Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. Provide a review of systems.Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results?Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential in or out. Explain you critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. Follow APA 7th edition formatting.Case Study 1:HPI: Ms. Lewis is a 63-year old female who comes into your office with concerns of low blood sugar in the morning, fasting. She reports seeing blood sugar as low as 50 fasting in the mornings for the last few weeks. She has a known history of Diabetes, Hypertension, Hyperlipidemia, and Chronic Osteoarthritis. She also reports elevated blood pressures. Her blood pressure at presentation is 165/90. RESOURCE FOR THIS WEEK: Review endocrine-related Evidence Based Practice Guidelines.Ms. Lewis is a 63 y/o female who is AAOX4. She makes no unusual motor movements and demonstrates no tics. She denies any visual or auditory hallucinations. She denies any suicidal thoughts or ideations. She denies any falls, denies any pain.(All other Review of System and Physical Exam findings are negative other than stated.)Vital Signs: BP 165/90, HR 89, RR 20, Temp 98.1PMH: Hypertension, Hyperlipidemia, Diabetes, Chronic OsteoarthritisAllergies: Penicillin, lisinoprilMedications:Women’s One A Day-Multivitamin dailyChlorthalidone 25mg dailyFish Oil 1 tablet dailyAmlodipine 5mg p.o. dailyAtorvastatin 40mg p.o. at bedtime dailyNovolog 10 units with meals TIDAspirin 81mg p.o. dailyLantus 25 units Subcutaneous nightlyErgocalciferol 50,000 units PO once a monthSocial History: as stated in Case StudyROS: as stated in Case studyDiagnostics/Assessments done:CXR- Last cxr showed no cardiopulmonary findings. Within normal limits.Basic Metabolic Panel and CBC as shown belowVitamin D Level- as noted below in lab resultsTESTRESULTREFERENCE RANGEGLUCOSE8565-99SODIUM134135-146POTASSIUM4.23.5-5.3CHLORIDE10498-110CARBON DIOXIDE2919-30CALCIUM9.08.6- 10.3BUN207-25CREATININE1.010.70-1.25GLOMERULAR FILTRATION RATE (eGFR)76>or=60 mL/min/1.73m2TESTRESULTREFERENCE RANGEVitamin D 1,25 OH5836-144TESTRESULTREFERENCE RANGEWBC7.33.4- 10.8RBC4.31135-146HEMOGLOBIN1413-17.2HEMATOCRIT42%36-50MCV9080-100MCHC3432-36PLATELET272150-400
Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S (subjective)
CC (chief complaint): a BRIEF statement identifying why the patient is here, stated in the
patient’s own words (for instance “headache,” NOT “bad headache for 3 days”).
HPI (history of present illness): This is the symptom analysis section of your note.
Thorough documentation in this section is essential for patient care, coding, and billing
analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to
complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34year-old AA male). You must include the seven attributes of each principal symptom in
paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might
look like the following example:
•
•
•
•
•
•
•
Location: Head
Onset: 3 days ago
Character: Pounding, pressure around the eyes and temples
Associated signs and symptoms: Nausea, vomiting, photophobia, phonophobia
Timing: After being on the computer all day at work
Exacerbating/relieving factors: Light bothers eyes; Aleve makes it tolerable but
not completely better
Severity: 7/10 pain scale
Current Medications: Include dosage, frequency, length of time used, and reason for
use; also include over the counter (OTC) or homeopathic products.
Allergies: Include medication, food, and environmental allergies separately, including a
description of what the allergy is (i.e., angioedema, anaphylaxis, etc.). This will help
determine a true reaction versus intolerance.
PMHx: Include immunization status (note date of last tetanus for all adults), past major
illnesses, and surgeries. Depending on the CC, more info is sometimes needed.
Soc and Substance Hx: Include occupation and major hobbies, family status, tobacco
and alcohol use (previous and current use), and any other pertinent data. Always add
some health promo question here, such as whether they use seat belts all the time or
whether they have working smoke detectors in the house, living environment, text/cell
phone use while driving, and support system.
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Fam Hx: Illnesses with possible genetic predisposition, contagious, or chronic illnesses.
Reason for death of any deceased first-degree relatives should be included. Include
parents, grandparents, siblings, and children. Include grandchildren if pertinent.
Surgical Hx: Prior surgical procedures.
Mental Hx: Diagnosis and treatment. Current concerns (anxiety and/or depression).
History of self-harm practices and/or suicidal or homicidal ideation.
Violence Hx: Concern or issues about safety (personal, home, community, sexual
(current and historical).
Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no),
Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse
(oral, anal, vaginal, other, any sexual concerns).
ROS (review of symptoms): Cover all body systems that may help you include or rule
out a differential diagnosis You should list each system as follows:
•
•
•
•
General:
Head:
EENT (eyes, ears, nose, and throat):
Etc.:
Note: You should list these in bullet format, and document the systems in order from
head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT:
•
•
Eyes: No visual loss, blurred vision, double vision or yellow sclerae.
Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore
throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations
or edema.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain
or blood.
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GENITOURINARY: Burning on urination. Last menstrual period (LMP), MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or
tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or
polydipsia.
REPRODUCTIVE: Not pregnant and no recent pregnancy. No reports of vaginal or
penile discharge. Not sexually active.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
O (objective)
Physical exam: From head-to-toe, include what you see, hear, and feel when doing your
physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and
History. Do not use “WNL” or “normal.” You must describe what you see. Always
document in head to toe format (i.e., General: Head: EENT: etc.).
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop
the differential diagnoses (support with evidenced and guidelines).
A (assessment)
Differential diagnoses: List a minimum of three differential diagnoses. Your primary or
presumptive diagnosis should be at the top of the list. For each diagnosis, provide
supportive documentation with evidence-based guidelines.
P (plan)
Includes documentation of diagnostic studies that will be obtained, referrals to other
health-care providers, therapeutic interventions, education, disposition of the patient,
and any planned follow up visits. Each diagnosis or condition documented in the
assessment should be addressed in the plan. The details of the plan should follow an
orderly manner.
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Also included in this section is the reflection. Reflect on this case, and discuss what
you learned, including any “aha” moments or connections you made.
Also include in your reflection, a discussion related to health promotion and disease
prevention taking into consideration patient factors (such as, age, ethnic group, etc.),
PMH, and other risk factors (e.g., socio-economic, cultural background, etc.).
References
You are required to include at least three evidence-based peer-reviewed journal articles
or evidenced-based guidelines, which relate to this case to support your diagnostics and
differentials diagnoses. Be sure to use correct APA 7th edition formatting.
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