SOAP Note _______

NU___:_________

Herzing University

Name:_________________________

Typhon Encounter #: _____________________

Comprehensive:____Focused:____

S: SUBJECTIVE DATA

CC:

“I’m having hot flashes and mood swings.”

HPI:

· Onset (O): Began approximately one year ago.

· Location (L): Generalized sensation of heat involving face, neck, and upper body.

· Duration (D): Each episode lasts several minutes, occurring multiple times daily and at night.

· Characteristics (C): Sudden intense warmth and sweating, followed by chills; associated with irritability and mood swings.

· Aggravating/Associated Factors (A): Nighttime warmth, stress, caffeine, and alcohol.

· Relieving Factors (R): Cooling environment, loose clothing, relaxation techniques.

· Treatment Tried (T): None; no prior use of hormone therapy.

· Summary (S): 51-year-old Black female with one year of menopause (12 months amenorrhea) reporting moderate vasomotor and mood symptoms, seeking non-hormonal management.

PMH:

· Hypertension, well-controlled on medication.

· No history of thromboembolic disease, breast cancer, or psychiatric hospitalization.

OBGYN History:

· G3P3 (all full-term vaginal deliveries).

· Menopausal: 12 months of amenorrhea.

· No post-menopausal bleeding.

· LMP: 12 months ago.

ALLERGIES

No known drug allergies (NKDA).

MEDICATIONS

Lisinopril 10 mg PO daily for hypertension.

SH

· Non-smoker, rarely drinks alcohol.

FH

· Mother: Type 2 diabetes and hypertension.

· Father: Hypertension.

· No known family history of breast, ovarian, or endometrial cancer.

HEALTH PROMOTION & MAINTENANCE

· Mammogram: Up to date.

· Colonoscopy: Up to date.

· Needs zoster (shingles) vaccine per CDC (2025) recommendations.

· Engages in minimal physical activity; counseled to increase to ≥150 minutes/week.

· Balanced diet; advised on calcium/vitamin D supplementation.

· Sees dentist and eye specialist annually.

ROS

(put N/A in sections not completed day of exam)

Constitutional

Reports night sweats and fatigue; denies fever, chills, or weight loss.

Head

No headache.

Eyes

No vision changes.

Ears, Nose, Mouth, Throat

No sore throat, tinnitus, or nasal congestion.

Neck

No thyroid tenderness or swelling.

Cardiovascular/Peripheral Vascular

Denies chest pain or palpitations.

Respiratory

Denies cough, dyspnea, or wheezing.

Breast

No pain, nipple discharge, or masses.

Gastrointestinal

No nausea, vomiting, constipation, or abdominal pain.

Genitourinary

No dysuria, frequency, or hematuria.

Pelvis

No pelvic pain or discharge.

Musculoskeletal

No joint pain or stiffness.

Integumentary

No rashes or lesions.

Neurological

No dizziness, weakness, or syncope.

Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7)

Reports irritability and mood changes; denies suicidal ideation.

Endocrine

Denies polyuria, polydipsia, or heat/cold intolerance.

Hematologic/Lymphatic

No bruising or lymphadenopathy.

Allergic/Immunologic

NKDA.

Other

N/A

O: OBJECTIVE DATA

VITALS:

HR: 74 bpm

RR: 16/min

BP: 128/78 mmHg

Temp: 98.1°F (36.7°C)

SpO2%: 99%

Ht: 165 cm

Wt: 72 kg (158 lbs)

BMI: 26.3 kg/m²

Age: 51 years

LMP: 12 months ago

PAIN: 0/10

PHYSICAL EXAM

General Appearance

Well-appearing, cooperative, no acute distress.

Head

Normocephalic, atraumatic.

Eyes

PERRLA, no conjunctival injection or scleral icterus.

ENT, Mouth

Oral mucosa moist, no lesions.

Neck

Supple, no thyromegaly, no lymphadenopathy.

Cardiovascular/Peripheral Vascular

Regular rate and rhythm, no murmurs or edema.

Respiratory

Clear to auscultation bilaterally, normal effort.

Breast

Deferred today (up to date mammogram).

Gastrointestinal

Abdomen soft, non-tender, no hepatosplenomegaly.

Genitourinary Female

· External Exam

Normal

· Internal Exam

Deferred (no complaints).

Obstetric

N/A (postmenopausal).

Musculoskeletal

Full range of motion, no tenderness.

Integumentary

Warm, dry, no rashes.

Neurological

Alert and oriented ×3; cranial nerves II–XII intact.

Psychiatric

Cooperative, mildly anxious affect, no psychosis.

Endocrine

No thyromegaly or tremors.

Hematologic/Lymphatic

No lymphadenopathy or pallor.

A: ASSESSMENT AND DIAGNOSIS

DIAGNOSIS

ICD-10 CODES

PRIORITIZE DIAGNOSIS

1. Menopausal disorder

N95.1

2. Sleep disturbance secondary to menopause

G47.00

3. Mood disorder associated with menopause

F32.A

VISIT CODES

CPT BILLING CODES

99214

DIAGNOSTICS

POC TESTING

None performed today.

TESTS REVIEWED

None; recommended follow-up labs

P: PLAN

ACTIONS

1.

Diagnosis: Menopausal Disorder

Diagnostics Ordered:

· TSH and CBC to rule out thyroid dysfunction or anemia.

· Lipid panel and fasting glucose for cardiovascular risk screening.

Therapeutic:

· Venlafaxine XR 37.5 mg PO daily, may increase to 75 mg after 4–6 weeks if tolerated.

· Encourage non-pharmacologic strategies: cooling techniques, layered clothing, reduce caffeine/alcohol, exercise ≥150 minutes/week, mindfulness or yoga.

Education:

· Explained medication use and potential side effects (nausea, insomnia, BP elevation).

· Reviewed non-hormonal vs. hormonal therapy options.

· Discussed calcium (1,200 mg/day) and vitamin D (800–1,000 IU/day) intake and weight-bearing exercise.

Consultation/Collaboration:

· Refer to gynecology if symptoms persist or patient elects to consider hormone therapy later.

2.

Diagnosis: Sleep Disturbance

Diagnostics Ordered:

· PHQ-9 and Insomnia Severity Index (ISI) screening.

Therapeutic:

· Continue venlafaxine XR; optimize dosing.

· Sleep hygiene: cool room, consistent bedtime, avoid caffeine/alcohol at night.

· Consider Trazodone 25–50 mg PO HS PRN for short-term insomnia.

Education:

· Maintain dark, quiet sleeping environment and limit screen exposure.

· Exercise earlier in the day.

Consultation/Collaboration:

· Behavioral health referral for Cognitive Behavioral Therapy for Insomnia (CBT-I) if persistent.

3.

Diagnosis: Mood Disorder

Diagnostics Ordered:

· PHQ-9 screening to monitor for depression.

Therapeutic:

· Continue venlafaxine XR; supportive counseling.

· Encourage relaxation, journaling, and faith-based coping strategies.

Education:

· Discussed link between menopause, mood, and sleep.

· Instructed to report any depressive or anxiety symptoms.

Consultation/Collaboration:

· Behavioral health referral if mood symptoms worsen or PHQ-9 ≥10.

PREVENTITIVE

· Encourage aerobic exercise ≥150 minutes/week and weight-bearing exercise.

· Diet: increase calcium, vitamin D, and whole grains.

· Maintain up-to-date screenings (mammogram, colonoscopy).

· Recommend shingles (zoster) vaccine.

· Continue annual dental and eye exams.

· Stress reduction: mindfulness, prayer, or counseling as culturally preferred.

FOLLOW UP

· Recheck in 6 weeks to evaluate medication tolerance and symptom improvement.

· Review TSH, CBC, and lipid panel results once available.

· Return sooner if symptoms worsen or new concerns arise.