Comprehensive Soap Note example

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Comprehensive Soap Note

The patient is a thirty-seven-year-old Hispanic woman. She is a divorcee based in Los Angeles. The Associates degree holder works as an Office Assistant for a fashion company in the city. Subjective AnalysisHPI: MS The 37-year-old patient complains about sharp and constant stomach pains that remain persistent in the morning and before meals. The pain worsens when the patient ingests foods like grains, beans, spices and chillies. However, the ingestion of other foods reduces the pain and gives the patient temporary relief. Particularly, the patient identifies milk as a critical part of her diet when the pain becomes worse. MS asserts that she sometimes experiences nausea, bloating and flatulence.

The condition seems to peak seasonally especially when the patient keeps a busy work schedule. MS rates the pain between 4 and 8 out of 10 depending on the nature of the attack. PMHMS mentions that she sought medical attention for the condition about six years ago. At the time, the pain felt mild and manageable. The doctor prescribed an anti-acid and to curb the pain. Moreover, the medical expert advised her to avoid spicy food and meals associated with bloating. MS reports no medical tests taken during her visits to the medical doctor. Since then, MS uses milk to manage her symptoms and mention no further consultations with a medical officer.Family Medical HistoryMS informs the examiner that her mother experienced indigestion for a long period because she suffered from dyspepsia. Her father died from a cardiac arrest five years ago.

Vital Signs

Temperature: 98.9 F

Body Weight: 132 pounds

Height: 5’6”

Pulse: 70bpm

Social History

MS is a Hispanic female born and raised in Los Angeles before moving to her current location. She finalized her divorce three months ago after eleven years of marriage. She received an associate degree in business administration and currently works as an office assistant. MS is a single mother of three children in their teenage years. Objective AnalysisGeneralThe patient appears ill, downcast and in slight discomfort. She constantly moves in the seat because of pain in her upper abdomen.


The patient’s pupils dilate in reaction to light and constrict in the absence of light. The heart rate remains regular in rhythm, and the patient displays normal ears and nose conditions. However, an abdomen press examination suggests that MS feels pain when the upper abdomen experiences normal pressure rate. In addition, the lower abdomen experiences periodic pain that lasts for a few minutes. She reports that she experiences sharp pains in the lower abdomen that pass quickly.

Lab Tests

MS undergoes a test to check for the levels of h-pylori in her system through a stool test. In addition, she needs a scan to establish the condition of her stomach lining in relation to ulcers. Results display the presence of a single wound in the stomach lining and the presence of h-pylori in the abdomen.AssessmentThe symptoms and …

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