For this assignment, students will create ONE SOAP notes reflective of the patient care experience in the clinical setting under the
supervision of the clinical preceptor in the role of the clinical provider. This assignment will evaluate the student’s clinical reasoning
skills, interviewing skills, physical exam skills, selection of diagnostic testing, differential diagnosis, pharmaceutical and non-
pharmaceutical treatment, patient education, and follow-up plan.
Students must develop the clinical skills and knowledge required for safe practice and deliver best patient outcomes upon graduation.
SOAP notes should be used to document each patient seen in the clinical setting. Clear, concise, and thorough documentation is
required for continuity of care, safe practice, appropriate reimbursement, and prudent risk management.
When developing the SOAP note, students should use the assignment criteria below and the ACON SOAP Note Template found in
Modules/Week X. Students should include complete subjective and objective information to support the assessment and plan. The
plan must include diagnostic and treatment measures, patient education, and follow-up.
Keep the following points in mind:
Use the ACON SOAP Note template as a guide
Identify and collect relevant subjective and objective data.
Use proper medical terminology and documentation.
Use proper ICD-10 coding and Current Procedural Terminology (CPT) E/M coding.
Identify any cultural/religious/racial/gender influences on care.
Assignment Criteria:
Students will complete a Soap note and include the following:
1. Subjective findings
a. Chief complaint (CC)
b. History of present illness (HPI)
i. Use mnemonic: onset, location/radiation, duration, character, aggravating factors, relieving factors, timing, and
severity (OLDCARTS)
c. Past medical/surgical/social/family history
d. Medications
i. Allergies, prescription/over the counter (OTC)/herbal medications
e. Comprehensive review of systems (ROS)
2. Objective findings
a. Appropriate physical examination based on subjective findings.
b. Relevant positive and negative diagnostic testing including previous pertinent diagnostic tests related to visit.
c. Screening tools and positive and negative results
3.Assessment
a. Correct primary diagnosis.
b. Correct differential diagnoses.
c. Correct ICD-10/Current Procedural Terminology (CPT) codes
4. Plan
a. Identify and orders correct diagnostics, prescriptions, referrals, and follow-up plan.
b. Patient education relative to treatment plan.
c. Correctly written out a prescription for one medication prescribed for the patient.
i. If a medication is not prescribed, write out a prescription for a medication that might be prescribed for a similar
patient.
I’m attaching thetemplate that needs to be used AND an example for a patient that you can use
Patient
Subjective (S):
Chief Complaint (CC): Patient is a 79-year-old male presenting with complaint of left sided low back pain without radiation.
History of Present Illness (HPI): Patient is a 79-year-old male who presents complaining of left side lower back pain. Patient was referred by Dr. A. Patient with a history of A. Fib on Warfarin. Symptoms began around 3 week(s) ago without precipitating event. Pain radiates to and from the sacral area to the left buttock. The patient’s symptoms causes stiffness in the morning constant throughout the day. Patient is not able to sleep throughout the night with current symptoms. Symptoms are exacerbated with laying down, sitting increases symptoms with transition from sitting to standing, standing, walking. Symptoms are alleviated with sitting but for a brief period of time. Patient describes pain as a sharp sensation that is a 10/10. He has started to use a wheelchair due to the pain, he utilized a four point cane since his fracture in 2022. He suffers from issues with his balance since 1998 ago after an infection and his ear perforated. He had a bilateral lower extremities NCS/EMG study by Dr. S. No red flags. Patient denies numbness, tingling, fever, chills, night sweats, bowel or bladder incontinence issues.
PMH:
Ongoing A. Fib
Asthma
Chronic anticoagulation
Chronic ulcer of left leg
Cirrhosis of liver
Dyslipidemia
Fall risk
Fracture of rib of left side
History of lumbar surgery
HTN (hypertension)
Lumbar compression fracture
Overweight
Procedure/Surgical History:
*Kyphoplasty Lvl 4 (11/28/2022)
*Back
*Cardioversion
*Laminectomy
*Spinal fusion
Objectives (O):
Review of Systems (ROS):
Constitutional: No unexplained weight gain or loss, fevers, chills, fatigue, night sweats
Eye: No recent visual changes
ENMT: No ear pain, nasal congestion, sore throat
Respiratory: No shortness of breath, cough
Cardiovascular: No chest pain, palpitations, leg edema
Gastrointestinal: No nausea, vomiting, diarrhea
Genitourinary: No dysuria, hematuria, and no evidence of urinary incontinence
Hema/Lymph: Negative for bruising tendency, swollen lymph glands
Endocrine: Negative for excessive thirst or urination, heat or cold intolerance
Musculoskeletal: As per the history of present illness
Integumentary: No rash, itching, abrasions
Neurologic: No history of fainting, memory loss, numbness
Psychiatric: No anxiety, depression
Allergic/Immun: No nasal allergies, itchy/red eyes, enlarged lymph nodes
Medications:
alfuzosin 10 mg oral tablet, extended release, 10 mg= 1 tab(s), Oral, Daily
ascorbic acid 1000 mg oral tablet, 1000 mg= 1 tab(s), Oral, Daily
diclofenac 1% topical gel, 1 appl, Topical, QID, PRN
dutasteride 0.5 mg oral capsule, 0.5 mg= 1 cap(s), Oral, Daily
epinephrine 0.3 mg injectable kit, 0.3 mg, IntraMuscular, As Directed, PRN
folic acid 1 mg oral tablet, 1 mg= 1 tab(s), Oral, Daily
ipratropium 21 mcg/inh (0.03%) nasal spray, 2 sprays, Nasal, TID
Lidoderm 5% topical film, 1 patches, TransDermal, Daily, PRN
Metoprolol Succinate ER 25 mg oral tablet, extended release, 25 mg= 1 tab(s), Oral, Daily
potassium chloride 8 mEq (600 mg) oral capsule, extended release, 8 mEq= 1 cap(s), Oral, Daily
ProAir HFA 90 mcg/inh inhalation aerosol, 2 puffs, Inhale, Every 8 hr, PRN
Rosuvastatin 5 mg oral tablet, 1 tab(s), Oral, Daily
sertraline 25 mg oral tablet, 25 mg= 1 tab(s), Oral, Daily
Symbicort 160 mcg-4.5 mcg/inh inhalation aerosol, 2 puffs, Inhale, BID
temazepam 30 mg oral capsule, 30 mg= 1 cap(s), Oral, Daily at bedtime
torsemide 40 mg oral tablet, 40 mg= 1 tab(s), Oral, Daily, 2 refills
triamcinolone 0.1% topical cream, 1 appl, Topical, BID
valsartan 80 mg oral tablet, 80 mg= 1 tab(s), Oral, Daily
warfarin 5 mg oral tablet, 5 mg= 1 tab(s), Oral, Every evening
Zioptan 0.0015% ophthalmic solution, 1 drops, Eye-Both, Every evening
Lab Results:
Hemoglobin: 11.7 g/dL Low
Hematocrit: 34.9 % Low
WBC: 5.79 K/uL
Platelet Count: 128 K/uL Low
PT – INR (Prothrombin Time): 26.3 seconds High
PT (Point of Care): 27.5 sec High
International Normalized Ratio: 2.4 High
INR (Point of Care): 2.3 High
PTT (Partial Thromb Time): 42.4 seconds High
Sodium on Blood: 138 mmol/L
Potassium on Blood: 3.5 mmol/L
Chloride on Blood: 98 mmol/L
CO2 on Blood: 38 mmol/L High
Anion Gap: 2 mmol/L
Glucose on Blood: 84 mg/dL
Creatinine on Blood: 0.8 mg/dL
BUN on Blood: 26 mg/dL High
Calcium (Total): 8.1 mg/dL Low
Total Protein on Blood: 6.8 g/dL
Albumin on Blood: 3.8 g/dL
Globulin: 3 g/dL
ALT (SGPT) on Blood: 26 U/L
AST (SGOT) on Blood: 38 U/L
AST/ALT Ratio: 1.5 ratio
Alkaline Phosphatase on Blood: 136 U/L High
Total Bilirubin on Blood: 1.6 mg/dL
Bilirubin (Direct): 0 mg/dL Low
Bilirubin, Indirect: 1.6 mg/dL High
Lactic Acid (Lactate): 1.1 mmol/L
Troponin I (Quant): 0.02 ng/mL
TSH: 0.971 uIU/mL
Color – UR: Yellow
Appearance-Ur: Clear
Glucose – Urine: Negative UC
Bilirubin – UR: Negative POC
Acetone (Ketones)-Urine: Negative POC
Specific Gravity: 1.035 High
Blood: Negative POC
PH in Urine: 5
Protein, UR SCR: 30 Abnormal
Urobilinogen: 1.0
Nitrite: Negative Chem
Leukocyte Esterase: Negative POC
WBCs – UR: 0 /HPF
RBCs – UR: 1 /HPF
Bacteria: None Seen
Culture Blood-Peripheral: Negative
Culture & Gram-Sputum: Negative
Influenza A by PCR: Negative- GenX
Influenza B by PCR: Negative- GenX
RSV by PCR: Negative- GenX
SARS-CoV-2 (COVID-19): Negative- GenX
Diagnostic Results:
-CT scan without contrast of the lumbar spine- laminectomy and fusion of L3, L4 and L5 resection of the spinous process of L3 and L4. There is old compression fracture deformity of the superior endplate of L1. L2-3 posterior disc bulge and osteophyte formation causing bilateral foraminal stenosis with mild stenosis of the thecal sac. L4-5 disc bulge and osteophyte formation resulting and bilateral foraminal narrowing with mild stenosis of the thecal sac. L5-S1 posterior disc bulge resulting in stenosis of bilateral foramina with no significant thecal sac stenosis.
-CT scan of the cervical spine shows C2-3 small focal central posterior disc extrusion asymmetric towards the right, mild narrowing of the canal, mild right uncovertebral hypertrophy. C3-4 grade 1 anterolisthesis with mild to moderate right uncovertebral hypertrophy and focal central posterior disc protrusion contributing to mild narrowing of the canal, severe right facet joint hypertrophy, severe right foraminal narrowing. C4-5 grade 1 retrolisthesis with mild bilateral uncovertebral hypertrophy, inferior endplate of C4 anterior osteophytes. Mild right facet hypertrophy. Moderate right foraminal narrowing. C5-6 moderate left and mild right uncovertebral facet joint hypertrophy, disc bulge, severe left and moderate to severe right foraminal narrowing. C6-7 disc bulge, mild bilateral uncovertebral hypertrophy contributing to moderate to severe left and moderate right foraminal narrowing. C7-T1 grade 1 anterolisthesis, mild right foraminal narrowing, moderate right and mild to moderate left facet arthropathy.
-MRI of the lumbar spine demonstrates mild acute compression fracture at L1 with marrow edema. There is laminectomy seen from L3-L5. L2-3 spondylolisthesis, osteoarthritis causing moderate narrowing of the spinal canal and marked narrowing of bilateral foraminal. L5-S1 small left paracentral disc with superior disc extrusion causing mild narrowing of the spinal canal unchanged since 6/28/2022.
Physical Exam:
Vitals & Measurements: HR: 55 (Peripheral), BP: 120/47, HT: 188 cm, WT: 87 kg (Measured), BMI: 24.62
GENERAL: The patient is a well-developed, well-nourished, and appears uncomfortable
Head: Normocephalic and atraumatic
Eyes: Conjunctivae clear. Eyelids normal and palpebral fissures equal. No discharge from the eyes.
Ears: Auditory acuity is functional.
Neck: Supple.
Skin: Inspection of the skin (including head and neck, the trunk, the right and left upper extremities, and the right and left lower extremities) yields no evidence of rashes or ecchymosis.
Cardiovascular: Examination of the peripheral vascular system yields no evidence of swelling or peripheral edema
Respiratory: Respirations are non-labored.
Lymphatic: No palpable or visible regional lymphadenopathy in the neck, axilla or other obvious locations.
Psych: Awake, alert and oriented x3, pleasant and cooperative
Motor Exam:
Right and Left Deltoid: 5/5
Biceps: 5/5
Triceps: 5/5
Brachioradialis: 5/5
Grip: 5/5
Hand Intrinsics: 5/5
-LOWER EXTREMITIES
Iliopsoas: left-5/5
right-4/5
Quadriceps: 5/5
Hamstrings: 5/5
Gastrocnemius: 5/5
Anterior Tibialis: 5/5
EHL: left-5/5
right-4/5
DEEP TENDON REFLEXES:
Right and Left Bicep: 2/4
Triceps: 2/4
Brachioradialis: 2/4
Patella: 1/4
Achilles: 0/4
GAIT/STATION:
No evidence of antalgic or ataxic gait. Able to walk on heels and toes with handheld assist.
Neck: Cervical spine is midline. No scoliosis or kyphosis is noted.
ROM: Full active range of motion of the cervical spine.
Palpation: No tenderness to palpation along the cervical paraspinals, levator scapula and upper trapezius muscles bilaterally
Special Tests: Negative Spurling test
Back: Lumbar spine is midline. Thoracic kyphosis is noted
ROM: Decrease active range of motion of the lumbar spine extension more limited than flexion. Extension elicited discomfort on the lumbar spine
Palpation: Mild tenderness to palpation along the left lower lumbar paraspinals, PSIS.
Special Tests: Negative straight leg raise; Negative seated slump test; Negative facet loading provocative maneuvers
Upper extremities:
Light touch sensation: Intact in all dermatomes tested
Pinprick sensation: Intact in all dermatomes tested
Tone: Normal in bilateral upper extremities. No clonus noted
Pulses: Radial pulses palpable
Special Test/Maneuvers: Negative Hoffmann reflex
Lower extremities:
Light touch sensation: Intact in all dermatomes tested
Pinprick sensation: Intact in all dermatomes tested, except decreased pinprick sensation along L4, L5 dermatome distribution on the right foot.
Tone: Normal in bilateral lower extremities. No clonus noted
Pulses: Dorsalis pedis pulses palpable
ROM: Hip range of motion within decreased bilateral, passive ROM pain free. Pain free resisted hip abduction in the sitting position.
Special Test/Maneuvers: Babinski sign negative; Provocative FABERE aggravated his left buttocks pain.
PHQ2 and PHQ9:
Feeling Down, Depressed, Hopeless: Not at all
Little Interest – Pleasure in Activities: Not at all
Initial Depression Screen Score: 0
Assessment/Plan:
1. Low back pain (M54.50: Low back pain, unspecified)
-This is a pleasant 79-year-old male with known history of atrial fibrillation on warfarin, presenting with complaint of acute left-sided low back pain with onset 3 weeks ago without precipitating event. He was referred by Dr. A.
-His pain is constantly increasing with transitional position, from laying down to sitting, from sitting to standing, walking alleviated mildly and for a brief period of time with sitting. This pain has limited his activities of daily living, walking distance, he was using a 4-point cane for more than 20 years and started using a wheelchair since his pain started for ambulation.
-He has been taking Baclofen 10 mg twice daily without relief. He tried tizanidine 2 mg in the past but stopped due to side effects. He also takes Tylenol arthritis 2 tabs twice daily without relief. He is on warfarin 5 mg for anticoagulative purposes and he avoids NSAIDs.
-He reports having steroid injections by Dr. A in the past with relief, his last injection was 5 years ago. He is unable to tell if they were epidural lumbar steroid injection versus sacroiliac joint steroid injections. He also has history of laminectomy and fusion by Dr. A and L2 kyphoplasty by Dr. S on 12/2022. He had a recent bilateral lower extremity EMG/NCS study by Dr. S with results of bilateral peripheral neuropathy.
-CT scan without contrast of the lumbar spine- laminectomy and fusion of L3, L4 and L5 resection of the spinous process of L3 and L4. There is old compression fracture deformity of the superior endplate of L1. L2-3 posterior disc bulge and osteophyte formation causing bilateral foraminal stenosis with mild stenosis of the thecal sac. L4-5 disc bulge and osteophyte formation resulting and bilateral foraminal narrowing with mild stenosis of the thecal sac.
-His exam is significant for left iliopsoas and EHL weakness (4/5), absent bilateral Achilles tendon reflex, provocative Fabere aggravated his left buttocks pain. His presentation is suggestive of lumbar radiculitis, Neurogenic claudication due to spinal stenosis and sacroiliac joint dysfunction are also in the differential.
-He has not participated in formal physical therapy for more than 6 months. I discussed the importance of core strengthening with patient and spouse who was present at the time of the visit. I will provide him with a prescription for physical therapy today.
-Patient is interested in a repeat steroid injection. We will request medical records from Dr. A. per patient and spouse request.
-We will obtain plan films and MRI of the lumbar spine with and without contrast for further evaluation and treatment planning. Patient states he is able to have MRIs done as he has done many in the past.
-I will discuss case with Dr. G for possible steroid injection. Patient verbalized understanding and agreed. He hopes to have this injection as soon as possible. Patient denies bowel or bladder changes, saddle anesthesia at the time of the visit.
2. History of lumbar surgery (Z98.890: Other specified postprocedural states)
-Physical Therapy Outpatient Treatment ordered.
3. Sacroiliac joint dysfunction of left side (M53.3: Sacrococcygeal disorders, not elsewhere classified)
4. History of kyphoplasty (Z98.890: Other specified postprocedural states)
5. On warfarin for atrial fibrillation (I48.91: Unspecified atrial fibrillation)
-The plan of care involves recommending to undergo physical therapy for core strengthening. Further evaluation includes obtaining plan films and an MRI of the lumbar spine with and without contrast. Repeat steroid injection, pending medical records from Dr. A, and consultation with Dr. G for possible injection are considered. The patient is advised to continue warfarin for atrial fibrillation.
-FULL CODE: CODE STATUS
