PRAC 6552 – Comprehensive History and Physical SOAP Note
Comprehensive History and Physical
SOAP Note
SUBJECTIVE DATA (S):
Identifying data:
Initials
: J.J
Age
: 18y/o
Race
: Caucasian
Gender
: Female
Marital Status
: Single.
CHIEF COMPLAINT (CC):
“Yeast infection or STD? I see a difference in my discharge and feel uncomfortable.”
HISTORY OF PRESENT ILLNESS (HPI):
J.J. is an 18-yo sexually active female presenting with vaginal discharge and mild vaginal discomfort x2 days. Symptoms began suddenly and are localized to the vagina. Pt describes discharge as thin, white, and increased from baseline without foul odor; reports mild vulvar irritation and intermittent itching. Severity mild but concerning to pt due to a change from usual discharge. Symptoms have been constant since the onset and noticed after recent unprotected vaginal intercourse with a male partner. Denies recent antibiotic use, new hygiene products, douching, or prior similar episodes. No alleviating factors; no OTC meds attempted. No aggravating factors identified. Associated symptoms include mild vaginal itching. Denies dysuria, hematuria, pelvic/abdominal pain, fever, chills, dyspareunia, abnormal bleeding, genital lesions, or urinary frequency. Pt is concerned about a possible STI due to unprotected intercourse.
PHQ-9 score: 3, showing minimal depression.
PAST MEDICAL HISTORY (PMH):
Allergies
: NKDA
Medications
: Levetiracetam (Keppra) 1000 mg PO BID
Age/health status
: 18-yo female; generally healthy; seizure disorder well controlled on medication.
Appropriate immunization status, including human papillomavirus (HPV) vaccine as appropriate by age
: Childhood immunizations up to date as reported by pt. HPV vaccine series
incomplete/unknown.
Previous screening Current test results
:
Depression screening: PHQ-9 score 3 → minimal depression
STI screening: urine NAAT pending
UA: negative for UTI
Dates of illnesses during childhood
: Denies rheumatic fever, asthma, congenital disorders, or chronic childhood illness.
Major adult illnesses
: Seizure disorder (stable). Denies hx of: HTN, DM, asthma, TB, cardiac disease, cancer, HIV/AIDS, STIs, renal disease, psychiatric disorders, substance abuse.
Injuries
: Denies significant injuries.
Hospitalizations: Denies prior hospitalizations.
Surgeries (include hospital and year): Denies surgical history.
FAMILY HISTORY (FH):
Mother
: 42 yo, alive, healthy. No HTN, DM, cancer, or psychiatric illness.
Father
: 45 yo, alive, HTN controlled with meds.
Paternal Grandfather
: 67 yo. Alive. History of HTN managed with meds
Paternal Grandmother
: 65yo. Alive. History of Type 2 DM managed with meds
Maternal Grandfather
: 66yo. Alive. HTN managed with meds
Maternal Grandmother
: 60. Alive. 60yo. History of asthma
Siblings
: 1 younger brother (15 yo), healthy.
Children
: none.
SOCIAL HISTORY (SH):
Patient is single and a full-time college student with no history of military service; she is a high school graduate currently pursuing higher education. She lives with her parents in a safe home environment, exercises occasionally (approximately 1–2 times per week), and follows a mixed diet with ongoing dietary counseling. She reports consistent seatbelt use, functional smoke detectors in the home, and denies firearms in the household. She has not traveled recently and reports no religious or cultural restrictions that affect medical care. She reports daily nicotine vaping and denies alcohol consumption or illicit drug use.
Resources / SDOH:
Has health insurance through parents. Denies financial barriers to care, food insecurity, transportation issues, or housing instability. No hx of postponing medical care.
Reproductive Hx
: Patient reports menarche at age 12 with regular monthly cycles lasting 2–7 days and moderate to heavy flow requiring approximately 4–6 pads per day, with mild dysmenorrhea and no intermenstrual bleeding. She is G0P0 with no history of pregnancy, miscarriage, or abortion, is not currently pregnant, and is not breastfeeding. She does not plan to become pregnant within the next 12 months. Current contraception is the withdrawal method, used inconsistently. She identifies as heterosexual and reports vaginal intercourse only, with concern about STI risk due to unprotected sex. She has never had a Pap smear, which is age-appropriate, with screening recommended starting at age 21.
REVIEW OF SYSTEMS (ROS):
Constitutional symptoms
: Reports overall good health; denies fever, chills, fatigue, night sweats, repeated infections, or weight change. Independent in ADLs.
Eyes
: Denies vision changes, diplopia, redness, tearing, pain, trauma. Does not use corrective lenses. Last vision screening within the past 2 yrs per pt, normal.
Ears, nose, mouth, and throat
: Ears: denies hearing loss, tinnitus, vertigo, infections, or hearing aids. Nose: denies congestion, discharge, epistaxis, sinus pain, and anosmia. Mouth/teeth: brushes daily; intermittent flossing; last dental visit 1 yr ago; denies oral lesions, gum bleeding, taste changes. Throat: denies sore throat, hoarseness, dysphagia.
Cardiovascular
: Occasional exercise 1–2x/week. Denies CP, palpitations, dyspnea on exertion, syncope, edema, claudication, murmurs, HTN hx. No prior ECG or lipid screening.
Respiratory
: Daily nicotine vaping exposure. Denies cough, wheeze, dyspnea, sputum, hemoptysis, TB exposure, night sweats. No prior CXR.
Gastrointestinal
: Mixed diet; receives dietary counseling. Denies abdominal pain, N/V, GERD, diarrhea, constipation, hematochezia, melena, jaundice. Normal bowel pattern. No supplements. CRC screening N/A.
Genitourinary
: Admits vaginal discharge and mild vulvovaginal discomfort x2 days. Denies dysuria, hematuria, urgency, nocturia, incontinence, or kidney stones. Sexually active with men; unprotected intercourse; STI screening pending.
Musculoskeletal
: Occasional exercise. Uses a seatbelt; no sports safety equipment reported. Denies joint pain, swelling, back pain, stiffness, weakness, deformities, or limited ROM. No osteoporosis screening indicated.
Integumentary (skin and/or breast)
: Denies rash, itching, lesions, hair loss, nail changes, bruising. Uses basic sun protection. Does not routinely perform skin or breast self-exams. Denies breast pain, lumps, or discharge. Mammogram N/A.
Neurologic
: Hx seizure disorder; controlled on levetiracetam. Denies HA, dizziness, syncope, paresthesia, weakness, tremors, memory loss.
Psychiatric
: PHQ-9 score 3 showing minimal depression. Patient denies anxiety, depression, delusions, hallucinations, stressors, or suicidal thoughts.
Endocrine
: Denies heat/cold intolerance, polydipsia, polyuria, polyphagia, hair/skin changes, weight changes, thyroid disease, or hormonal therapy use.
Hematologic/lymphatic
: Denies easy bruising, bleeding disorders, anemia, or swollen glands.
Allergic/immunologic
:Denies environmental or medication allergies. No history of immunologic disorders.
OBJECTIVE DATA:
Vital Signs (VS):
T 98.5°F, BP 111/69 mmHg, HR 95 bpm, RR 18/min, SpO₂ 97% RA. Ht 65 in, Wt 115.5 lb (52.4 kg), BMI 19.2 kg/m².
General
: 18-yo female, alert, oriented x3, well appearing, well hydrated, in no acute distress, cooperative. Mood and affect are appropriate. Ambulates independently without difficulty.
Skin
: Warm, dry, intact; good turgor. No rashes, lesions, bruising, or abnormal pigmentation noted.
Hair
: Normal texture and distribution.
Nails
: Normal color and shape; no clubbing, cyanosis, or deformities.
HEENT
:
Head:
Normocephalic, atraumatic, no lesions or deformities.
Eyes:
PERRLA, EOMI, conjunctiva clear, sclera non-icteric.
Ears:
External ears normal, no discharge or tenderness; hearing grossly intact.
Nose:
Mucosa pink, no discharge or congestion.
Mouth:
Mucous membranes are moist, with no lesions.
Teeth/Gums:
Good dentition, no caries or gingival inflammation.
Pharynx:
No erythema, exudate, or tonsillar enlargement.
Neck
: Supple, no lymphadenopathy, no thyromegaly, trachea midline.
Heart
: Regular rate and rhythm, S1/S2 normal, no murmurs, rubs, or gallops. No JVD or peripheral edema.
Lungs:
Lungs clear to auscultation bilaterally; no wheezes, rales, or rhonchi. No respiratory distress.
Abdomen
: Soft, non-tender, non-distended. Normoactive bowel sounds. No masses, guarding, or organomegaly. No CVA tenderness.
Back
: Spine midline, no deformity or tenderness. No CVA tenderness.
Rectal:
Normal sphincter tone, no hemorrhoids or masses palpable
Extremities:
No edema, cyanosis, or deformities. Peripheral pulses 2+ and equal bilaterally.
Musculoskeletal:
Full ROM in all extremities. Normal gait and station. No joint swelling, tenderness, or weakness.
Neurologic:
Alert and oriented x3. CN II–XII grossly intact. Strength 5/5 in all extremities. Sensation intact. DTRs 2+ and symmetric. No focal deficits.
Psychiatric:
Oriented X4, Appropriate mood and affect. Cooperative. Normal judgment, insight, and cognition. No evidence of acute distress .
Pelvic:
External genitalia normal in appearance with no lesions, masses, or ulcerations. Mild vaginal discharge noted: Thin, white, homogenous, non-foul-smelling. Vaginal mucosa is mildly irritated. Cervix visualized, no lesions, no cervical motion tenderness. Uterus is of normal size, mobile, and non-tender. Adnexa are non-tender bilaterally with no masses.
Breast
: Breasts symmetrical, no palpable masses, no nipple discharge, no skin changes, and no axillary or supraclavicular lymphadenopathy.
DIAGNOSTIC TESTING (Results)
Urinalysis (UA):
Negative for UTI; trace WBC esterase, protein 1+, nitrites negative, blood negative
Whiff test (KOH):
Positive
Urine STI panel (GC/CT/Trich NAAT):
Collected, results pending
ASSESSMENT (A):
Bacterial vaginosis (BV) – ICD-10: N76.0
Acute, self-limited vaginal infection characterized by a 2-day history of thin white, non-foul vaginal discharge and mild irritation with positive whiff test and absence of UTI findings. Consistent with BV (Kairys & Garg, 2024). No evidence of pelvic inflammatory disease based on the absence of pelvic pain, fever, or cervical motion tenderness. The condition is acute. Appropriate response expected with therapy. Justification for STI testing due to overlapping symptom profile and high-risk sexual behavior (unprotected intercourse).
Vaginal discharge – ICD-10: N89.8
Symptom-based diagnosis associated with abnormal vaginal discharge x2 days. Etiology most consistent with BV based on exam and diagnostic testing. Requires continued monitoring to ensure resolution and exclude co-infection (e.g., Candida, Trichomonas, GC/CT) (Lakshmi & Amrin, 2023). Additional data justified: STI NAAT results, pH confirmation, and symptom response to treatment.
Screening for sexually transmitted infections (STI) – ICD-10: Z11.3
Health maintenance diagnosis due to unprotected sexual activity with a male partner and no prior STI history. Increased risk profile warrants routine screening (Crowley et al., 2023). UA STI panel sent. Additional recommended testing: HIV, syphilis (RPR), and repeat screening in 3–6 months, depending on results and ongoing risk.
Seizure disorder – ICD-10: G40.909 (epilepsy, unspecified, not intractable, without status epilepticus)
Chronic condition, well-controlled on levetiracetam 1000 mg BID. No reported recent seizure activity or medication noncompliance. No acute neurologic concerns during visit.
Family planning / contraceptive management – ICD-10: Z30.09
Health maintenance issue. Patient is currently sexually active with inconsistent/no reliable contraception (withdrawal method). At risk for unintended pregnancy and STI exposure (World Health Organization, 2025). Condition inadequately addressed (behavioral risk factor) requiring counseling on long-acting reversible contraception (LARC), condoms, and reproductive planning.
Health education / dietary and preventive counseling – ICD-10: Z71.3
Preventive care diagnosis addressing lifestyle counseling. BMI within normal range; counseling provided on nutrition, exercise, and STI prevention. No disease present, but ongoing preventive management is indicated.
Depression screening – ICD-10: Z13.31 / Z13.89
Screening completed with PHQ-9 score of 3, indicating minimal depressive symptoms. No functional impairment or suicidal ideation. Condition well controlled / negative screening, no further psychiatric intervention required at this time.
PLAN (P) – Shared Decision Making
Bacterial Vaginosis (N76.0)
Laboratory/Diagnostics:
Whiff test already positive
STI NAAT (GC/CT/Trich) pending
No additional labs required unless symptoms persist or worsen
Medications:
Metronidazole 500 mg PO BID x 7 days, dispense #14, no refills
Ondansetron 4 mg PO q6h PRN nausea, dispense #28, no refills
Lifestyle Modifications:
Avoid douching, scented soaps, vaginal irritants
Abstain from sexual activity or use condoms until treatment is completed.
Patient Education:
Medication adherence emphasized; complete full antibiotic course
Avoid alcohol during and 24 hrs after metronidazole
Educated on BV recurrence risk and prevention strategies
Patient Responsibility:
Report worsening symptoms (odor, pelvic pain, fever)
Notify the provider if symptoms do not improve within 3–5 days
Follow-up:
Return PRN if symptoms persist or worsen; routine follow-up in 2–4 weeks if needed.
Vaginal Discharge (N89.8)
Laboratory/Diagnostics:
Await STI results (GC/CT/Trich NAAT)
Consider HIV and RPR screening if not previously done
Patient Education:
Explained that discharge is likely related to BV, but STIs must be ruled out due to risk factors
Educated on normal vs abnormal vaginal discharge characteristics
Counseling:
Reinforced safe sex practices and condom use
Follow-up:
Review lab results when available (call/portal follow-up)
STI Exposure Risk / Screening (Z11.3)
Laboratory/Diagnostics:
GC/CT/Trich NAAT (already sent)
Recommend HIV 4th generation test and RPR for syphilis
Consultation:
No specialty referral required at this time unless positive results
Patient Education:
Education on STI prevention, condom use, and partner reduction strategies
Importance of routine screening every 3–6 months if ongoing risk
Coordination of Care:
If positive results, arrange partner notification and treatment per guidelines
Follow-up:
Follow up in 1–2 weeks for results review or sooner if symptoms worsen
Seizure Disorder (G40.909)
Medications:
Continue Levetiracetam 1000 mg PO BID, no changes
Monitoring:
No recent seizure activity reported
Patient Education:
Reinforced medication adherence and seizure trigger avoidance (sleep deprivation, alcohol)
Follow-up:
Neurology follow-up as scheduled or PRN breakthrough seizures
Family Planning / Contraception Needs (Z30.09)
Laboratory/Diagnostics:
Pregnancy test recommended if clinically indicated
Patient Education:
Counseling on LARC options (IUD, implant) and barrier protection
Discussed the failure risk of the withdrawal method
Emphasized dual protection (condoms + hormonal/LARC method)
Lifestyle Modification:
Encourage consistent condom use for STI and pregnancy prevention
Coordination of Care:
Offered referral to a gynecology and family planning clinic for contraceptive counseling/placement
Follow-up:
Reassess contraception plan at next visit or within 1 month
Preventive Health / Depression Screening (Z13.31)
Patient Education:
PHQ-9 reviewed; minimal symptoms, no intervention required
Discussed sleep hygiene strategies due to intermittent insomnia symptoms
Lifestyle Modification:
Encouraged regular sleep schedule, exercise ≥150 min/week
Follow-up:
Repeat screening annually or sooner if mood changes occur
Reflection
My “aha” moment in this encounter was recognizing how easily vaginal discharge complaints in young sexually active patients can be misinterpreted by patients as a “yeast infection or STD,” yet clinically require a structured, evidence-based approach to avoid assumptions and ensure accurate diagnosis. The key turning point was aligning the symptom pattern (thin, white discharge, mild irritation) with the positive whiff test, which strongly supported bacterial vaginosis over other etiologies. I agree with the diagnostic process and treatment regimen, particularly the use of metronidazole as first-line therapy and the inclusion of STI screening, given the patient’s risk profile, as this reflects appropriate adherence to clinical guidelines and preventive care principles. If I were to manage this case again, I would ensure a documented point-of-care pregnancy test is explicitly completed, strengthen the assessment of the reported breast symptoms noted in the ROS for consistency, and place even greater emphasis on structured contraceptive counseling earlier in the visit, including a more detailed discussion of long-acting reversible contraception options rather than focusing primarily on withdrawal method correction. I would also consider earlier reinforcement of partner treatment and sexual health communication strategies to reduce reinfection risk and improve outcomes. While the patient appears to have stable housing, insurance coverage, and family support, key concerns include high-risk sexual behavior without barrier protection, daily nicotine vaping, and potential gaps in sexual health literacy, all of which may influence recurrence risk and long-term reproductive health outcomes.
References
Crowley, J. S., Geller, A. B., & Vermund, S. H. (2023). STI screening and treatment guidelines issued by health professional societies. In
www.ncbi.nlm.nih.gov
. National Academies Press (US).
https://www.ncbi.nlm.nih.gov/books/NBK573163/
Kairys, N., & Garg, M. (2024).
Bacterial vaginosis
. Nih.gov; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK459216/
Lakshmi, Gj., & Amrin, S. (2023). Vaginal discharge: The diagnostic enigma.
Indian Journal of Sexually Transmitted Diseases and AIDS
,
0
(0), 0.
https://doi.org/10.4103/ijstd.ijstd_92_18
World Health Organization. (2025, July 3).
Family planning/contraception
. Who.int; World Health Organization: WHO.
https://www.who.int/news-room/fact-sheets/detail/family-planning-contraception
PRAC 6552 – Comprehensive History and Physical SOAP Note
Guidelines for a Comprehensive History and Physical
SOAP Note
Label each section of the SOAP note (each body part and system).
Do
not
use unnecessary words or complete sentences.
Use standard abbreviations.
SUBJECTIVE DATA (S):
(information the patient/caregiver tells you)
Includes all of the information the patient tells you. Identifying data: Initials, age, race, gender, marital status. Name of informant, if not patient.
CHIEF COMPLAINT (CC):
The reason for this health care visit. A statement describing the symptom(s), problem, condition, diagnosis, physician-recommended return, or other factors that are the reason for this patient visit (even if they bring no specific problem). If possible, use the patient’s own words in quotation marks.
HISTORY OF PRESENT ILLNESS (HPI):
If the patient presents with specific problems, symptoms, or complaints, a chronological description of the development of the patient’s present illness from the first sign of each symptom to the current visit is recorded using the elements of
a symptom analysis.
Those elements are:
Location
: Where it started, where it is located now
Quality
: Unique properties or characteristics of the symptom
Severity
: Intensity, quantity, or impact on life activities; duration: length of episode
Timing
: When symptom started, frequency (patient’s “story” of the symptom), context (under what conditions it occurs)
Setting
: Under what conditions the symptoms occur, activities that produce the symptoms
Alleviating and aggravating factors
: What makes it better and/or worse, what meds have been taken to relieve symptoms, did the meds help or not, does food make symptoms worse or better
Associated signs and symptoms
: Presence or absence of other symptoms or problems occurring with their complaint; include pertinent negatives and information from the patient’s charts (e.g., lab data or previous visit information)
In the case of a
well visit
, describe the patient’s usual health and summarize health maintenance needs and activities.
PAST MEDICAL HISTORY (PMH):
Allergies
Current medications: prescription and over the counter
Age/health status
Appropriate immunization status, including human papilloma virus (HPV) vaccine as appropriate by age.
Previous screening tests result
Dates of illnesses during childhood (may not be very important in adults; exceptions may include rheumatic fever or chronic illnesses continuing into adulthood)
Major adult illnesses (include history of diabetes, hypertension, gastrointestinal diseases, pulmonary disease, cardiovascular disease, cancer, tuberculosis, sexually transmitted infections (STIs), HIV/AIDS, gynecological or urological problems, drug and/or alcohol abuse, and psychiatric illness)
Injuries
Hospitalizations (reason, hospital, attending physician [if known])
Surgeries (include hospital and year)
FAMILY HISTORY (FH):
Age and current health status or age at death and cause of death of each family member (parents, siblings, and children) is recorded. Occurrence within the family of illnesses of an environmental, genetic, or familial nature are recorded in family history. Ask about the presence in the family of any of the following conditions: asthma, glaucoma, myocardial infarctions, heart failure, hypertension, cancer, tuberculosis, diabetes, kidney disease, hemophilia, sickle cell trait or disease, psychiatric diseases, alcoholism allergies, family violence, intellectual disabilities, epilepsy, and congenital abnormalities.
Record any specific diseases related to problems identified in CC, HPI, or review of symptoms (ROS).
SOCIAL HISTORY (SH):
Record important life events: marital status, occupational history, military service, level of education. Record lifestyle and current health habits (may be here or in ROS): exercise, diet, safety (smoke alarms, seatbelts, firearms, sports), living arrangements, hobbies, travel. Record religious preference relevant to health, illness, or treatment. Record habits: use of drugs, alcohol, and tobacco.
Resources: resources to pay for care, insurance, worries about cost of care, history of postponing care, other Social Determinants of Health (SDOH) affecting care
Reproductive Hx
: Menstrual history (date of last menstrual period [LMP]), age of menarche, cycle frequency, duration, flow (number of pads/ tampons used on heaviest day), symptoms that occur with menses (e.g., dysmenorrhea, migraine headaches), intermenstrual bleeding. Pregnancy (gravida, para), duration of pregnancy, type of delivery, complications (e.g., gestational diabetes, hypertension, preeclampsia), elective abortions, miscarriages, living children. Plan to become pregnancy in the next 12 months (yes or no), nursing/lactating (yes or no), contraceptive use, past and current (method used- satisfaction with current method), types of intercourse (oral, anal, vaginal, other), gender sexual preference, and any sexual concerns. Menopause (if applicable, use of hormone replacement therapy). Last pap smear (date and result),
REVIEW OF SYSTEMS (ROS):
There are 14 systems for review. Record a summary for each system.
Unexpected or positive findings need complete symptom analysis.
Constitutional symptoms
: Overall health, weight gain or loss, ideal weight, fever, fatigue, repeated infections, ability to carry out activities of daily living.
Eyes
: eye care, poor eyesight, double or blurred vision, use of corrective lenses or medications, redness, excessive tearing, pain, trauma, date and results of last vision screening or eye exam
Ears, nose, mouth, and throat
: Ears: hearing acuity, exposure to high noise level, tinnitus, and presence of infection or pain, vertigo, use of assistive hearing device. Nose: sense of smell, discharge, obstruction, epistaxis, sinus trouble. Mouth and teeth: use of oral tobacco or smoking cigarettes, last dental exam date and result, pattern of brushing and use of dental floss and fluoride toothpaste, dentures, bleeding of gums, sense of taste, mouth odor or ulcers, sore tongue. Throat: sore throat, hoarseness, dysphagia.
Cardiovascular
: Exercise pattern to maintain cardiovascular health. History of abnormal heart sounds (including murmur), chest pains, palpitations, dyspnea, activity intolerance, usual blood pressure, ECG (date, reason), cholesterol level (date), edema, claudication, varicose veins.
Respiratory
: Exposure to passive smoke. History of respiratory infections, usual self-treatment, cough, last chest x-ray (date, result), exposure to tuberculosis (TB) and last TB skin test (date and result), difficult breathing, wheezing, hemoptysis, sputum production (character, amount), night sweats.
Gastrointestinal
: Dietary pattern, fiber and fat in diet, use of nutritional supplements (vitamins, herbs), heartburn, epigastric pain, abdominal pain, nausea and vomiting, food intolerance, flatulence, diarrhea, constipation, usual bowel pattern, change in stools, hemorrhoids, jaundice. Date of last colorectal cancer screening (if applicable).
Genitourinary
: Nocturia, dysuria, incontinence, sexual practices, sexual difficulty, vaginal discharge and or/ pain, history of kidney stones.
Musculoskeletal
: Exercise pattern, use of seatbelts, use of safety equipment with sports, neck pain or stiffness, joint pain or swelling, incapacitating back pain, paralysis, deformities, changes in range of motion of activity, screening for osteoporosis, knowledge of back injury/pain prevention. Date of last bone density scan if applicable.
Integumentary (skin and/or breast)
: Use of skin protection with sun exposure, self-examination practices in assessing skin, general skin condition and care, changes in skin, rash, itching, nail deformity, hair loss, moles, open areas, bruising. Breast: practice of self-breast exam, lumps, pain, discharge, dimpling, last mammogram (date and result).
Neurologic
: Muscle weakness, syncope, stroke, seizures, paresthesia, involuntary movements or tremors, loss of memory, severe headaches.
Psychiatric
: Nightmares, mood changes, depression, anxiety, nervousness, insomnia, suicidal thoughts, potential for exposure to violence.
Endocrine
: Thyroid problems, cold or heat intolerance, polydipsia, polyphagia, polyuria, changes in skin, hair or nail texture, unexplained weight change, changes in facial or body hair, change in hat or glove size, use of hormonal therapy.
Hematologic/lymphatic
: Bruising, unusual bleeding, fatigue, history of anemia, last HCT and result, history of blood transfusions, swollen and/or tender glands.
Allergic/immunologic
:Seasonal allergies, previous allergy testing, potential for exposure to blood and body fluids, immunized for hepatitis B, immunosuppression in self or family member, use of steroids.
OBJECTIVE DATA:
A concise report of physical exam findings. Examples of systems and conclusions are below.
General
: (VS: Temp, BP, pulse, Ht, Wt, BMI). Well appearing, well nourished, in no distress. Oriented x 3, everyday mood and affect. Ambulating without difficulty.
Skin
: Good turgor, no rash, unusual bruising or prominent lesions
Hair: Normal texture and distribution.
Nails: Normal color, no deformities
HEENT
: Head: Normocephalic, atraumatic, no visible or palpable masses, depressions, or scaring.
Eyes: Visual acuity intact, conjunctiva clear, sclera non-icteric, EOM intact, PERRL, fundi have standard optic discs and vessels, no exudates or hemorrhages.
Ears: EACs clear, TMs translucent & mobile, ossicles nl appearance, hearing intact.
Nose: No external lesions, mucosa non-inflamed, septum and turbinates normal. Mouth: Mucous membranes are moist, and there are no mucosal lesions.
Teeth/Gums: No apparent caries or periodontal disease. No gingival inflammation or significant resorption.
Pharynx: Mucosa non-inflamed, no tonsillar hypertrophy or exudate
Neck: Supple, without lesions, bruits, or adenopathy, thyroid non-enlarged and non-tender
Heart
: No cardiomegaly or thrills; regular rate and rhythm, no murmur or gallop
Lungs:
Clear to auscultation and percussion
Abdomen
: Bowel sounds normal, no tenderness, organomegaly, masses, or hernia.
Back
: Spine normal without deformity or tenderness, no CVA tenderness
Rectal:
Normal sphincter tone, no hemorrhoids or masses palpable
Extremities:
No amputations or deformities, cyanosis, edema or varicosities, peripheral pulses intact
Musculoskeletal:
Normal gait and station. No misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions, decreased range of motion, instability, atrophy or abnormal strength or tone in the head, neck, spine, ribs, pelvis or extremities.
Neurologic:
CN 2-12 normal. Sensation to pain, touch, and proprioception regular. DTRs normal in upper and lower extremities. No pathologic reflexes.
Psychiatric:
Oriented X3, intact recent and remote memory, judgment and insight, normal mood and affect.
Pelvic:
External genitalia with symmetric labia, no visible lesions. Labia majora and minora are without erythema or masses. Clitoris is normal in appearance. Perineum intact with no visible tears or scarring. No tenderness noted upon palpation of the external genitalia. Vagina and cervix without lesions or discharge. No cervical motion tenderness. Uterus, smooth, appropriate size, mobile, non- tender, adnexa (ovaries) /parametria nontender without masses.
Breast: Symmetrical, no nipple abnormality, dominant masses, tenderness to palpation, axillary or supraclavicular adenopathy.
Results of any diagnostic testing available during patient visit.
ASSESSMENT (A):
List and number the possible diagnoses (problems) you have identified. These diagnoses are the conclusions you have drawn from the subjective and objective data.
Diagnosis must be codable (CPT codes).
Provide adequate information to justify ordering additional data (e.g., lab, x-ray).
Do not write that a diagnosis is to be “ruled out.” State the working definitions (symptoms, probable diagnoses) of patient problems in the following areas:
Health maintenance
Acute self-limited problems
Chronic health problems
In cases where the diagnosis is
already established
, indicate whether the diagnosis has the following characteristics: improved, well controlled, resolving, resolved, inadequately controlled, worsening or failing to change as expected.
Note
: Inadequately controlled chronic conditions should have a possible etiology written (e.g., exacerbation, progression, side effects of treatment) if known.
PLAN (P):
(The patient should discuss and agree on the plan.) Shared decision- making.
The treatment plan includes a wide range of management actions:
Laboratory test
Consultation requested and justification
Medications prescribed (name, dose, route, amount, refills)
Appliances prescribed
Lifestyle modifications: diet, activity modification
Patient education and patient responsibilities (e.g., keeping food diary or BP record)
Patient counseling related to lab/diagnostic results, impression, or recommendations
Family education
Details concerning coordination of care: arranging and organizing patient’s care with other providers and agencies
Follow-up should be specified with time (in days, weeks, months) and/or circumstances of return or noted as PRN
Note: Number the plan to correlate with the problem list in the Assessment.
Include your reflection per the assignment rubric
Include references per the assignment rubric
Allowed Attempts
2
Back to Week at a Glance
Comprehensive Well-Woman Paper
For a wide variety of medical conditions, early detection of the problem enables timely and more effective treatment. Annual well-woman
exams are among the best tools available for health care professionals to identify potential diseases and medical conditions in women.
Advanced nurse practitioners can play an active role in these important visits. This role can include a physical examination as well as collection of details about such factors as nutrition habits, sexual activity, stress, and more. By participating in comprehensive well-woman exams, advanced nurse practitioners can help patients engage in preventative health.
For this Assignment, you will complete your well-woman exam using a focused note format in which you will gather patient information, relevant diagnostic and treatment information and reflect on health promotion and disease prevention in light of patient factors, such as age, ethnic group, past medical history (PMH), socio-economic status, cultural background, etc.
Note
: All Focused Notes must be signed, and each page must be initialed by your preceptor. When you submit your Focused Notes, you should include the complete Focused Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your Focused Notes using Turnitin.
Note
: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.
Resources
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
WEEKLY RESOURCES
tO prepare
Reflect on your practicum experience and select a female patient whom you have examined with the support and guidance of your Preceptor.
Think about the details of the patient’s background, medical history, physical exam, labs and diagnostics, diagnosis, and treatment and management plan, and education strategies and follow-up care.
Use the “Guidelines for Comprehensive History and Physical SOAP Note” document found in this week’s Learning Resources to guide you as you complete this Assignment.
Assignment:
Write an 8- to 10-page Comprehensive Well-Woman Paper that addresses the following:
Age, race and ethnicity, and partner status of the patient
Current health status, including chief concern or complaint of the patient
Contraception method (if any)
Patient history, including medical history, family medical history, gynecologic history, obstetric history, and personal social history (as appropriate to current problem)
Review of systems
Physical exam
Labs, tests, and other diagnostics
Differential diagnoses
Management plan, including diagnosis, treatment, patient education, and follow-up care
Provide evidence-based guidelines to support treatment plan.
Note
: Use your Learning Resources and evidence from scholarly sources from your personal search to support your treatment plan of care.
Reflection
Reflect on some additional factors for your patient:
What are implications if you have observed or know of some domestic violence? Would this change your plan of care? If so, how?
Use your Learning Resources and evidence from scholarly sources from your personal search to support your reflection.
Reminder
Links to an external site.
: The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at http://writingcenter.waldenu.edu/57.htm).
Note
: Your Comprehensive Well-Woman Paper must be signed by Day 7 of Week 10.
By Day 7
Submit
your Comprehensive Well-Woman Paper
by Day 7
. (
Note
: You will submit two files, your Comprehensive Well-Woman Paper, and a Word document of pdf/images of each page that is initialed and signed by your preceptor by Day 7 of Week 10.)
submission information
Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the
Turnitin Drafts
from the
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area.
To submit your completed assignment, save your Assignment as
WK10Assgn2_LastName_Firstinitial
Then, click on
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near the top of the page.
Next, click on
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and select
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for review.
Rubric
PRAC_6552_Week10_Assignment2_Rubric – PRAC 6552 – Comprehensive History and Physical SOAP Note
PRAC_6552_Week10_Assignment2_Rubric
Criteria
Ratings
Pts
This criterion is linked to a Learning OutcomeWrite an 8- to 10-page Comprehensive Well-Woman Exam that addresses the following: • Age, race and ethnicity, and partner status of the patient• Current health status, including chief concern or complaint of the patient• Contraception method (if any) • Patient history, including medical history, family medical history, gynecologic history, obstetric history, and personal social history (as appropriate to current problem) • Social Determinants of Health assessment• Review of systems• Physical exam• Labs, tests, and other diagnostics• Differential diagnoses• Management plan, including diagnosis, treatment, patient education, and follow-up care• Provide evidence-based guidelines to support treatment plan.
45 to >40.0 ptsExcellent
All required points are addressed, with results that are presented fully and clearly … Provides 5 current and credible scholarly sources to support the treatment plan of care.
40 to >35.0 ptsGood
At least 8 points are addressed with results that are presented clearly. … Provides at least 4 current and credible scholarly sources to support the treatment plan of care.
35 to >34.0 ptsFair
No fewer than 7 points are addressed. One or more results presented in a manner that is vague or incomplete. … Provides at least 3 current and credible scholarly sources to support the treatment plan of care.
34 to >0 ptsPoor
Fewer than 7 points are addressed. One or more results are presented in a manner that is vague, incomplete, or inaccurate. … Provides at least 2 current and credible scholarly sources to support the treatment plan of care.
45 pts
This criterion is linked to a Learning OutcomeReflect on the following: Reflect on some additional factors for your patient: • What are implications if you have observed or know of some domestic violence? Would this change your plan of care? If so, how?
40 to >39.0 ptsExcellent
Reflection is clearly presented, with implications that are well-formed, clear, and fully expressed. … Provides at least 3 current and credible scholarly sources to support reflection.
39 to >31.0 ptsGood
Reflection is clearly presented, with implications that are clearly expressed. … Provides at least 3 current and credible scholarly sources to support reflection.
31 to >30.0 ptsFair
Reflection is presented in manner that is vague or unclear. Implications are not fully or clearly expressed. … Provides at least 2 current and credible scholarly source to support reflection.
30 to >0 ptsPoor
Reflection is presented in manner that is vague or unclear. Implications are unclear, or one or both implications not expressed. … Provides at least 1 current and credible scholarly source to support reflection.
40 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction is provided which delineates all required criteria.
5 to >4.0 ptsExcellent
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. … A clear and comprehensive purpose statement, introduction, and conclusion is provided which delineates all required criteria.
4 to >3.5 ptsGood
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. … Purpose, introduction, and conclusion of the assignment is stated, yet is brief and not descriptive.
3.5 to >3.0 ptsFair
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60–79% of the time. … Purpose, introduction, and conclusion of the assignment is vague or off topic.
3 to >0 ptsPoor
Paragraphs and sentences follow writing standards for flow, continuity, and clarity <60% of the time. … No purpose statement, introduction, or conclusion was provided.
5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation
5 to >4.0 ptsExcellent
Uses correct grammar, spelling, and punctuation with no errors.
4 to >3.5 ptsGood
Contains a few (1 or 2) grammar, spelling, and punctuation errors.
3.5 to >3.0 ptsFair
Contains several (3 or 4) grammar, spelling, and punctuation errors.
3 to >0 ptsPoor
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/in-text citations, and reference list.
5 to >4.0 ptsExcellent
Uses correct APA format with no errors.
4 to >3.5 ptsGood
Contains a few (1 or 2) APA format errors.
3.5 to >3.0 ptsFair
Contains several (3 or 4) APA format errors.
3 to >0 ptsPoor
Contains many (≥5) APA format errors.
5 pts
Total Points: 100