BPlease read the following scenario for the SOAP NOTE:
SCENARIO FOR SOAP NOTE #1.docx
Please review the rubric for the complete instructions for this assignment.
S – Write a focused history based on the chief complaint and include the 7 characteristics of a symptom, pertinent medical histories, review of systems (2 points)
O – Document findings of physical examination (2 points)
A – Give 3 differential diagnoses – three possible diagnoses (with codes) based on history and physical (3 points)
Keep in mind the 3 differential diagnoses should directly be related to the CC and the HPI. The problem list would include the patient’s other co-morbidities.
Give a scholarly defense of the ONE diagnosis that you chose.
P – Plan of care, including both pharmacological and non-pharmacological treatments, any diagnostic tests ordered, health promotion, and problem list. (3 points)
Problem List:
1. diagnosis from this visit
2. any other co-morbidities (from the medical history)
SAMPLE SOAP NOTE
C: “My cold is not getting better.”
HPI: P.L. is a 47 year old male, presenting with cold symptoms which he reports began 2 weeks ago but seemed to be improving until 3 days ago when he began experiencing a 7/10 frontal headache, a toothache, and increasing facial pressure, especially when bending over. He reports he has been coughing and occasionally producing thick mucus with the cough. The cough is worse in the morning. He denies fever, chills, shortness of breath, wheezing, body aches, neck pain, otalgia. Denies sick contacts within the last week. He has taken OTC multisymptom cold medicine and Nyquil with minimal relief. He does not recall a previous similar episode and has not taken antibiotics. He has a history of allergic rhinitis and recalls using a nasal spray. He denies a history of asthma.
PMH: Pt. reports hypertension and diabetes. Did not receive a flu shot this season. Tonsillectomy at age 10.
Medications: HCTZ 25mg once daily, Metformin 500 mg once daily, and OTC multivitamins
Allergies: Sulfonamides, aspirin. Reactions include swelling of the face, difficulty breathing and swallowing. Has an epi pen at home but does not carry it.
FH: Pt. is adopted and has no knowledge of significant family history.
SH: Pt. smokes 1 PPD (x 20 years) and drinks 2 beers 3 nights per week. He lives alone but lives next to his sister and her two preschool children. He eats dinner with them every night. He has no exposure to chemicals, pesticides, or other toxic agents. He just lost his job and his health care insurance, has no prescription coverage either.
ROS: Denies fever, chills. Denies sore throat, ear pain. Reports nasal discharge and bad breath. Denies SOB, chest pain, wheezing. Denies diarrhea, nausea, body aches, or neck pain. (Some of this is redundant-I moved the pertinent positives and negatives to the HPI)
Vital signs: Temperature 99.9 Pulse 88 regular RR 12 BP 160/88 Weight 180 lbs. BMI 25
PE: General: A & O x 3, in no acute distress. Well nourished.
Skin: Warm, dry, & intact, no unusual lesions, ulcers, rash, jaundice, or cyanosis. Nails pink.
HEENT: PERRLA. EOMs intact. No eyelid edema or erythema. TMs intact BL with + light reflex. Maxillary and frontal sinus tenderness upon palpation. Nasal mucosa erythematous and swollen. Turbinates large and pale (+3). Septum intact. Tonsils surgically absent. Pharynx erythematous. Post nasal drip noted at posterior pharynx. No oral lesions. Good dentition with a few fillings. No cervical lymphadenopathy. No goiter, carotid bruit or JVD.
Heart & Lungs: S1, S2 brief and clear, RRR, no murmurs or extra heart sounds. Lungs CTA. Congested cough noted.
Abdomen: Large, soft, non-tender, (+) BS, (-) HSM, masses, tenderness or CVAT
Neuro: CN II-XII grossly intact. No change in sensation. DTRs +2 BL
Extremities: Warm, no edema, no joint swelling. DP, PT + 2.
Assessment and Plan
Give me 3 possible diagnoses, WITH ICD 10 codes. Then choose which one it is and give a scholarlydefense of why you chose that diagnosis.
Then your diagnosis will be number one on your problem list, and the patient’s other co-morbidities will be listed according to priority.
Acute bacterial rhinosinusitis (new)
Start Augmentin XR 1000/62 mg take 2 tabs every 12 hours for 7 days-advised of SE
Alternative due to lack of insurance Amoxicillin 500 mg 2 take 2 tabs every 8 hours for 7 days
Probiotics recommended
Nasal sinus rinses as needed-Neil Med given to patient and technique demonstrated
Allergic rhinitis (chronic)
Restart Flonase 2 sprays/nostril daily advised of adverse effects
Environmental control-dust mite covers
Consider allergy testing
Diabetes (well controlled)
Continue metformin
SMBG 2-3 week
Therapeutic lifestyle changes-dietary plan provided
HbA1c
CMP, lipid panel, TSH, UA for microalbumin and EKG
Hypertension (poorly controlled)
Start lisinopril 5 mg daily, advised of SE
CMP in one month
Continue HCTZ ask about rash and discuss sulfa allergy
Advise against OTC medications that increase BP
Tobacco use
Smoking cessation discussed-FL Quit line recommended
Alcohol use
Discussed a plan for decreasing alcohol consumption
CAGE questionnaire
History of anaphylaxis
Reviewed procedure for epinephrine administration
EPI pen 2 pack use as directed
Health promotion
Recommend influenza vaccine
TSE
RTC in one week or sooner if S/S don’t improve
