Problem-Focused SOAP Note

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