SOAP NOTE TEMPLATE

Demographics

Name: A.B. Age: 48 years old Gender: Female

Chief Complaint (Reason for seeking health care )

“I am having severe hot flashes, mood swings, weight gain around my waist, and vaginal dryness.”

History of Present Illness (HPI)

A.B. is a pleasant 46-year-old white female presenting to the clinic with a 6-month history of worsening climacteric symptoms, including 6–8 daily hot flashes, night sweats, mood swings, irritability, and unwanted weight gain around the waist. She describes the hot flashes as sudden, intense sensations of heat, primarily affecting her face and chest, accompanied by sweating, which disrupt her daily activities. The night sweat disturbs her sleep, causing fatigue and irritability during the day. A.B. reports significant mood changes, including increased emotional sensitivity and difficulty managing stress, which is affecting her personal and work life. She has also noticed progressive weight gain concentrated around her midsection, despite no major changes in her diet or activity level. Her menstrual history reveals irregular cycles over the past year, with periods occurring every 35–50 days and lasting 2–3 days, lighter than her usual flow. She denied any vaginal bleeding in the past three months. A.B. denies breast tenderness, hair loss, or acne but reports vaginal dryness, which has led to mild discomfort during intercourse. She denies urinary symptoms, such as dysuria or urgency. There is no history of galactorrhea, headaches, or visual disturbances. She denies symptoms of thyroid dysfunction, including heat or cold intolerance, palpitations, or tremors. A.B. has a history of hypertension, well-controlled on Losartan 50 mg daily. She denies any other chronic illnesses or medications. She has a surgical history of two cesarean sections (G2P2002) . She denies any history of spontaneous or elective abortions. She denies any history of STIs. She is a nonsmoker, does not consume alcohol, and denies recreational drug use. Her family history is significant for her mother’s diagnosis of sarcopenia and menopause-related osteoporosis at the age of 60. She engages in regular physical activity and is open to adopting diet lifestyle modifications.

Allergies

No known allergies.

Review of Systems (ROS)

General: The patient reports a history of fatigue, night sweats and weight gain around waist, but denies experiencing fever, changes in appetite, or sensitivity to heat or cold.

HEENT: Head: She denies headaches, head trauma, or episodes of lightheadedness.

Eyes: She denies conjunctival icterus, excessive tearing, vision loss, blurred vision, eye infection. She has presbyopia and wear glasses to read.

Ears: She reports no tinnitus, earaches, infection, discharge or hearing loss.

Nose: She denies epistaxis, septum deviation, sinus infection, nose discharge, sneezing.

Throat: She denies changes in voice, difficulty swallowing and throat tenderness and redness.

Neck: denies tenderness, masses or pain against resistance.

Lungs: She denies SOB, exposure to tuberculosis, coughing, sputum production, adventitious sounds, or coughing up blood.

Cardio: She denies heart palpitations or pain, swelling in the extremities, difficulty breathing, or any history of dysrhythmias.

Breast: Denies tenderness, masses and no discharge.

GI: Reports moving her bowls daily, denies GERD, epigastric pain, nausea, vomiting and diarrhea.

M/F genital: Reports vaginal dryness, denies redness and discharge.

GU: Reports dyspareunia, reduced libido. Denies urinary urgency, dysuria, anuria or hematuria or STIs. She reports that her menstrual cycles are irregular, she has two children born both through C-sections, is sexually active, with a partner and uses the rhythm cycle as a contraceptive method. She denies painful menses, previous abortions or miscarriages and any BHRT or HRT.

Neuro: Denies epileptic episodes, loss of consciousness, numbness, dyskinesia, migraines, paresthesia and memory loss.

Musculo: denies any ROM problems, stiffness, joint swelling or pain.

Activity: Reports exercising twice a week despite fatigue and disrupted sleep.

Psychosocial: Reports on Irritability and mood swings. Denies suicidal thoughts.

Derm: Denies rashes, alopecia, skin/nail fungus, itchiness, redness, skin discoloration, lesions and lumps.

Nutrition: Reports eating three meals per day, but reports a habit of consuming fast food.

Sleep/Rest: Wakes up frequently due to night sweats, reports sleeping 4 hours per night.

LMP: 3 months ago.

STI Hx: Denies any infections of sexually transmitted diseases.

Vital Signs

Blood Pressure: 126/78 mmHg

Heart Rate: 76 bpm

Respirations: 18 breaths/min

Temperature: 94.6°F

BMI: 28

Labs

CBC, FSH, LH, Estradiol, Progesterone, Prolactin, testosterone free and total, TSH, and lipid profile were completed to assess her menopausal status and exclude thyroid dysfunction. Results are consistent with perimenopause: FSH: 38mIU/mL, LH: 15mIU/mL, Estradiol 20pg/mL, Progesterone: 0.5ng/m, Prolactin: 12ng/mL (Lee et al., 2020)

Medications

Currently medication: Losartan 50 mg tab orally daily in the morning for chronic hypertension (Rabi et al., 2020).

Past Medical History

Chronic hypertension was diagnosed 2 years ago and managed with Losartan.

Past Surgical History

Cesarean section (2). (2001), (2003). Breast Implants at 24 years old.

Family History

Mother with a history of sarcopenia, osteoporosis and hypertension; father with a history of type 2 diabetes.

Social History

She does not smoke, drinks a glass of wine on weekends, and does not use recreational drugs.

Health Maintenance/ Screenings

Mammogram: 2023, normal.

Colonoscopy: Age-appropriate, normal.

Bone density scan: Pending.

Physical Examination

General: Alert and oriented. She appears tired but in no acute distress.

HEENT: Normocephalic, with clear conjunctiva and no scleral icterus noted.

Neck: Soft, no lymphadenopathy, trachea is midline with slight deviation to the right.

Lungs: Clear to auscultation bilaterally.

Cardio: Regular rate and rhythm, no murmurs.

Breast: No tenderness, masses, nipple diversion or discoloration, no discharge during breast examination.

GI: Soft, non-tender abdomen, normal active bowel sounds.

M/F genital: The vaginal mucosa appears pale, dry, thin and lacks normal lubrication, labia minora and majora appear atrophied and less plump, discomfort on palpation of the vaginal introitus and reduced vaginal secretions noted upon a speculum exam.

GU: Deferred.

Neuro: Normal. No focal deficits.

Musculo: No tenderness or swelling.

Activity: Reports limitations because of fatigue.

Psychosocial: Mildly apprehensive about symptoms.

Derm: No rash or lesions seen.

Diagnosis

Primary: Perimenopause (N95.0) Perimenopause is the transitional phase before menopause characterized by fluctuating hormone levels. Symptoms such as irregular menstrual cycles, hot flashes, mood changes, and vaginal dryness overlap with menopause. Perimenopause should be considered if the patient is still experiencing irregular periods, as hormonal fluctuations can precede the cessation of menses for several years (North American Menopause Society, 2022).

Differential Diagnosis

Polycystic Ovary Syndrome (PCOS) (E28.2) PCOS can present with weight gain, mood changes, and irregular menses. While vaginal dryness is less common, metabolic disturbances in PCOS can exacerbate weight gain. Differentiating PCOS from menopause or perimenopause requires evaluating androgen levels and imaging for ovarian cysts (Teede et al., 2018).

Menopause (N95.1) Menopause is diagnosed when a woman has not had a menstrual period for 12 consecutive months and experiences symptoms related to decreased estrogen levels. Hot flashes, mood swings, unwanted weight gain around the waist, and vaginal dryness are hallmark symptoms of menopause (Santoro et al., 2021). These symptoms result from ovarian follicular depletion and the associated decline in estradiol production, which impacts thermoregulation, mood, fat distribution, and Hypothyroidism (E03.9) Hypothyroidism can present with symptoms such as fatigue, mood swings, weight gain, and menstrual irregularities, which overlap with menopausal symptoms. A thyroid-stimulating hormone (TSH) test would differentiate this condition, as hypothyroidism requires specific treatment with levothyroxine (Chaker et al., 2017).

ICD 10 Coding

Polycystic Ovary Syndrome (PCOS)(E28.2)

Menopause (N95.1)

Hypothyroidism (E03.9)

Pharmacologic treatment plan

Hormone Replacement Therapy (HRT): Symptomatic treatment with low-dose estradiol 0.5 mg and medroxyprogesterone 2.5 mg daily based on FSH (95 mIU/mL) and estrogen (20 pg/mL) levels (Yuksel et al., 2021).

Vaginal estrogen cream: Estradiol 0.01% cream, apply intravaginally twice weekly based on vaginal atrophy results (Faubion et al., 2020).

Diagnostic/Lab Testing

CBC, FSH, TSH, and lipid profile: FSH: 95 mIU/mL, LH: 52 mIU/mL, Estrogen: 20 pg/mL, Progesterone: 0.5 ng/mL, Prolactin: 12 ng/mL.

Education

Discussed the benefits and risks of HRT, such as cardiovascular and breast cancer risks (Marsden & Pedder, 2020). Educating the patient on the importance of a balanced diet, regular exercise, and stress reduction can mitigate weight gain and improve mood. Weight loss may help reduce hot flashes. Behavioral therapy and mindfulness-based techniques are also beneficial (North American Menopause Society, 2022). Discuss alternative treatment if patient is unable or unwilling to take HRT, non-hormonal options like selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) may help alleviate hot flashes. Low-dose paroxetine is an FDA-approved option (Santoro et al., 2021).

Anticipatory Guidance

Instructed the patient on the importance of stress-reduction techniques that include weight-bearing exercises to support the health of bones (McKinney, 2021). Educated the patient on signs of abnormal uterine bleeding and instructed her to report immediately (McKinney, 2021). Discussed the importance of routine breast self-examinations (Yuksel et al., 2021). Recommended avoiding alcohol intake to reduce cardiovascular risk (McKinney, 2021). The North American Menopause Society provides detailed recommendations on managing menopausal symptoms, emphasizing individualized care for hormone therapy (North American Menopause Society, 2022). Clinical guidelines from the Endocrine Society support hormone replacement therapy for symptomatic relief, balancing benefits and risks for each patient (Santoro et al., 2021). The American College of Obstetricians and Gynecologists endorses vaginal estrogen therapy for treating genitourinary syndrome and advises lifestyle interventions for weight management (Kingsberg et al., 2020).

Follow up plan

Follow-up scheduled in 6 weeks to assess treatment response.

Prescription

See Below”

References

Faubion, S. S., Kingsberg, S. A., Clark, A. L., Kaunitz, A. M., Spadt, S. K., Larkin, L. C., ... & McClung, M. R. (2020). The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society.  Menopause,  27(9), 976-992.

Lee, S. R., Cho, M. K., Cho, Y. J., Chun, S., Hong, S. H., Hwang, K. R., ... & Kim, T. (2020). The 2020 menopausal hormone therapy guidelines.  Journal of menopausal medicine,  26(2), 69.

Marsden, J., & Pedder, H. (2020). The risks and benefits of hormone replacement therapy before and after a breast cancer diagnosis.  Post Reproductive Health,  26(3), 126-135.

McKinney, A. (2021). Lifestyle Medicine in Menopause and Bone Health. In  Improving Women’s Health Across the Lifespan (pp. 255-272). CRC Press.

Rabi, D. M., McBrien, K. A., Sapir-Pichhadze, R., Nakhla, M., Ahmed, S. B., Dumanski, S. M., ... & Daskalopoulou, S. S. (2020). Hypertension Canada’s 2020 comprehensive guidelines for the prevention, diagnosis, risk assessment, and treatment of hypertension in adults and children.  Canadian Journal of Cardiology,  36(5), 596-624.

Yuksel, N., Evaniuk, D., Huang, L., Malhotra, U., Blake, J., Wolfman, W., & Fortier, M. (2021). Guideline No. 422a: Menopause: vasomotor symptoms, prescription therapeutic agents, complementary and alternative medicine, nutrition, and lifestyle.  Journal of Obstetrics and Gynaecology Canada,  43(10), 1188-1204.

Chaker, L., Bianco, A. C., Jonklaas, J., & Peeters, R. P. (2017). Hypothyroidism. The Lancet, 390(10101), 1550-1562. https://doi.org/10.1016/S0140-6736(17)30703-1

Kingsberg, S. A., Schaffir, J., & Krychman, M. L. (2020). Female sexual health: Vaginal health and hormone therapy. Obstetrics & Gynecology, 135(4), 975-988. https://doi.org/10.1097/AOG.0000000000003756

Santoro, N., Epperson, C. N., & Mathews, S. B. (2021). Menopausal symptoms and their management. JAMA, 325(23), 2448-2459. https://doi.org/10.1001/jama.2021.5052

The North American Menopause Society. (2022). The 2022 hormone therapy position statement. Menopause, 29(7), 767-794. https://doi.org/10.1097/GME.0000000000002005

Grammar

EA#: 101010101 STU Clinic LIC#10000000

Tel: (000) 555-1234

FAX: (000) 555-12222

Patient Name: (Initials): A.B

Age: 48

Date: 1/22/2025

RX: Estradiol 0.5 mg tab daily and Estradiol Vaginal Cream 0.01%.

SIG: Use as directed.

Dispense: 30 tablets and one cream tube

Refill: 3/5/2025

No Substitution

Signature:

_____________Alexsandra Lima______________________________________

SOAP NOTE TEMPLATE

Review the Rubric for more Guidance

Demographics

Chief Complaint (Reason for seeking health care)

History of Present Illness (HPI)

Allergies

Review of Systems (ROS)

General:

HEENT:

Neck:

Lungs:

Cardio

Breast:

GI:

M/F genital:

GU:

Neuro

Musculo:

Activity:

Psychosocial:

Derm:

Nutrition:

Sleep/Rest:

LMP:

STI Hx:

Vital Signs

Labs

Medications

Past Medical History

Past Surgical History

Family History

Social History

Health Maintenance/ Screenings

Physical Examination

General:

HEENT:

Neck:

Lungs:

Cardio

Breast:

GI:

M/F genital:

GU:

Neuro

Musculo:

Activity:

Psychosocial:

Derm:

Diagnosis

Differential Diagnosis

ICD 10 Coding

Pharmacologic treatment plan

Diagnostic/Lab Testing

Education

Anticipatory Guidance

Follow up plan

Prescription

See Below (scroll down)

References

Grammar

EA#: 101010101 STU Clinic LIC# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: (Initials)______________________________ Age ___________

Date: _______________

RX ______________________________________

SIG:

Dispense: ___________ Refill: _________________

No Substitution

Signature:____________________________________________________________