soap for brilliant

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