Soap
K.F. 37 F,
S.
CC Well Exam, ongoing fatigue, stress, issues falling asleep and staying asleep, and
financial concerns.
HPI: K.F. presents today with complaints of ongoing fatigue, stress, and financial
concerns. Reports difficulties falling and staying asleep. She states being stressed and
having to move in with her parents and currently shares a room with her two younger
children. K.F. recently separated from her spouse and states there is an impending
divorce. She also reports not having a menses since giving birth of her last child
O – Symptoms started when she moved in with her parentsL –GeneralizedD – Every
night C – Has trouble falling asleep and staying asleepA – Stress and sleeping in same
room with two younger children, ongoing divorceR- None T –Advil PM every night and
drinks a glass of wine.
Current Meds: Advil PM 200 mg/38 mg 1 CAP PO Nightly
Allergies: No allergies
PMHx: Denies medical history other than four pregnancies, three births, one pre-term.
Had one miscarriage at 10 weeks when she was 16. Reports PCOS as a teenager and has
irregular menses. Diagnosed with gestational diabetes with last birth and preeclampsia.
Had two C-sections.
Social History: Currently going through a divorce and recently moved in with her
parents. She was a 15 year smoker of 1PPD up until 18 months ago. She drinks 1 glass of
wine a night. She does not routinely exercise. She often skips breakfast and lunch and
eats a quick, often processed dinner. She is not currently sexually active and has been
abstinent for the last 6 months.
Family History: Mother has history of hypertension, hyperlipidemia, Type 2 DM,
glaucoma and breast cancer at age 50 treated with lumpectomy. Father has history of
hypertension, hyperlipidemia and MI with stenting 5 years ago. She has two siblings who
are in good health. She has had other family members die of old age.
CONSTITUTIONAL: No weight loss, fever, chills, (-) weakness, (-) fatigue.
HEENT: Eyes: (-) visual loss, (-) decreased night vision, blurred vision, double vision or
yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or
sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No
palpitations (-) BLLE edema.
RESPIRATORY: (-) shortness of breath, cough or sputum.
, GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain
or blood.
GENITOURINARY: No Burning on urination. tenderness to palpation in the super-pubic
area
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or
tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or
polydipsia.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
O: V/S: Height: 160 cm, Weight: 67 kg. B/P: 140/76, HR: 82, T: 98.7, Resp: 16, SpO2:
97%
Physical Exam:
General: Awake, alert, appropriate; well groomed; tearful at times throughout the exam;
skin: warm, dry, intact; HEENT: head normocephalic; Conjunctiva clear, non-icteric,
PERRLA, EOM’s intact; tympanic membranes intact, unremarkable; nares patent with
pink, moist, intact inferior and medial turbinates; pharynx unremarkable tonsils 2/4 bil;
neck supple w/o lymphadenopathy or thyromegaly.
Cardiopulmonary: Heart RRR w/o murmur; lungs CTA throughout; respirations even and
unlabored.
Breast Exam: Breasts of normal development bil. Areola unremarkable. Nipples without
discharge or tenderness. No masses or tenderness upon palpation
Abdomen: abdomen, soft, with normoactive bowel sounds throughout; tenderness to
palpation in the super-pubic area; no masses or organomegally; peripheral pulses reg.,
equal
External Genitalia: Mons intact with normal hair distribution, labia majora, minora,
clitoris intact, Bartholin’s and Skene’s glands. Intact. No piercings. No hymen.
Vagina: Pink, moist, with rugae, no odor, tone good. No rectocele, cystocele, or
discharge.
Cervix: pink with multi-parous patent os, no lesions, sl. anterior and freely mobile
without tenderness.
Uterus: small, firm, pear shaped, midline, smooth, mobile, and non-tender uterus non-
tender uterus. Adnexae: present, smooth, non-tender.
A: Assessment:
K.F. 37 F,
S.
CC Well Exam, ongoing fatigue, stress, issues falling asleep and staying asleep, and
financial concerns.
HPI: K.F. presents today with complaints of ongoing fatigue, stress, and financial
concerns. Reports difficulties falling and staying asleep. She states being stressed and
having to move in with her parents and currently shares a room with her two younger
children. K.F. recently separated from her spouse and states there is an impending
divorce. She also reports not having a menses since giving birth of her last child
O – Symptoms started when she moved in with her parentsL –GeneralizedD – Every
night C – Has trouble falling asleep and staying asleepA – Stress and sleeping in same
room with two younger children, ongoing divorceR- None T –Advil PM every night and
drinks a glass of wine.
Current Meds: Advil PM 200 mg/38 mg 1 CAP PO Nightly
Allergies: No allergies
PMHx: Denies medical history other than four pregnancies, three births, one pre-term.
Had one miscarriage at 10 weeks when she was 16. Reports PCOS as a teenager and has
irregular menses. Diagnosed with gestational diabetes with last birth and preeclampsia.
Had two C-sections.
Social History: Currently going through a divorce and recently moved in with her
parents. She was a 15 year smoker of 1PPD up until 18 months ago. She drinks 1 glass of
wine a night. She does not routinely exercise. She often skips breakfast and lunch and
eats a quick, often processed dinner. She is not currently sexually active and has been
abstinent for the last 6 months.
Family History: Mother has history of hypertension, hyperlipidemia, Type 2 DM,
glaucoma and breast cancer at age 50 treated with lumpectomy. Father has history of
hypertension, hyperlipidemia and MI with stenting 5 years ago. She has two siblings who
are in good health. She has had other family members die of old age.
CONSTITUTIONAL: No weight loss, fever, chills, (-) weakness, (-) fatigue.
HEENT: Eyes: (-) visual loss, (-) decreased night vision, blurred vision, double vision or
yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or
sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No
palpitations (-) BLLE edema.
RESPIRATORY: (-) shortness of breath, cough or sputum.
, GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain
or blood.
GENITOURINARY: No Burning on urination. tenderness to palpation in the super-pubic
area
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or
tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or
polydipsia.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
O: V/S: Height: 160 cm, Weight: 67 kg. B/P: 140/76, HR: 82, T: 98.7, Resp: 16, SpO2:
97%
Physical Exam:
General: Awake, alert, appropriate; well groomed; tearful at times throughout the exam;
skin: warm, dry, intact; HEENT: head normocephalic; Conjunctiva clear, non-icteric,
PERRLA, EOM’s intact; tympanic membranes intact, unremarkable; nares patent with
pink, moist, intact inferior and medial turbinates; pharynx unremarkable tonsils 2/4 bil;
neck supple w/o lymphadenopathy or thyromegaly.
Cardiopulmonary: Heart RRR w/o murmur; lungs CTA throughout; respirations even and
unlabored.
Breast Exam: Breasts of normal development bil. Areola unremarkable. Nipples without
discharge or tenderness. No masses or tenderness upon palpation
Abdomen: abdomen, soft, with normoactive bowel sounds throughout; tenderness to
palpation in the super-pubic area; no masses or organomegally; peripheral pulses reg.,
equal
External Genitalia: Mons intact with normal hair distribution, labia majora, minora,
clitoris intact, Bartholin’s and Skene’s glands. Intact. No piercings. No hymen.
Vagina: Pink, moist, with rugae, no odor, tone good. No rectocele, cystocele, or
discharge.
Cervix: pink with multi-parous patent os, no lesions, sl. anterior and freely mobile
without tenderness.
Uterus: small, firm, pear shaped, midline, smooth, mobile, and non-tender uterus non-
tender uterus. Adnexae: present, smooth, non-tender.
A: Assessment:
