Medical Assessment SOAP Note

History & Physical Format

IDENTIFICATION:

Date: 20/09/2021 Time: 09:45 am

Name: J.D.R Sex: F Race: Caucasian

Marital status: Married

Address: Miami.FL

Tel. #: 345-789-1234

DOB: 26/03/1981

SUBJECTIVE:

CHIEF COMPLAINT (CC): “Annual physical exam”

HISTORY OF PRESENT ILLNESS (HPI): The patient is a 40-year-old female who comes in today for annual health maintenance and routine physical. Her last physical was last year. She just had a Pap recently. She states that she has a couple of different problems that she would like to address.

One is that she has had a lot of gas pain, and it is very uncomfortable. She is bloated often times. She has not been eating regularly, but she has noticed that her belly swells a lot. Lately, she has been a little dizzy and lightheaded. She will get very lightheaded and she will start to have a little shakes. Has fainted a couple of times. Medical Assessment SOAP Note

Another problem is heartburn. She said that she has had some heartburn. The patient has a little shortness of breath and some shooting pain; it lasts for a minute or so, and it is especially on the left side.

PAST MEDICAL HISTORY (PMH): Unremarkable. The patient does have mitral valve prolapse.

FAMILY HISTORY (FH): A paternal aunt was recently diagnosed with breast cancer at age 50. Her father is healthy. Her mother is healthy.

SOCIAL HISTORY (SH): The patient does not smoke, does not drink alcohol.

REVIEW OF SYSTEMS (ROS): Denies any palpitation. Does have occasional shortness of breath with the shooting pain running across her chest, no real chest pain per se. No migraine headaches. Sometimes constipated, but no diarrhea, mostly no blood in her stools. No musculoskeletal pain, no headaches. Review of systems basically noncontributory.

ALLERGIES: No known allergies.

MEDICATIONS: TriNessa.

HEALTH MAINTENANCE: The patient does exercise all the time. She is very active. She does wear her seat belt. She does use sunscreen. Her last Pap was on 10/07/2020. Her last period was 08/29/2021. She has never had a STD. Never had any abuse or any domestic violence.

OBJETIVE:

PHYSICAL EXAMINATION (PE):

GENERAL: The patient is a pleasant female, in no acute distress. Well developed, well nourished. VITAL SIGNS: The patient is 170 cm tall. She weighs 140 pounds. Her blood pressure is 110/70.

HEENT: Head is normocephalic and atraumatic. Pupils are equal and reactive to light with good red light reflex. TMs are pearly gray, clear, with good cone of light reflex. Nasal mucosa is pink. Oropharynx is pink. No exudate Dentition is good. NECK: Supple. No lymphadenopathy noted. No carotid bruits. No thyroid mass or thyromegaly. LUNGS: CTAP bilaterally. No wheezes, rales or rhonchi. HEART: Well-beaten, rhythmic heart sounds, not murmurs. Normal S1 and S2. . There are no lifts, heaves or thrills noted on palpation. EXTREMITIES: Upper and Lower extremities without  CCE. GENITOURINARY: EGBUS normal. Denies dysuria, urgency, discharge or bleeding currently.

SKIN: There are no rashes, lesions or ulcers noted. Warm and dry with good turgor.

RECTAL: Normal sphincter tone. No masses or tenderness.

NEUROLOGIC: No focal sensory or motor deficits are noted. Gait is normal. Cranial nerves II through XII are intact. Deep tendon reflexes are intact. PSYCHIATRIC: The patient is awake, alert, and oriented x3. Recent and remote memory is intact. Appropriate mood and affect. Medical Assessment SOAP Note

ASSESSMENT:

1. Gas pain, abdomen bloated and constipation —- SUGGESTED of Irritable bowel syndrome with constipation (K58.1).

2. Dizziness and a question of fainting —- SUGGESTED of Hypoglycemia (E16.2)

3. Shortness of breath and shooting pain – SUGGESTED of Nonrheumatic mitral (valve) prolapse (I34.1)

PLAN:

1. We did postural blood pressures, and they were perfectly fine. She does not have postural hypertension. Also, do 24-hour urine for catecholamines to rule out any adrenal problems or thrombocytosis.

2. Will get a stress test and do an echocardiogram to rule out any abnormalities, for the patient’s shortness of breath and shooting pain because of her mitral valve prolapse.

3. Omeprazole (40mg) every 12 hours and Mylanta II after each meal for the patient’s heartburn and gas pains, she does have to eat healthy.

4. Increase fiber intake and Metamucil (0.4g Cap) 2 times a day for the patient´s constipation.

5. The patient has dizziness and a question of fainting. Most likely, it could be a questions of hypoglycemia. We will do a glucose tolerance test to rule out that and also we will do blood work.

6. She will try to eat six small meals a day. She does have to eat, and we do not think she has enough of food in her system post all the exercise that she does do.

7. We will follow up with the results by a letter or by phone call.

Grading Rubric

 

Student______________________________________

This sheet is to help you understand what we are looking for, and what our margin remarks might be about on your write ups of patients. Since at all of the white-ups that you hand in are uniform, this represents what MUST be included in every write-up.

 

1) Identifying Data (___5pts): The opening list of the note. It contains age, sex, race, marital status, etc. The patient complaint should be given in quotes. If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number.

 

2) Subjective Data (___30pts.): This is the historical part of the note. It contains the following:

 

a) Symptom analysis/HPI(Location, quality , quantity or severity, timing, setting, factors that make it better or worse, and associate manifestations.(10pts).

b) Review of systems of associated systems, reporting all pertinent positives and negatives (10pts).

c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem (10pts). If more than one chief complaint, each should be written u in this manner.

 

3) Objective Data(__25pt.): Vital signs need to be present. Height and Weight should be included where appropriate.

 

a) Appropriate systems are examined, listed in the note and consistent with those identified in 2b.(10pts).

b) Pertinent positives and negatives must be documented for each relevant system.

c) Any abnormalities must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe things. (5pts).

 

4) Assessment (___10pts.): Encounter paragraph and diagnoses should be clearly listed and worded appropriately including ICD10 codes.

 

5) Plan (___15pts.): Be sure to include any teaching, health maintenance and counseling along with the pharmacological and non-pharmacological measures. If you have more than one diagnosis, it is helpful to have this section divided into separate numbered sections.

 

6) Subjective/ Objective, Assessment and Management and Consistent (___10pts.): Does the note support the appropriate differential diagnosis process? Is there evidence that you know what systems and what symptoms go with which complaints? The assessment/diagnoses should be consistent with the subjective section and then the assessment and plan. The management should be consistent with the assessment/ diagnoses identified.

 

7) Clarity of the Write-up(___5pts.): Is it literate, organized and complete?

 

Comments:

 

Total Score: ____________ Instructor: __________________________________

 

 

 

 

 

 

Guidelines for Focused SOAP Notes

· Label each section of the SOAP note (each body part and system).

· Do not use unnecessary words or complete sentences.

· Use Standard Abbreviations

S: SUBJECTIVE DATA (information the patient/caregiver tells you).

Chief Complaint (CC): a statement describing the patient’s symptoms, problems, condition, diagnosis, physician-recommended return(s) for this patient visit. The patient’s own words should be in quotes.

History of present illness (HPI): a chronological description of the development of the patient’s chief complaint from the first symptom or from the previous encounter to the present. Include the eight variables (Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Treatment, Severity-OLDCARTS), or an update on health status since the last patient encounter.

Past Medical History (PMH): Update current medications, allergies, prior illnesses and injuries, operations and hospitalizations allergies, age-appropriate immunization status.

Family History (FH): Update significant medical information about the patient’s family (parents, siblings, and children). Include specific diseases related to problems identified in CC, HPI or ROS.

Social History(SH): An age-appropriate review of significant activities that may include information such as marital status, living arrangements, occupation, history of use of drugs, alcohol or tobacco, extent of education and sexual history.

Review of Systems (ROS). There are 14 systems for review. List positive findings and pertinent negatives in systems directly related to the systems identified in the CC and symptoms which have occurred since last visit; (1) constitutional symptoms (e.g., fever, weight loss), (2) eyes, (3) ears, nose, mouth and throat, (4) cardiovascular, (5) respiratory, (6) gastrointestinal, (7) genitourinary, (8) musculoskeletal, (9-}.integument (skin and/or breast), (10) neurological, (11) psychiatric, (12) endocrine, (13) hematological/lymphatic, {14) allergic/immunologic. The ROS should mirror the PE findings section.

0: OBJECTIVE DATA (information you observe, assessment findings, lab results).

Sufficient physical exam should be performed to evaluate areas suggested by the history and patient’s progress since last visit. Document specific abnormal and relevant negative findings. Abnormal or unexpected findings should be described. You should include only the information which was provided in the case study, do not include additional data.

Record observations for the following systems if applicable to this patient encounter (there are 12 possible systems for examination): Constitutional (e.g. vita! signs, general appearance), Eyes, ENT/mouth, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin, Neurological, Psychiatric, Hematological/lymphatic/immunologic/lab testing. The focused PE should only include systems for which you have been given data. Medical Assessment SOAP Note

NOTE: Cardiovascular and Respiratory systems should be assessed on every patient regardless of the chief complaint.

Testing Results: Results of any diagnostic or lab testing ordered during that patient visit.

A: ASSESSMENT: (this is your diagnosis (es) with the appropriate ICD 10 code)

List and number the possible diagnoses (problems) you have identified. These diagnoses are the conclusions you have drawn from the subjective and objective data.

Remember: Your subjective and objective data should support your diagnoses and your therapeutic plan.

Do not write that a diagnosis is to be “ruled out” rather state the working definitions of each differential or primary diagnosis (es).

For each diagnoses provide a cited rationale for choosing this diagnosis. This rationale includes a one sentence cited definition of the diagnosis (es) the pathophysiology, the common signs and symptoms, the patients presenting signs and symptoms and the focused PE findings and tests results that support the dx. Include the interpretation of all lab data given in the case study and explain how those results support your chosen diagnosis.

P: PLAN (this is your treatment plan specific to this patient). Each step of your plan must include an EBP citation.

1. Medications write out the prescription including dispensing information and provide EBP to support ordering each medication. Be sure to include both prescription and OTC medications.

2. Additional diagnostic tests include EBP citations to support ordering additional tests

3. Education this is part of the chart and should be brief, this is not a patient education sheet and needs to have a reference.

4. Referrals include citations to support a referral

5. Follow up. Patient follow-up should be specified with time or circumstances of return. You must provide a reference for your decision on when to follow up.