To prepare:
Review the Comprehensive SOAP Note Template.
Select a patient who you saw at your practicum site during the last 5 weeks. With this patient in mind, consider the following:
Subjective: What details did the patient provide regarding the personal and medical history?
- Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities and psychosocial issues.
- Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their CPT and ICD-10 codes for the diagnosis. What was your primary diagnosis and why?
Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
- Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluatio
- Patient
- CC: Eric is a 46 y/o AA male for new a New Patient visit and to establish care with the practitioner. The pt c/o generalized abdominal pain and cramping. The pain started a few months ago. The pain is aggravated by food. He states he sometimes feels like he is bloated. He takes omeprazole and pepcid and gets temporary relief from these medications. He is also concerned about his prostate and wants a check-up for his prostate. Otherwise, his over health is good
- HistoryLAST UPDATEDLAST UPDATEDPast Medical History (PMHx)
- Abdominal Pain – pain/cramp
- GERD
- 21 Apr 202301:21 PMPast Surgical History (PSHx)
- Cholecystectomy/bile duct surgery – 2021
21 Apr 202301:23 PMFamily History (FHx)
brother (first): Alive, +No Health Concern
father: Deceased
mother: Deceased at 57, +Hypertension, +Diabetes
sister (first): Alive, +No Health Concern
21 Apr 202301:31 PMSocial History (SHx)
Alcohol: Do not drink
Birth Gender: Male
Cardiovascular: Regular exercise
Others: Caffeine – 2 cups a day
Safety: Household Smoke detector / Wear seatbelts
Sexual Activity: Sexually active
- Tobacco: Never smokerVitals List
RECORDEDBPHRRRTEMPHEIGHT/LENGTHWEIGHTBMISPO2INHALED O2HEAD CIRCCOMMENTRECORDEDBPHRRRTEMPHEIGHT/LENGTHWEIGHTBMISPO2INHALED O2HEAD CIRCCOMMENT21 Apr 202301:08 PM136/94782098.26′ 0″278 lbs 2 oz37.7298.0%
- CCEric is a 46 y/o AA male for new a New Patient visit and to establish care with the practitioner. The pt c/o generalized abdominal pain and cramping. The pain started a few months ago. The pain is aggravated by food. He states he sometimes feels like he is bloated. He takes omeprazole and pepcid and gets temporary relief from these medications. He is also concerned about his prostate and wants a check-up for his prostate. Otherwise, his over health is good. SubjectiveConst: Denies weakness or night sweatsHead: Denies headache, confusion, or lightheadednessNeuro: Denies syncope, slurred speech, or numbness/tinglingEyes: Denies changes to visionENT: Denies rhinorrhea sore throat, or hearing loss.Cardiac: Denies CP or palpitationsPulm: Denies cough, shortness of breath, or wheezingHeme: Denies bruising or petechiaeSkin: Denies itching, rashes, or lesionsGI: Denies diarrhea, constipation, or indigestionGU: Denies any problemsMSK: Denies any musculoskeletal painPsych: Denies thoughts of self harm or SIMedicationsAllergiesNo allergy history has been documented for this patient.Mental/FunctionalThe patient was sitting upright, and eyes contact and facial expression were appropriate. Grooming hygiene and dress code were appropriate for age and season. The patient is friendly and cooperative. Mood and affect were appropriate. Though process was significant. The patient is alert to person, place, time, and current situation and responds appropriately to questions, and physical and environmental stimuli.Vitals21 Apr 2023 – 01:08 PM – recorded by Faith StaggersBP:136.0 / 94.0HR:78.0 bpmRR:20.0 rpmTemp:98.2 °FHt/Lt:6′ 0″Wt:278 lbs 2 ozBMI:37.72SpO2:98.0%ObjectiveGENERAL: No weight loss, fever, chills, weakness, or fatigue.HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss; no sneezing, congestion, runny nose, and itching throatSKIN: No rash or itchingCARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.RESPIRATORY: No shortness of breath, cough, or sputum.GASTROINTESTINAL: Admit to abdominal pain. No anorexia, nausea, vomiting, or diarrhea. No blood in stool.NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.HEMATOLOGIC: No anemia, bleeding, or bruising.LYMPHATICS: No enlarged nodes. No history of splenectomy.PSYCHIATRIC: No history of depression or anxiety.ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or polydipsia.GENITOURINARY/REPRODUCTIVE: Denies Burning on urination.ALLERGIES: No history of asthma, hives, eczema, or rhinitis.AssessmentGeneralized abdominal pain (finding) (R10.84/789.07) Generalized abdominal pain (acute) started 17 Jan, 2023 modified 21 Apr, 2023Encounter for general adult medical exam w abnormal findings (Z00.01/V70.0) Encounter for general adult medical exam w abnormal findings (acute) started 21 Apr, 2023 modified 21 Apr, 2023Disorder of vitamin D (disorder) (E55.9/268.9) Vitamin D deficiency, unspecified (chronic) modified 21 Apr, 2023PlanCBC, CMP, TSH, lipid panel, A1c, Vit-D, and PSA level Abdominal ultrasound Maalox 15cc before each meal x1 week Return in 1 week for lab review and consultation Will discuss health maintenance and disease prevention on F/U visit Generalized abdominal pain (finding)Encounter for general adult medical exam w abnormal findingsDisorder of vitamin D (disorder)
