Jan 24, 2024 Week 4: Problem-Focused SOAP Note
Week 4: Problem-Focused SOAP Note
Criteria Ratings Pts
This criterion is linked to a
Learning Outcomes
(Subjective)
2.5 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.
2.5 pts
This criterion is linked to a
Learning Outcome
(Objective)
2.5 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.soap
2.5 pts
This criterion is linked to a
Learning Outcome A
(Assessment)
2.5 pts
Accomplished
Diagnosis and differential dx are correct,
include ICD code, and are supported by
subjective and objective data.
2.5 pts
This criterion is linked to a
Learning Outcome (Plan)
2.5 pts
Accomplished
The 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).
2.5 pts
Total Points: 10
Pls write soap note for otitis media. I can give you five days.
Patient initial: V. F.
DOB: 7/18/1946 Sex: F
Encounter Type: Office Visit
SUBJECTIVE:
Chief Complaint:
History Of Present Illness:
Pt is here for otitis/URI
Medical History:
.
#. Hyperlipidemia
#. trace-mild valvular dz
#. PAD, Venous stasis
#. b/l Thyroid nodules
#. Asthma, Allergic Rhinitis
#. Insomnia
#. Vitamin D deficiency
#. left forearm lipoma
#. osteopenia, DDD and sacral fx s/p repair, R plantar fascitis
Surgical History:
-Repair of sacral fracture in 2016
-Discectomy in 2008
Gynecological History:
G0P0A0
-Denies history of abnormal Pap smears or mammograms
Family History:
-Mother: deceased; CAD, COPD
-Father: deceased; PNA, COPD
-Brother: deceased age 79 d/t Lung CA, smoker
Social History:
-Married
-Lives with husband
-retired lawyer
-Former Smoker. Quit in 1982. 30 PY hx
-Reports 3-4 drinks/week
-Denies illicit drug use
Smoking Status: Never Smoked
Allergies:
No known allergies
Current Medications:
——————————————-
-atorvastatin 20mg qhs
-ASA 81mg qd
-Allergy shots qmo
-Breo Ellipta 200-25 1 puff 3x/wk
-Fluticasone NS
-Azelastine NS
-Ambien 10 mg qhs prn
——————————————-
Alternative Medications: ————————
-Mg 500m daily
-Flaxseed oil daily
-Vit D 5000IU daily
-Calcium 500mg qd
-MVI qd
Viviscal
Hair, skin and nails with biotin
—————————-
Advanced Directives:
FC
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: #blurry vision#
Ears: #R ear muffle hearing s/p URI#
Nose: Patient denies rhinorrhea, stuffiness, sneezing, itching.
Mouth: Patient denies ulcers, bleeding gums, taste problems.
Throat: Patient denies throat pain, difficulty swallowing,
Cardiovascular: Patient denies chest pain, chest pressure, palpitations, DOE, orthopnea.
Respiratory: Patient denies shortness of breath, cough, increased sputum, hemoptysis.
Gastrointestinal: Patient denies nausea, vomiting, heartburn, dysphagia, diarrhea,
constipation, melena, abdominal pain, jaundice, hemorrhoids.
Genitourinary: Patient denies abnormal frequency, urgency, hesitancy, incontinence,
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: #intermittent Insomnia#
Otherwise, patient denies depression, mood abnormalities, anxiety, memory loss, appetite
changes
Endocrine: Patient denies sensitivity to cold or heat, polyuria, polydipsia.
Hematologic/Lymphatic: Patient denies bleeding, bruising, lymphadenopathy.
GYN: Patient denies abnormal bleeding, changes in menstrual cycle, hot flashes.
OBJECTIVE:
Vital Signs:
Blood Pressure: 113/71 mmHg
Temperature: 97.70 F
Pulse: 68 beats/min
Physical Exam:
Constitutional:
WD, WN, Alert, Oriented X3 in NAD. Affect appropriate. Gait normal.
Eye: PERRLA, EOMI, nl conjunctiva
Ear: #erythematous R TM#
Nose: N1 mucosa. N1 Nasal septal walls and turbinates.
Mouth: N1 bucal mucosa, no lesions noted.
Throat: Clear, no erythema or exudates.
Neck: supple, no masses. No thyromegaly. 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: symmetric. No palpable breast masses or LAN. No nipple discharge.
Gastrointestinal (Abdomen): soft, nt, nd, bs(+). No palpable masses.
Genitourinary: Deferred to GYN
Lymphatic: -No LAN noted
Musculoskeletal: #left forearm lipoma#
good ROM. Strength symmetrical and wnl. No muscle weakness or stiffness. No joint
effusion or ttp.
Skin: #Extensive photodamage w/numerous moles#
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
ECG: –
-7/27/23 EKG normal
#. 2/22/21 EKG – SR
Imaging: .
#. 3/2022 echo – stable
#. 4/9/21- echo, carotid, venous, arterial U/S
#. 3/30/21- thyroid u/s
ASSESSMENT:
Diagnosis:
ICD-10 Codes:
1)H6690; Otitis media, unspecified, unspecified ear
2)J069; Upper respiratory infection, unspecified
PLAN:
Procedures:
1) 99213; Detailed
Medications:
Amoxicillin-Pot Clavulanate 875-125 MG Oral Tablet; Take 1 tablet orally 2 times a
day; Qty: 10; Refills: 0
Care Plan:
***otitis media- c/o muffled hearing s/p URI about 2 weeks ago after international travel.
COVID tests at home have been negative. R greater than L decreased hearing and
fullness, however denies any other associated sxs. on exam R TM slightly erythematous.
denies fever, drainage.
-Rx augmentin 875/125 x5 days, r/b d/w pt
-f/u 1 week if no resolution
***Hyperlipidemia- On 3/22/23, FLP showed 157/92/46/52, stable. well controlled on
Atorvastatin 20mg qhs and ASA 81mg qd. f/b cards Dr. Geisler. No s/e.
-low fat diet/exercise
-FLP annually
***mild valvular dz, DD – per Echo 4/9/21 showed Grade 1 diastolic dysfunction, mild
MR and trace MR, EF 61%. f/b cards Dr. Geisler. f/u echo 3/15/22 is stable, no evidence
of diastolic dysfunction
-mgmt per cards
***Mild PAD and mincarotid atherosclerosis- noted on U/S 4/9/21.
-monitor
-tx xol
***Asthma- F/b allergist, Dr. Farnam. controlled on Breo Ellipta 200-25 1 puff x3/wk
-cont
***Allergic Rhinitis, PND- F/b allergist, Dr. Farnam. controlled with monthly allergy
shots, Fluticaone and Azelastine NS. Eos 555H on 3/30/21.
-per A/I
***osteopenia- 5/16/22 DEXA showed -0.2/-1.1/-0.3, does not fulfill FRAX criteria.
Takes calcium 500mg bidand vit D 5K IU qd. does weight bearing exercises
-cont calcium and D, wt bearing
-DEXA due 5/16/24
Plan Notes Continued: .
***Insomnia- controlled on ambien 10 mg po qhs prn, infrequently. no s/e. requesting
refill
-CURES
-Rx ambien 10mg qhs prn insomnia, r/b d/w pt
-caution advise
***left forearm lipoma- On 12/6/19, MRI L FA wo contrast showed oval lipoma
between brachioradialis muscle and supinator muscle at the radial neck measuring 3.6
cm, which has increased in size.
-Monitor qyr
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: –
76 y/o F
-Annual PEX: done 3/13/23–next due 3/13/24
-Annual Labs: done 3/15/22–done 3/23/23
-HCV screening: nonreactive 9/28/18
-Cervical CA screening: mgmt per gyn
-Breast CA screening: done 4/12/22 neg- scr mammo ordered 3/13/23
-DEXA: done 5/16/22 osteopenia–next due 5/16/24
-Colon CA screening: Done 09/27/21 polyp +internal hemorrhoids– Normal– 09/2026
-Skin CA screening: mgmt by derm
Immunizations:
-influenza: fall 2022, and sep 2023
-RSV: sep 2023
-tetanus: done 2015–next due 2025
-zostervax: done 2016
-shingrix: 2 doses completed by 1/25/21
-prevnar: done 2016
-pneumovax: per pt report, she completed
-COVID-19: completed 2/19/21. Booster 9/17/21, Bivalent Fall 2022, and 9/18/23.
Week 4: Problem-Focused SOAP Note
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