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
- Week 3: Problem-Focused SOAP Note
