SAOP Note

SAOP Note

 

This is a SOAP Note from 2019, in need of revision to 2022. Item will be uploaded. Thank you.

 

SOAP NOTE: NSG 6020 Week 6
Name: K. R. Date: 2/19/2019 Time: 9:20 a.m.
Age: 25 Sex: Female
SUBJECTIVE
CC:
“I have a bump in my left groin”
HPI:
This is a 25-year-old female here with complaint of painful bump in L groin area since
yesterday. Denies fever, chills, sore throat, cough, or difficulty breathing. Denies chest
pain, abdominal pain, nausea, diarrhea, or difficulty with urination. She denies resting
SOB, dizziness, palpitations, syncope or swelling. She denies any skin changes, rash, or
suspicious lesions. She denies insect bite, recent medication, exposure to poison ivy or
poison oak.
Medications: None
PMH
Allergies: NKDA
Medication Intolerances: None
Chronic Illnesses/Major traumas: None.
Hospitalizations/Surgeries: Tonsillectomy.
Family History
Patient is adopted
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Social History – Smoker: Never. Alcohol: Socially. Occupation: Waitress. No children. She
is sexually active at this time and is worried that the bump in her groin might be from an
STD. Patient denies vaginal discharge or odor.
ROS
General
No fatigue, fevers, chills, sweats, anorexia,
weight loss, malaise.
Cardiovascular
Denies chest pain, palpitations, syncope,
dyspnea on exertion, orthopnea, PND,
peripheral edema.
Skin
Denies rash, itching, dryness, skin
discoloration, or suspicious lesions or
moles.
Respiratory
Denies cough, wheezing, dyspnea,
excessive sputum, hemoptysis or history of
TB.
Eyes
Denies blurring, diplopia, irritation,
discharge, vision loss or changes, eye pain,
photophobia.
Gastrointestinal
Denies N/V/D or abdominal pain,
constipation, hepatitis, hemorrhoids, eating
disorders, ulcers, black tarry stool.
Ears
Denies hearing difficulty, ear pain, ear
discharge, or tinnitus.
Genitourinary/Gynecological
Denies dysuria, frequency, burning,
hematuria, retention or incontinence.
Urgency, frequency burning, or change in
color of urine. Reports she is sexually
active.

Nose/Mouth/Throat
Denies sore throat, hoarseness, dysphagia,
sinus problems, nose bleeds or discharge,
dental disease, or throat pain.
Musculoskeletal
Denies joint pain, swelling, stiffness, back
pain, recent injury.
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Breast:
N/A
Neurological
Denies weakness, paresthesia, seizures,
tremors, or transient paralysis.
Heme/Lymph/Endo
Denies abnormal bruising or bleeding.
Denies swelling to extremities. Denies
enlarged lymph nodes. Reports HIV status
negative. Denies blood transfusion hx,
night sweats, increase thirst, increase
hunger, cold or heat intolerance
Psychiatric
Denies depression, memory loss, mental
disturbance, suicidal ideation
hallucinations, paranoia.
OBJECTIVE
Weight: 142 BMI: 36.01 Temp: 98.7 BP: 154/99
Height: 66” Pulse: 81 Resp: 14
General Appearance – This is a very pleasant 25 year old female, with normal affect but
with a little anxiety about the bump in her groin.
Skin:
Warm and dry. Skin pink. No bruising, rashes or redness noted.
HEENT
Head- is normocephalic, no facial tenderness
Eyes -PERRLA, Sclera white.
Ears- External canals clear, no excessive cerumen, tympanic membrane pearly gray, no
redness or bulging.
Nose- Moist, no drainage, septum midline, nasal mucosa pink and normal turbinates.
Mouth- no tonsil enlargement, pharynx is unremarkable. No lesions, or exudate. Some
dental decay noticed in front upper teeth.
Neck – Supple, no JVD, no masses or nodules noted on thyroid. Full ROM; no cervical
lymphadenopathy; no occipital nodes.
Cardiovascular
S1, S2 with regular rate and rhythm. No extra sounds, clicks, or rubs. Murmur heard.
Capillary refill 2 seconds. Carotid pulses are 2+ and without bruits. No edema.
Respiratory:
Symmetric chest wall. Lungs clear to auscultation bilaterally, respirations regular and
non-labored, no wheezing or tactile fremitus
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Gastrointestinal
Abdomen soft and nontender, no organomegaly, active bowel sounds all quadrants. No
hernia or distension.
Breast
N/A
Genitourinary
No bladder tenderness, vaginal discharge, or lesions. Patient does have left inguinal
lymphadenopathy with tenderness upon palpation. No suprapubic pain.
Musculoskeletal
Full ROM in all extremities, No deformities or tenderness of upper or lower extremities.
Neurological
Alert and oriented x 4, speech clear, gait steady with no shuffling or ataxia. Normal
function of cranial nerves and normal sensation bilaterally. Speech clear. Good tone.
Posture erect.
Psychiatric
Patient is calm and cooperative.
Lab Tests:
Pelvic exam performed. UA performed in office with no leukocytes, nitrites, or bacteria.
Gonorrhea and Chlamydia culture gathered.
Special Tests:
None
Diagnosis: Neuropathy
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Differential Diagnoses
▪ STD
▪ UTI
Plan/Therapeutics
Plan:
 Pelvic exam
 Wet mount
 Gonorrhea and chlamydia
 UA with culture
Evaluation of patient encounter
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Solution

 

 

Name: T. S	Date: 2/19/2022		Time: 1:20 p.m
Age: 26		Sex: Female
Subjective
Chief complaint: “I have a bump in my left groin.”
HPI:   T.S is a 26-year-old female, and she presents to the clinic complaining of a lump on the left groin region since yesterday. She denies experiencing fever, chills, chest pain, difficulty in breathing, sore throat, nausea, abdominal pain, diarrhea, swelling, difficulty in urination, skin changes, rashes or lesions, insect bites, and exposure to poisons ivy and oak, and any palpitations. She also denied having shortness of breath while resting. She denied a vaginal discharge.
Medications: The patient is not on any medications.
PMH Allergies: No known drug allergies Chronic Illnesses/Major traumas: none Hospitalizations/Surgeries: Tonsillectomy.
Family History: The patient was adopted.
Social history; She does not smoke. Occasionally takes alcohol in social events She is sexually active. Has no children She is a waitress.
Review of the systems (ROS)
General; No fever, chills, coughs, fatigue, loss of appetite, or weight loss.		Cardiovascular; Denies chest pain, palpitations, fainting/passing out, shortness of breath during exercise or sleep, peripheral edema, and breathlessness in recumbent positions.
Skin Denied skin rash, lesions, moles, dryness, or discoloration.		Respiratory: Denied coughs, sputum, wheezing sounds, or history of respiratory illnesses such as tuberculosis.
Eyes: Denies changes in vision, blurred vision, photophobia, irritation, or yellowing of the sclerae		Gastrointestinal: Denies abdominal pain, constipation, abnormal bowel sounds and movements, ulcers, or nausea
Ears: Denies loss of hearing, pain, or discharge.		Genitourinary She is sexually active denies burning urination, changes in urine color, dysuria, and incontinence.
Nose/Mouth/Throat Denies sore throat, dysphagia, dental discharges, nose bleeds, sinusitis, throat hoarseness, or pain.		Musculoskeletal Denies joint and back pain, recent injuries, muscle pains, swelling, and stiffness.
Breast, N/A		Neurological Denies tremor, paralysis, ataxia, headaches, tingling in the hands or legs, or dizziness.
Heme/Lymph/Endo: Denies bruising, bleeding, swelling in the extremities and lymph nodes, heat intolerance, increased hunger and thirst,		Psychiatric Denies depression, suicidal ideation, hallucination and memory loss, or paranoia.
Objective
Weight: 142 BMI: 36.01	Temp: 98.3		BP: 154/99
Height: 65”	Pulse: 83		Resp: 16
General Appearance T.S is a 26-year-old female patient; she is well-groomed and appears pleasant. She is, however, a little worried about the bump in her groin region.
Skin: The skin is warm, dry, pink, and intact; no bruising, tenderness, or rashes were observed.
HEENT Head; is normocephalic, with no facial tenderness Eyes; No blurred or double vision, no visual loss or yellowing of the sclerae. Ears; nor hearing loss or pain. Nose; no runny nose, sneezing, or congestion. Mouth; no exudates, lesion, or enlargement of tonsils.   Throat/neck; no sore throat observed. The neck is supple, with no occipital nodes.
Cardiovascular; Regular rhythms, no murmurs, no chest pain, edema, or other discomforts. Stage 1 blood pressure. Capillary refill 2 seconds.
Respiratory; No shortness of breath or cough, no wheezing or tactile fremitus, respirations regular, Lungs clear to auscultation bilaterally.
Gastrointestinal; Normal bowel sounds, No masses or abnormal bowel movements, no organomegaly, hernia, or distension.
Breast; N/A
Genitourinary; No bladder tenderness, vaginal discharge, or lesions, no suprapubic pain.
Musculoskeletal; No joint stiffness or joint pain, no deformities or tenderness of upper or lower extremities
Neurological; Steady gait with no ataxia, clear speech, normal sensation, and erect posture.
Psychiatric; The patient is cooperative, appears calm, and has a normal affect.
Lab Tests: Pelvic exam; Urinary analysis; no leukocytes, nitrites, or bacteria. Gonorrhea and Chlamydia culture gathered.
Special Tests: none
Diagnosis: Cysts; are noncancerous growths that occur under the skin, including the groin area. They are usually harmless and painless, and most of the time, they resolve on their own without medical intervention. They can either be epidermoid or sebaceous cysts. Cysts are not infected and therefore not contagious; however, they are usually painful, contain pus, and redden when infected. The patient in this case only reported having a lump, and during the examination, she observed she denied any pain around the abdomen or groin areas, hence the cyst diagnosis (Beaux & Patel, 2018).
Differential diagnosis; STDs; lumps around the groin region can also be caused by sexually transmitted diseases, including chlamydia, HIV, and gonorrhea. However, such infections are usually accompanied by other symptoms, including discharge from the vagina, painful lumps, odor from the vaginal, swollen lymph nodes, burning urination, and lower abdominal pain. The patient, in this case, denied experiencing all the other symptoms associated with STDs except the existence of lumps, and therefore it is unlikely that she has an STD infection. Urinary tract infection; involves infection of any part of the urinary tract. It can also cause the appearance of lumps or swellings around the groin region. However, the possibility of the UTI is low since the associated symptoms such as burning and frequent urination and presence of WBC and cloudy urine were negative (Beaux & Patel, 2018).
Plan/Therapeutics
Plan: The care provider, in this case, should apply a wait and watch strategy; since the lumps are only one day old and they are not painful care provider should wait to see how they progress before initiating treatment. If they are cysts, they will resolve on their own without other symptoms. However, the care provider should educate the patients on symptoms to look for and schedule a follow-up visit to assess their progress (Beaux & Patel, 2018).

 

References

Beaux, A. C. D., & Patel, D. (2018). Diagnosis of a Lump in the Adult Groin. In Management of Abdominal Hernias (pp. 195-207). Springer, Cham. https://link.springer.com/chapter/10.1007/978-3-319-63251-3_11