Sie sind auf Seite 1von 11


SOAP: Older Well Woman

Minnie Mouse 56-year-old Caucasian Woman DOB 1/1/1956


Subjective Chief Complaint(s) Presents for an annual physical and Pap Smear and to discuss left wrist, and right toe pains. HPI Wrist/Hand The patient has experienced intermittent pain in the left distal medial wrist for about 6 months. Edema noted intermittently. She has treated with Ibuprofen, 800 mg, with some relief. No use of heat or ice. Ankle/Foot The patient has experienced pain in 2nd digit right foot for approximately 6-8 months, which happens with walking or at rest. Ibuprofen 800 mg has brought some relief. No edema or erythema. Current Medications y y y y y y y y y Fish oil 1000mg 2 capsules daily Celexa 40 mg tablet daily Zinc 50 mg 1 tablet daily Vitamin C 500 mg tablet 2 tab daily Ziac 10 mg-6.25 mg tablet 1 tab(s) 2 times per day Calcium 600+D 600 mg-200 units tablet 1 tablet daily Ferrous sulfate 325 mg tablet 2 tabs daily Multivitamin-- Multiple Vitamins capsule 1 cap(s) daily Vitamin D 2000 units 1 daily

Medical History


y y y

Depression HTN Colon polyps; colonoscopy 10/2009, to be repeated in one year

Allergies/Intolerance N.K.D.A. Immunizations y y y Influenza-2011 Pneumococcal-never Tetanus-over 10 years

Gynecological History y y y y Menarche at age 14 Date of Last Period 02-07-2012 Last pap smear date 3/2011; negative Periods : Every 28 days; flows heavy for first 3 days then lightens up and flows for 3-4 days, lots of clots; has been more irregular lately y y y y Sexual activity: Not currently sexually active. STD history: None Last mammogram date: 11/2010. Monthly Self Breast Exam: yes

OB History y y Total pregnancies: 3 Total live births: 3

Surgical and Hospitalization History


y y y y y

C-Section: 1990 Vaginal delivery: 1977, 1987 Appendectomy: 1975 Surgery: Pin placed in left leg from go cart accident resulting in fractured tibia, 1971 Tonsillectomy and adenoidectomy: 1969

Family History y y y y y y y y Father: Deceased, at 46 yrs of kidney failure Mother: Alive, Osteoarthritis, hip replacement, knee replacement Sister: Deceased at 46 yrs, ovarian cancer Brother: Alive, HTN Paternal Grand Father: Deceased, unknown Paternal Grand Mother: Deceased, unknown Maternal Grand Father: Deceased, leukemia Maternal Grand Mother: Deceased, history of Osteoarthritis

Social History y y y y y y y y Occupation: data entry Marital Status: widowed Children: 3 Tobacco use: never smoked Alcohol: denies Recreational drug use: denies Safety: wears seatbelt regularly Caffeine Intake: thermos of coffee daily


y y ROS

Exercise program: walks at work, no cardio Last eye exam in 2010; last dental exam in 2011

Nutrition Negative for unintentional weight change, trouble chewing or swallowing Neurological Reported headaches last week with recorded elevated blood pressure, no numbness or tingling in hands or legs. Integumentary No non-healing wounds or rashes Ophthalmology No significant changes in vision. Wears glasses. Cardiology History of hypertension. Negative for ankle or pedal edema. Positive for palpitations intermittently, doesn't last long. Respiratory Negative for dyspnea, wheezing or cough. Gastroenterology Negative for diarrhea, constipation, or heartburn. Urology Negative for pain with urination, difficulty urinating or incontinence. GYN Negative for abnormal discharge, odor, or unusual bleeding.


Objective Vitals Ht 69.5, Wt 280.8, BMI 40.87, HR 64, BP 160/88 large cuff R, Pain scale 0/10, General Examination General Appearance NAD, pleasant. No suicidal ideations, desires to hurt self or others. HEENT Head: NC/AT, tympanic membranes normal with landmarks visible. PERRLA, turbinates normal, moist membranes, no sinus tenderness, pharynx without erythema or edema. Neck: Supple, no lymphadenopathy, no thyroidmegaly, no carotid bruit. Fundoscopic: unable to view due to cataracts Heart No murmurs, regular rate and rhythm, S1, S2. No rubs or gallops. Lungs Clear to auscultation bilaterally; no wheezes/rhonchi/rales. Abdomen Soft, NT/ND, BS present, no masses palpated, no hepatosplenomegaly. No aortic enlargement or bruit auscultated. Neurologic Exam Reflexes intact bilaterally. Skin Normal, no rash, dry patches noted to extremities.


Extremities ` No edema in LE bilaterally.

Muscoloskeletal 2nd digit right foot without erythema or edema, no tenderness with palpation; mild edema ant. distal med. aspect left wrist. full rom left wrist. Peripheral pulses PT normal (2+) bilaterally, radial pulses, normal (2+) bilaterally. Back No CVA tenderness. Spine midline without curvature. Breasts No palpable masses bilaterally, or axillary lymphadenopathy. Polypoma appearing at 7 o'clock of the right nipple. Female Genitourinary Normal external genitalia. Vagina-light pink moist mucosa, slight atrophy appreciated, no lesions or abnormal discharge. Cervix-no discharge or lesions or CMT. Adnexa-no masses or tenderness. Uterus nontender and normal size on palpation. Rectal Sphincter tone good, no stool, hemoccult card negative, external hemorrhoids, mild.

Assessment Exam Gynecological - V72.31 HTN [Hypertension] - 401.9 Depressive disorder NEC - 311


Obesity 278.00 External hemorrhoids 455.5 Over use injury left wrist 726.4 Concern (about increased risk, cancer, other genetic condition) V61.49

Plan EKG for reported history of palpitations and baseline Lab y y y y y CA-125 per patient family history CBC with differential Comprehensive metabolic (Fasting) Urinalysis Lipid Panel (already drawn last year)

Blood Pressure Check blood pressure twice weekly. Blood pressure wallet card given to patient Medication y y y y y y y Continue use of Ibuprofen for pains in wrist and toe, if increases RTC Continue Ziac tablet, 10 mg-6.25 mg, 1 tab(s), orally, 2 times a day Start lisinopril tablet, 20 mg, 1 tab(s), orally, once a day Continue Celexa Tablet, 40 mg, 1QD orally, once a day Continue Vitamin D, 2000 units, 1 daily, orally, once a day Continue multivitamin capsule, Multiple Vitamins, 1 cap(s), orally, once a day Continue ferrous sulfate tablet, 325 mg, 2 tabs, orally, once a day


y y y y

Continue Calcium 600+D tablet, 600 mg-200 units, 1 tablet, orally, once a day Continue Vitamin C tablet, 500 mg, 2 tab, orally, once a day Continue Zinc, 50 mg, 1 tablet, once a day Continue fish oil, 1000mg, 2 capsules, daily

Immunizations Tdap >10 years Influenza 10/2011 Preventive Medicine y y y y y Schedule colonoscopy today Schedule Mammogram today Schedule optometrist visit today Schedule appt. with nutritionist Discussed possible physical therapy for over use injury, pt does not want to do it at this time. Order for wrist brace given to patient y TDAP today

Counseling y y y y y y Seatbelts: recommended continued regular use Diet: all 4 food groups reviewed. Increase fruits and vegetables, decrease portion sizes Referral to nutritionist for diet and food intake planning Exercise: encourage moderate exercise 5 days a week. Breast self-exam/self-awareness encouraged. Encouraged to do pneumococcal vaccine, written information given, declined today.


Next Appointment The patient should return in 4 Weeks for hypertension medication check.



Domino, F.J., Baldor, R.A., Golding, J., Grimes, J.A., & Taylor, J.S. (Eds.). (2012). The 5 Minute Clinical Consult 2012. Philadelphia, PA: Lippencott Williams & Wilkins. Hawkins, J.W., Roberto-Nichols, D.M., Stanley-Haney, J.L. (2011). Guidelines for Nurse Practitioners in Gynelogic Settings (10th ed.). New York, NY: Springer Publishing Company, LLC. United States Department of Health and Human Services. (2004). National High Blood Pressure Education Program. Retrieved from