Wk3soap668B

Week 3: 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.

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

Use the template that I gave you before. The first page needs blank for cover sheet.

Diagnoses is R300; Dysuria. Needs ICD 10 codes for differential dx,

CPT codes for labs and procedures such as UA, Urine culture and sensitivity, physical

examination etc Do not paste and copy all (it needs paraphrasing). Research a lot for

patient education, pertinent positive and pertinent negative, non-pharmacologic

treatment etc. APA 7 format. I can give you five days to complete it.

Patient initial: J. V.

Patient DOB: 1963 Sex: F

SUBJECTIVE:

Chief Complaint:

History Of Present Illness:

-Patient is seen today for flank pain and dysuria

Medical History:

COVID pos 5/7/22

anemia

UTI, pyelonephritis s/p hospitalization w/sepsis

Mx kidney stones

Varicose Veis

Scoliosis

Surgical History:

Lithotripsy 2020

Gynecological History:

G5P5A0

denies h/o abnormal pap or mammo

Family History:

M: dementia, lupus, hypothyroid

F: varicose veins

Social History:

-single

-lives with children

-works as food service worker HMH

-denies tobacco

-denies ETOH

-denies recreational drugs

Smoking Status: Never Smoked

Allergies:

Macrobid; ; Dizziness

Morphine; ;

Current Medications:

Currently not taking medications

Review of System:

Constitutional: #fatigue#

Patients deny weight change, fever, chills, weakness, 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: 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: #R flank pain, dysuria, increased frequency#

Patient denies abnormal urgency, hesitancy, incontinence, hematuria, 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, changes in hair, changes in

nail, pruritus

Neurological: Patient denies headache, syncope, seizures, vertigo, ataxia, diplopia,

tremor, numbness, tingling.

Psychiatric: #insomnia#

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:

Height: 64.50 in

Weight: 139.40 lbs

BMI: 23.56

Blood Pressure: 135/78 mmHg

Temperature: 98.60 F

Pulse: 86 beats/min

Physical Exam:

Constitutional:

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: 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: 4/12/22: #L breast 3 o clock lumpiness, ttp#

Gastrointestinal (Abdomen): soft, nt, nd, bs(+). No palpable masses.

Genitourinary: #R flank CVAT#

Lymphatic: -No LAN noted

Musculoskeletal: #ttp over medial aspect of L knee with preserved ROM with small

healed 1 x1 cm scar from abrasion#

strength symmetrical and wnl. No muscle weakness or stiffness. No joint effusion

Skin: #callus noted between 4th and 5th metatarsal on L foot#

Normal color and texture.

Extremities: #varicose veins R greater than L#

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

Imaging: 9/21/22 arterial u/s neg

ASSESSMENT:

Diagnosis:

ICD-10 Codes:

1)M545; Low back pain

2)R300; Dysuria

3)R946; THYROID ABNORMAL RESULT

4)D649; Anemia, unspecified

5)R5383; Fatigue

PLAN:

Procedures:

1) 99215; Comprehensive

2) 99401; 15 min

3) 99000; Handling of specimen from doctor to lab

4) 81002; Urinalysis/Dip

Orders:

1) 5463; UA complete (lab order)

2) 395; UCX (lab order)

Medications:

Augmentin 500-125 MG Oral Tablet; Take 1 tablet orally every 12 hours; Qty: 14;

Refills: 0

Care Plan:

.

***recurrent UTI, h/o pyelo and sepsis- last UCx 4/12/22 showed 100K E coli resistant to

cipro and levaquin. Pt reports 2 day h/o R flank pain, dysuria, frequency and fatigue.

Tried Macrobid in the past which caused severe dizziness.

-UA 12/23/22 pos for leukocytes

-send out Ucx 12/23/22

-Rx Augmentin 500/125mg bid x7 days, r/b d/w pt

-ER precautions over holiday weekend

-referred to uro given recurrent UTI and high-risk history

***abnormal TSH- noted on labs 4/19/22. TSH 0.266 unsure if ever discuss

-reordered TSH 12/23/22

**fatigue- h/o anemia. pt reports hgb dropped to 9 once, donates blood occasionally. per

pt took iron in the past. no overt bleeding 4/19/22 cbc and irons normal. Pt requesting

again to check

-ordered iron panel, ferritin 12/23/22 per pt request

***elevated B12- 4/19/22 B12 level over 1500

-discuss nv, but will need to stop any supplementation

***L knee pain- fell and landed on L knee. worsen with prolonged standing. Reports she

had same pain on R knee and had steriod injection, which resolved it. On PEX, ttp over

medial aspect of L knee with preserved ROM with small healed 1 x1 cm scar.

-on 8/8/22 spoke to pt regrading her L knee x ray. MRI is recommended given that she

sustained a trauma to her knee and has radiologic findings of possible soft tissue injury.

She is in significant pain, takes Ibuprofen, reports difficulty with ambulation. Pt states

that she tried to make appt with ortho and radiology, but no slots were available anytime

soon.

-Needs MRI. Can either order or she can see ortho and do it with them. I was able to

arrange an appt for her to see Dr Panosyan tomorrow at 1:30.

***varicose veins, bil leg pain- to b/l LEX, R greater than L, chronic. c/o occasional

aching. prolonged standing and walking at work. 9/21/22 arterial duplex neg

-Ordered venous u/s 8/3/22

-referred to vein specialist 4/12/22 and 8/3/23

Plan Notes Continued: .

***Tinea cruris bilaterally – noted on PEX on 10/26/22

-Rx ketoconazole 2% cream top bid x 2wks, r/b, d/w pt

***Callus- Pt reports painful, itchy lesion in between 4th and 5th metatarsal. Works long

hours on her feet. Pt reports she has new shoes and tried OTC counter products with

no relief. Admits to trying her son's salicylic acid acne med on lesion. On PEX, small,

hardened callus is noted.

-Referred to podiatry on 10/26/22

***insomnia- chronic. has failed melatonin and hydroxyzine 50 mg. also took Ambien

5mg prn in past

-cont w/caution

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.

-Pt received counseling regarding stress management

PHCM: .

58 yo F:

-annual PEX: done 4/12/22–next due 4/12/23

-annual labs: done 4/19/22 unsure if ever discussed

-cervical CA screening: referred to gyn 4/12/22

-breast CA screening: dx mammo L breast u/s ordered 4/12/22

-colon CA screening: referred to GI 4/12/22

-skin CA screening: referred to derm 4/12/22

Immunizations:

-influenza: fall 2021

-tetanus: unsure, rec 4/12/22

-shingrix: rec 4/12/22

-COVID: Pfizer 5/2021, 6/2021, booster 3/2022