Week 3: Problem-Focused SOAP Note
Some Rubric
Criteria Ratings Pts
This criterion is linked to a
Learning Outcomes
(Subjective)
10 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.
10 pts
This criterion is linked to a
Learning Outcome (Objective) 10 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.
10 pts
This criterion is linked to a
Learning Outcome
(Assessment)
10 pts
Accomplished
Diagnosis and differential dx are correct, include
ICD code, and are supported by subjective and
objective data.
10 pts
This criterion is linked to a
Learning Outcome (Plan) 10 pts
Accomplished
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).
10 pts
Total Points: 40
Name: M*** Bostwick
DOB: 1947 Sex: F Encounter Date: 07/10/2023 Encounter Type: Telehealth
appt is requested for lab review
-Patient is seen today via Virtual Visit/Telehealth through VSee Clinic by agreement and
consent of patient in light of current COVID-19 pandemic. This patient encounter is
appropriate and reasonable under the circumstances given the patient’s particular
presentation at this time. The patient has been advised of the potential risks and limitations of
this mode of treatment (including but not limited to the absence of in-person examination)
and has agreed to be treated in a remote fashion in spite of them. Any and all of the
patient’s/patient’s family’s questions on this issue have been answered and I have made no
promises or guarantees to the patient. The patient has also been advised to contact this office
for worsening conditions or problems, and seek emergency medical treatment and/or call 911
if the patient deems either necessary.
Medical History:
Hyperlipidemia
Microscopic colitis on colonoscopy
Vitamin B12 insufficiency
Osteopenia
Shingles
CDiff associated with IV Abx
Skin CA to nose s/p Mohs
Hair loss
Surgical History:
Mohs 12/2022
Gynecological History:
G2P2A0
denies h/o abnormal pap or mammo
Family History:
M: CHF
F: Lung CA
brother: Prostate CA
Social History:
-Married
-Lives with spouse
-Retired Nursery Manager in Women’s prison
-denies tobacco
-ETOH: 1 glass wine with dinner (roughly 1 bottle per week)
-denies recreational drugs
Smoking Status: Never Smoked
Allergies:
No known allergies
Current Medications:
Currently not taking medications
Alternative Medications: IBguard
Calcium 600mg with Vit D 400IU bid
MV with vit D 1K IU qd
Biotin qd
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: 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: 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: Patient denies depression, mood abnormalities, anxiety, memory loss, difficulty
sleeping, appetite changes
Endocrine: Patient denies sensitivity to cold or heat, polyuria, polydipsia.
Hematologic/Lymphatic: Patient denies bleeding, bruising, lymphadenopathy.
GYN: Patient denies abnormal bleeding, hot flashes.
OBJECTIVE:
Physical Exam:
Constitutional:
#last exam done on 3/7/23 showed#
WD, WN, Alert, Oriented X3 in NAD. Affect appropriate. Gait normal.
Eye: PERRLA, EOMI, nl conjunctiva
Ear: #dry wax occluding b/l ear#
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: deferred to gyn per pt request, referred
Gastrointestinal (Abdomen): soft, nt, nd, bs(+). No palpable masses.
Genitourinary: deferred to gyn
Lymphatic: -No LAN noted
Musculoskeletal: good ROM. Strength symmetrical and wnl. No muscle weakness or
stiffness. No joint effusion or ttp.
Skin: #photodamage#
#thickened yellow Left foot 1st digit#
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
ASSESSMENT:
Diagnosis:
ICD-10 Codes:
1)E784; Other hyperlipidemia
PLAN:
Procedures:
1) 99213; Detailed
Medications:
Atorvastatin Calcium 10 MG Oral Tablet; Take 1 tablet orally nightly; Qty: 90; Refills: 0
Care Plan:
***hyperlipidemia- 3/21/23 FLP 243/67/113/153. ASCVD 9.3%. eats red meat and walks
3x/wk. declined statin previously and is trying lifestyle modifications with healthy diet and
walks 4-5K step daily. On 7/5/23 repeat FLP 234/67/116/144, no significant improvement.
-Rx atorvastatin 10mg qhs, r/ b d/w pt
-cont low fat diet, increase CV exercise
-f/u in 3 mos, order FLP
***vitamin B12 insufficiency- 3/21/23 vit B12 420.
-rec MV with B12 or B complex qd
-vit B12 annually
***Osteopenia- in the past. Per pt unkonwn last DEXA, several years ago. Takes Calcium
600mg with vit D 400IU bid. 3/21/23 vit D level 32.
-ordered DEXA 3/7/23
***b/l ear ceruminosis- dry wax noted to both ears
-debrox x4 d
-rtc for lavage
***onychomycosis- left great toe. saw derm and is only applying vinger with improvement.
-discussed terbninafine, pt will let us know if she is interested in Tx
Patient Instructions: .
-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 yo F:
-annual PEX: done 3/7/23–next due 3/7/24
-annual labs: done 3/21/23–next due 3/21/24
-cervical CA screening: 2022–referred to local gyn 3/7/23
-breast CA screening: 2022–referred to local gyn for screening per pt request
-DEXA: osteopenia, several years ago–ordered 3/7/23
-colon CA screening: 5/24/23 colonoscopy microscopic colitis–mgmt per GI
-skin CA screening: s/p Mohs, mgmt per derm
Immunizations
-influenza: 11/2022
-tetanus: over 10 years ago. rec on 3/7/23
-shingrix: rec on 3/7/23
-pneumovax: recommended for pt. will discuss in detail nv
Instead of telehealth, write as in person visit. Use template
Week 3: Problem-Focused SOAP Note
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