SAMPLE MINI-SOAP NOTE
Patient Demographics:
Race: Hispanic Sex: Female Marital Status: Single. Age: 21 years
CC: prenatal follow up
Subjective:
21 yo G2 P1001 at 14.4 weeks by lmp c/w 11 week ultrasound presents to clinic for prenatal follow up
She has yet to endorse active fetal movement
She denies vaginal bleeding, loss of fluid, abdominal pain / uterine contractions
She reports the following symptoms: none
She had her FTS and NT ultrasound previously completed – results negative x 2
Objective:
Vitals: BP 121/69 weight: 138lbs P 73 T 98.5
Urine: ( – ) glucose / ( – ) protein / ( – ) blood / ( + ) leukocytes / ( +) nitrites / SG: 1.020
FH: 13weeks
FHT: 156bpm by doppler
Abdomen: ( – ) Suprapubic tenderness / ( – ) CVAT
Cervical exam: NA
Edema: negative
Assessment:
1. Supervision other normal pregnancy, second trimester (IUP at 14.4 weeks)
2. 14 weeks gestation
3. +nitrites, r/o urinary tract infection
Plan:
Dx:
•
•
Th:
•
Edu:
•
•
•
F/U:
•
Level II anatomy scan ordered (or can be ordered at next visit)
urine culture ordered
will treat empirically for +nitrites with Macrobid 100mg BID x 7 days (will notify patient if
alternative therapy indicated)
FTS + NT ultrasound negative x 2 – reviewed results with patient
Increase water intake, perineal hygiene reviewed
SAB precautions reviewed
rtc in 4 weeks, prn — STS to be drawn at next visit
SAMPLE MINI-SOAP NOTE
Patient Demographics
Race: Black / African-American Sex: Female Marital Status: Single. Age: 33 years
CC: contraception – depo provera
Subjective
33 yo F presents to clinic to initiate depo provera for contraception
She is sexually active and reports having 1 male partner. Condom use 50% of the time
she has used depo in the past and was pleased with method
she denies any unprotected intercourse within the past 2 weeks
she denies any significant medical conditions
she is declining STI screening
Objective:
Vitals: BP 134/85 Weight 146 P 86 RR 16 T 97.9 BMI 33.5
Urine pregnancy test: negative
Gen: well appearing, obese
Psych: appropriate mood, affect
Assessment:
Depo provera initiation
Plan:
Dx:
•
Th:
•
Edu:
•
•
•
•
•
F/u:
•
•
none / declined STI screening
Depo provera 150mg IM x 1 now
side effects, risks, benefits of depo reviewed
Discussed most common side effects associated with use including but not limited to: irregular
spotting, absent menses, increased weight gain, possibility of decreased bone density
Condoms encouraged
patient handout for depo provera given to patient
abstain from intercourse for 7 days or back up method x 7 days encouraged
rtc in 3 mos, prn for next depo injection or alternative contraception method
pap smear encouraged
SAMPLE PROBLEM-FOCUSED SOAP NOTE
Patient Demographics
Race: Caucasian. Sex: Female. Marital Status: Married. Age: 28 years
CC: Vaginal Discharge
HPI:
Screening for Depression:
PHQ 2: In the last two weeks have you been bothered by:
Little interest or pleasure in doing things: No
Feeling down, depressed, or hopeless: No
26 yo F presents to clinic for vaginal infection check
She states that she has had vaginal discharge x 4 months, increasing in amount for the past month. She
describes the discharge as brown in color and malodorous
She reports intermittent pelvic discomfort with intercourse and notes that sometimes she has minimal
vaginal bleeding after intercourse
She denies vaginal ulcers, itching
She reports unknown alleviating factors
She states that symptoms are similar to a bacterial vaginal infection that she has had in the past
She is sexually active with 1 male partner, husband x 4 years.
Contraception: none, seeking pregnancy
Last CT / HIV screening: 05/2018 – negative per patient
LMP: 08/31/2018
Current Medications: prenatal vitamins
PMH: unremarkable
Surgical History: denies past surgical history
Family History:
• Father: alive, 55yrs, HTN, HLD
• Mother: alive, 52yrs, HLD
Gyn History:
• LMP: 08/31/2018
• Menses: every 28 days
• Menarche: age 12
• Contraception: seeking pregnancy
• Pap smear: 03/2014, normal per patient
OB History: G0
Social History:
• Occupation: full-time college student
• Alcohol: denies
• Smoking: never smoker
Sexual history:
• Gender identity: female
• Sexual orientation: straight
•
•
•
Preferred pronoun: she, her
Current partners: 1 male partner x 4 years
History of STIs: denies
ROS:
General: denies changes in diet or weight; denies fever, chills, night sweats, or recent illness
Respiratory: denies difficulty breathing; denies cough
Cardiac: denies chest pain, palpitations, or cyanosis
Breast: denies pain, lumps, rashes, or discharge; performs monthly SBE
GI: denies abdominal pain or cramping; denies nausea, vomiting
GU: See HPI
Objective
Vitals: BP 111/80 P 79 RR 22 T 98.5 Weight: 176 BMI: 28.4
General: no apparent distress, overweight, able verbally communicate
Cardiac: regular rate and rhythm; no murmurs
Lungs: clear to auscultation bilaterally at bases
GU/Pelvic Exam:
• External genitalia: no lesion, masses
• Vagina: thin, homogenous grey discharge, malodorous, pH: 6.0
• Cervix: erythematous, friable, pap smear performed (spatula and cytobrush), CT / GC probe
used for STI screening; wet mount collected
• Uterus: posterior, non-tender
• Adnexa: non-palpable
Differential Diagnosis:
• Bacterial vaginosis
o Pertinent positives: malodorous vaginal discharge, vaginal pH 6.0, thin homogenous
grey discharge
o PATHOPHYSIOLOGY TO BE DOCUMENTED BY STUDENT
• Cervical cancer:
o Pertinent positives: thin discharge with odor, pain with intercourse / dyspareunia, post
coital bleeding
o PATHOPHYSIOLOGY TO BE DOCUMENTED BY STUDENT
• Cervicitis:
o Pertinent positives: erythematous cervix, discharge
o PATHOPHYSIOLOGY TO BE DOCUMENTED BY STUDENT
Assessment
• Bacterial Vaginosis
• Cervicitis
• Screening for cervical cancer
• Postcoital bleeding
• Dyspareunia
•
Screening for sexually transmitted disease
Plan
Dx:
•
•
•
•
Th:
•
•
wet mount
GC / GC probe
HIV / RPR
Cytology
Bacterial vaginosis:
o will treat based on 3 out of 4 criteria: rx metronidazole 500mg PO BID x7days #14
Cervicitis:
o Will treat: rx azithromycin 1gm PO x 1 now
Education:
• Bacterial vaginosis: educated patient about bacterial vaginosis diagnosis, treatment, and
prevention. Encouraged to abstain from any alcohol consumption for 24 hrs before and after
completion of treatment. Avoid intercourse for 7 days. Patient handout provided
• Cervicitis: educated patient about cervicitis diagnosis, treatment, and prevention. Patient
handout provided. Condoms encouraged. Routine STD screening encouraged
• Pap smear: recommendation for routine pap smear every 3 – 5 years, based on age, history, and
risk factors
• Seeking pregnancy: continue prenatal vitamins, healthy diet encouraged
Follow-up:
• rtc in 2 weeks, prn for lab results
• consider pelvic ultrasound / imaging if symptoms continue post treatment / at next visit
Health maintenance:
• breast self-awareness encouraged
• routine pap smear screening encouraged
• flu shot encouraged
References
TO BE IN APA FORMAT BY STUDENT
Case Scenario 1
Table 1
Standard level of HCG during pregnancy.
GA weeks
HCG level
3 weeks LMP
4 weeks LMP
5 weeks LMP
6 weeks LMP
7-8 weeks LMP
9-12 weeks LMP
13-16 weeks LMP
17-24 weeks LMP
25-40 weeks LMP
Non pregnant
Table 2
Scenario
A normal ongoing pregnancy, the expectation for the
beta HCG level is to _____ (hint: increase by how much)
within 48-72 hours
During a spontaneous abortion (miscarriage), the
expectation for the beta HCG level is to ____ (hint:
decrease by how much) within 48-72 hour
During an ectopic pregnancy, the expectation for the
beta HCG level is to ____ within 48-72 hour
During a gestational trophoblastic pregnancy, the
expectation for the beta HCG level is to ____ within 4872 hour
Table 3
Common complaints during pregnancy.
Keep in mind these symptoms are during pregnancy, make sure the cause,
presentation, and treatment is related to pregnancy status of the patient.
Definition
and Cause
Presentation Treatment
(include
possible DDX)
Education
Constipation
Back pain
GERD
Fatigue
Heart palpitations
Urinary frequency
Nausea and
Vomiting
Round ligament
pain
Hyperpigmentation
Sleep disturbance
Tonia is an 18-year-old female who presents to your office complaining of two
months of amenorrhea. Her pregnancy test is positive and her LMP indicates she
is 5.6 weeks EGA. She reports she has had some bleeding for the past 3 days, that
started as spotting, but has continued to be a light period- like bleeding today. She
denies any pain. She indicates plans to continue the pregnancy.
1. Subjective:
a. What other relevant questions should you ask regarding the HPI?
b. What other medical history questions should you ask?
c. What other social history questions should you ask?
2. Objective:
a. Describe all elements of the head-to-toe assessment you will perform
for her initial prenatal visit
b. Explain what test(s) you will order and perform, and discuss your
rationale for ordering and performing each test.
3. Assessment/ Diagnosis:
a. What are your presumptive and differential diagnoses, and why?
b. Any other diagnosis or differential diagnosis you would like to add?
c. Assume you ordered an HCG today and the result was 1200. She
returns to the clinic in 2 days and her HCG results is 550. What would
be her diagnosis?
4. Plan:
a. How will you explain the HCG results to your patient?
b. Explain treatment guidelines and side effects including any possible
side effects of the medication and treatment(s), partner notification,
and follow-up plan of care.
c. What patient education is important to include for this patient?
(Consider when can the patient resume sexual activity, birth control
options, when she can resume trying to conceive again).
Provide evidence from the research to support your decision-making.
