Lymphocytes	23	%	18-52, adult
Monocytes	1	%	3-10, adult
Eosinophils	1	%	0-6, adult
Basophils	1	%	0-3, adult
Segmented neutrophils	72	%	36-72, adult
Band Cells	2	%	0-6, adult

hCG, urine

Name	Value	Units	Reference Range
Human chorionic gonadotropin (HCG), urine	Negative		None (♂ and non-pregnant ♀); detectable (pregnant ♀)

Name	Value	Units	Reference Range
Color	Amber		Interpreted by physician
Clarity	Clear		clear
Odor	Normal		slightly nutty
pH	5.4		4.5-8
Protein	1	mg/dL	0-8
Specific gravity	1.019		1.002-1.030
Osmolarity	> 400	mOsm/L	>400
Leukocyte esterase	Negative		negative
Nitrites	Negative		0
Ketones	Negative		negative
Bilirubin	Negative		negative
Blood (heme)	Negative		negative
Urobilinogen	0.5	EU/dL	0.2-1.0
Crystals	None		Interpreted by physician
Casts	0-1	hyaline casts/lpf	0-4
Glucose, urine	Negative		negative
White blood cells (WBCs)	0-1	hpf	0-5
Red blood cells (RBCs)	0-1	hpf	0-5
Red blood cell casts	None		none
SQEP	0-1	lpf	<5
Bacteria	Negative		negative on spun specimen
Creatinine	8		5-19
Occult blood	Negative		negative

STAT GYN surgical referral for removal of right torsed ovary STAT.

Start IV access to provide for analgesia. Order blood work for chemistries and coagulation studies as part

Of the preoperative workup. Monitor vital signs. Patients’ tachycardia will most likely improve with

Analgesia and pain control. Prep for emergent laparoscopy to detorse the ovary and thereby restore

Perfusion.

Referral for education, counseling, supported decision making and support groups for infertility and loss of ovary.

Name	Value	Units	Reference Range
Human chorionic gonadotropin (HCG), urine	Negative		None (♂ and non-pregnant ♀); detectable (pregnant ♀)