Week 6: Problem-Focused SOAP Note
USE the template that I gave you before. Needs the 1st blank paper for cover sheet.
Some Rubric
Some Rubric
Criteria Ratings Pts
This criterion is linked to a
Learning Outcomes (Subjective)
10 pts
Accomplished
Symptom analysis is well organized, with C/C, OLD
CART, pertinent negatives, and pertinent positives. All
data needed to support the diagnosis & differential
are present. Is complete, concise, and relevant with
no extraneous data.
10 pts
This criterion is linked to a
Learning Outcome (Objective)
10 pts
Accomplished
Complete, concise, well organized, well written, and
includes pertinent positive and pertinent negative
physical findings. Organized by body system in list
format. No extraneous data.
10 pts
This criterion is linked to a
Learning Outcome
(Assessment)
10 pts
Accomplished
Diagnosis and differential dx are correct, include ICD
code, and are supported by subjective and objective
data.
10 pts
This criterion is linked to a
Learning Outcome (Plan) 10 pts
Accomplished
Plan is organized, complete and supported with 2
evidence-based references. Addresses each diagnosis
and is individualized to the specific patient and
includes medication teaching and all 5 components:
(Dx plan, Tx plan, patient education, referral/follow-
up, health maintenance).
10 pts
Total Points: 40
Patient initial: R. R
DOB: June/1991 Sex: F
Encounter Date: 08/08/2023
SUBJECTIVE:
Chief Complaint:
History Of Present Illness:
appt is requested for URI
Medical History:
#. COVID 1/2022
#. hemorrhoids
#. Postpartum Depression, Anxiety, panic attacks
#. ADD
#. Insomnia
#. Allergic rhinitis
#. Psoriasis
#. Onychymycosis
Surgical History:
none
Gynecological History:
G2 P2 A0
Family History:
M: living, arrhythmia, palpitations
F: living, healthy
S: asthma
Social History:
-Married
-Lives with husband, 2 kids, and grandparents
-Authorization coordiinator at USC Keck, also student in digital marketing
-Denies tobacco use
-etoh use: Socially
-Denies illicit drug use
Smoking Status: Never Smoked
Allergies:
No known allergies
Current Medications:
———————————-
Paxil 10 mg po qd
xanax 0.25 mg prn panic attacks
Adderall 20mg bid prn
———————————
Review of System:
Constitutional: Patient denies weight change, fever, chills, weakness, fatigue, sleep
changes, appetite changes.
Head: Patient denies headache.
Neck: Patient denies abnormal masses, neck stiffness.
Eyes: Patient denies vision loss, blurring, discharge, excessive tearing, dryness.
Ears: Patient denies hearing loss, tinnitus, vertigo, discharge, pain
Nose: #sinus congestion#
Mouth: Patient denies ulcers, bleeding gums, taste problems.
Throat: #sore throat#
Cardiovascular: Patient denies chest pain, chest pressure, palpitations, DOE,
orthopnea.
Respiratory: #dry cough#
Patient denies shortness of breath, increased sputum, hemoptysis.
Gastrointestinal: #looser stools, frequency, occ incontinence#
Patient denies nausea, vomiting, heartburn, dysphagia, constipation, melena,
abdominal pain, jaundice, hemorrhoids.
Genitourinary: #urinary urgency and frequency, occasional incontinence#
Patient denies abnormal hesitancy, hematuria, dysuria, nocturia, stones.
Musculoskeletal: Patient denies arthralgias, joint stiffness, myalgias, muscle
weakness, instability and abnormal range of motion
Integumentary (Skin and/or Breast): Patient denies rash, lesions, changes in hair,
changes in nail, pruritus
Neurological: Patient denies headache, syncope, seizures, vertigo, ataxia, diplopia,
tremor, numbness, tingling.
Psychiatric: #depression, anxiety, ADD#
Patient denies mood abnormalities, memory loss, difficulty sleeping, appetite
changes
Endocrine: Patient denies sensitivity to cold or heat, polyuria, polydipsia.
Hematologic/Lymphatic: Patient denies bleeding, bruising, lymphadenopathy.
GYN: #menorrhagia#
Patient denies changes in menstrual cycle, hot flashes.
OBJECTIVE:
Physical Exam:
Constitutional: #last exam done on 7/10/23 showed#
WD, WN, Alert, Oriented X3 in NAD. Affect appropriate. Gait normal.
Eye: PERRLA, EOMI, nl conjunctiva
Ear: No pinnea/tragal tenderness. Drums are visualized, no wax in canals
Nose: N1 mucosa. N1 Nasal septal walls and turbinates.
Mouth: N1 bucal mucosa, no lesions noted.
Throat: Clear, no erythema or exudates.
Neck: #thyroid fullness R#
supple, no masses. Trachea is midline. N1 carotid auscultation. No JVD
Cardiovascular: RRR, N1 S1 and S2, No cardiac murmurs, rubs or gallops.
Lungs: ctab, no wheezes, rhonchi or crackles
Chest/Breasts: deferred
Gastrointestinal (Abdomen): soft, nt, nd, bs(+). No palpable masses.
Genitourinary: #negative CVAT#
deferred
Lymphatic: -No LAN noted
Musculoskeletal: good ROM. Strength symmetrical and wnl. No muscle weakness or
stiffness. No joint effusion or ttp.
Skin: Normal color and texture. No lesions seen.
Extremities: Warm, no clubbing, cyanosis or edema. N1 DP/PT pulses bilaterally
Neurological/Psychiatric: CN I-XII intact, neurosensory wnl, strength (5/5), (2+) DTR
UE/LE bilaterally -Judgment and insight intact
ASSESSMENT:
Diagnosis:
ICD-10 Codes:
1)J069; Upper respiratory infection, unspecified
PLAN:
Procedures (CPT code):
1) 99213; Detailed
2) 99401; 15 min
Medications:
Promethazine-DM 6.25-15 MG/5ML Oral Syrup; Take 5 ml orally every 4 hours Take
as needed for dry cough; Qty: 120; Refills: 0
Care Plan:
.***URI- x4 days, sore throat, sinus congestion, dry cough, headache. took
tylenol/cough syrup, claritin with not much relief. sent home today from work, COVID
test today from work pending results. sisters also similar sxs, but has tested
negative for COVID.
-off work this week
-Rx promethazine/DM 5mL prn cough, r/b d/w pt
-sudafed and tylenol prn
-f/u 1 week, if no improvement and covid neg, come back in office for exam
***urinary incontinence- h/o occasional stress incontinence, however over last 1 mo,
c/o increasing urengency, frequency and 2 episodes of incontinence, which occured
with only minimal alcohol use. denies hematuria, dysuria. c/o menorrhagia
worsening after delivering her 2 yo. denies LBP/trauma/saddle paresthesia
-pelvic floor PT ordered
-UA/UCx ordered
-referred to uro gyn
-ordered transvaginal u/s r/o uterine fibroids
-counseled on wt loss. keep voiding journal
-avoid irritants such as caffeine/ETOH
***diarrhea- c/o looser stools, 4-5xd and few episodes of incontinence. c/o abd
cramping after bm, othewise no abd pain, fever, melena, wt loss. has had h/o abd
pain and cramping which we ordered stool studies, CRP, ESR but pt never did.
denies LBP/trauma/saddle paresthesia. abd exam normal today
-ordered stool studies, ESR, CRP
-referred to GI
-ER precautions
***Hyperlipidemia, lipoprotein deficiency- On 1/16/23, FLP showed 237/47/182/156.
Has lost 6 lbs intentionally since last visit.
-Rec low fat, low carb diet
-FLP with next annual
***obesity- BMI 31.37, wt 221 lbs, Has lost 6 lbs intentionally since last visit.
-counseled
***thyroid fullness- noted on exam. 1/16/23, TSH wnl.
-ordered thyroid u/s 11/8/22, pt has not done yet
Plan Notes Continued: .
***trigger finger- unsure of duration, ono/off. R ring finger locks. Pt has seen hand
specialist in the past for another issue
-Rx ibuprofen as noted above, r/b d/w pt
-pt rec to f/u with hand specialist
***Vitamin D deficiency- On 1/16/23, Vitamin D level was 24. not supplementing.
-Rec Vitamin D 4000 IU qd
-Vitamin D level with next annual
***Onychymycosis- b/l feet on PEX on 2/1/23. pt is interested in tx.
-given the interactions between terbinafine and her psychiatric meds, I rec she
checked with them first before we start
***Depression, Anxiety- F/b psychiatrist, Dr. Askins and psychologist, Dr. Tricia
Duncan Hassle. Takes Paxil 10 mg po qd and xanax 0.25 mg prn panic attacks.
Denies SI/HI.
-mgmt per psych
***ADD- F/b psychiatrist, Dr. Askins. Takes Adderall 20mg bid prn.
-mgmt per psych
Patient Instructions: .
.
-Pt has been instructed to take medications as prescribed
-Pt received education on compliance with medications and recommendations
-Pt received counseling regarding Medication Side Effects
-Pt received counseling on following a well-balanced healthy diet with veg, fruit and
fiber.
-Pt was instructed to do CV exercise at least 3-4 times every week for 30 minutes.
PHCM: .
.
31 y/o F:
-Annual physical: done 2/1/23- next due 2/1/24
-Annual labs: done 1/16/23- next due 1/16/24
-Cervical CA screening: managed by GYN
-Skin CA screening; Referred to derm on 3/30/22
Immunizations:
Tetanus: doen 2021- next due 2031
Influenza: Fall 2022
COVID19: Pfizer in 7/1/21, bivalent booster Pfizer 1/14/23
HPV: will check records
- Week 6: Problem-Focused SOAP Note