Complete a MINI SOAP note based on the
below data. Even if some information is not
included, you should list EXPECTED findings
(physical exam, labs, etc.) based on your
presumptive diagnosis.
SCENARIO:
Robert is a 67-year-old male who presents to
clinic with chief complaint, “I worry about
everything under the sun.” He reports equal
worry about small tasks as well as his wife
who is undergoing treatment for breast
cancer. Robert reports he is unable to control
his worrying causing difficulty failing asleep,
impatience with others, difficulty focusing at
work, and significant muscle tension.
Past medical history is unremarkable
Allergies: None
Meds: Daily Multivitamin
BMI: 28. VS: 123/78, 65, 16, 98.6, 98% RA
In order to earn full credit, follow the
instructions below:
1. Discuss what questions you would
ask the patient, what physical exam
elements you would include, and what
further testing you would want to have
performed.
2. In SOAP format, list:
a. Pertinent positive and
negative information
b. Differential and working
diagnosis
c. Treatment plan, including:
pharmacotherapy with
complementary and OTC
therapy, diagnostics (labs and
testing), health education and
lifestyle changes, age-
appropriate preventive care,
and follow-up to this visit.
d. Use at least one scholarly
source other than your
textbook to connect your
response to national
guidelines and evidence-
based research in support of
your ideas.
