Soap Note x 3 (20 Hours)

 

1)  Submit 1 document per part

Part 1: Complete the file “Template Soap Note”  according to:

Name: NM

Gender: Male

Age: 77 years old

Diagnosis:  (L57.0) Actinic keratosis 

Chief complain:  scaly patches of skin 

Part 2: Complete the “Template Soap Note” taking into account the following information:

     Name: Rl

 

    Gender: Female

     Age: 67 years

     Diagnosis:  (I49.9) Cardiac arrhythmia, unspecied 

    Chief complain:  Rapid heartbeat and pounding in the chest

Part 3: Complete the “Sample Soap ” taking into account the following information:

Name: KY

    Gender: Female

    Age: 44

    Diagnosis:  (K64.9) Unspecied hemorrhoids  

    Chief complain:  Irritation and pain around the anus.

2)¨******APA norms, please use headers

          All paragraphs must be narrative and cited in the text- each paragraphs

          Bulleted responses are not accepted

          Dont write in the first person 

          Dont copy and pase the questions.

          Answer the question objectively, do not make introductions to your answers, answer it when you start the paragraph

         Submit 1 document per part

3) It will be verified by Turnitin and SafeAssign

4) Minimum 4 references per part not older than 5 years

Patient Initials:	Pt. Encounter Number:
Date:	Age:	Sex:
Allergies: Advanced Directives:
SUBJECTIVE
CC:
HPI: Describe the course of the patient’s illness: Onset: Location: Duration: Characteristics: Aggravating Factors: Relieving Factors: Treatment:
Current Medications:
PMH Medication Intolerances: Chronic Illnesses/Major traumas: Screening Hx/Immunizations Hx: Hospitalizations/Surgeries:
Family History:
Social History:
ROS
General
	Cardiovascular
	Skin
	Respiratory
Eyes
	Gastrointestinal
Ears	Genitourinary/Gynecological

SOAP NOTE

Skin

Cardiovascular

Respiratory

Gastrointestinal

Breast

Musculoskeletal

Neurological

Psychiatric

Nose/Mouth/Throat
	Musculoskeletal
	Breast
	Neurological
Heme/Lymph/Endo
	Psychiatric
OBJECTIVE
Weight BMI	Temp	BP
Height	Pulse	Resp
PHYSICAL EXAMINATION
General Appearance
HEENT
Genitourinary
Lab Tests

Special Tests

Diagnosis

· Primary Diagnosis-  Evidence for primary diagnosis should be documented in your Subjective and Objective exams. o Differential Diagnoses- Include three minimum diagnoses PLAN including education o Plan:  Further testing  Medication  Education  Non-medication treatments · Referrals  Follow-up visits

References

Patient: Mr. H, male 54 years old

Hispanic, Spanish

Chief complaint: “I been in pain for the last 3 months with minimal or without relief.”

History of present illness: Mr. H 54 year’s old male came to the office c/o left shoulder pain 8/10 without reliefs since last 3 months. He been taking OTC analgesic without success.

Objective

Information Allergies: NKDA.

Social History:

Patient 51 years old male denied smoking, alcohol intake or illicit drugs. Flu Vaccine 10/2019.

Past Medical History:

* Hypertension.

Medications:

* Lisinopril 25 mg PO daily.

Subjective:

Review of Systems:

Constitutional: Denies fever or distress.

Eyes: Denies any eye pain, redness, or tearing. Denies headache.

Ears, Nose, Mouth, and throat: Denies hearing loss or tinnitus or pain. No nasal congestion, drainage, redness, or swelling reported. Denies any throat pain.

Neck: Denies lumps or swollen glands, pain, or neck stiffness.

Cardiovascular: Denies chest pain, SOB or lightheadedness along with any palpitations at this time.

Respiratory: Denies any cough or shortness of breath.

Gastrointestinal: Denies abdominal pain, nausea, vomiting, diarrhea, or constipation. Patient reports having daily bowl movements.

Genitourinary: Denies discharge. Denies urgency, dysuria, or hematuria.

Musculoskeletal: Denies joint pain, stiffness, swelling, or muscle pain, other than left shoulder pain for the past 3 months.

Skin: Denies rashes, dryness, color change. No abnormalities of hair or nails.

Neurological: Denies headaches, dizziness, or vertigo. Denies numbness, paresthesias, or tremors.

Mental Health: Denies Psychiatric disorder/ Patient reports good memory and concentration. • Endocrine: Denies endocrine disorder.

Hematologic/Lymphatic: Denies bruising or bleeding. No prior blood transfusions/ No intermittent claudication. Denies leg cramps.

Allergic/Immunologic: No known allergies.

Objective

Physical assessment:

Vital Signs: Temp: 98F B/P (left arm): 131/77 mmHg P: 86bpm R: 19rpm O2 sat: 100% RA Weight: 144lbs High: 5’5” BMI: 24kg/m2

General: Patient AAO x3, well nourished, no acute distress, also denies weight change, fatigue, fever, chills, or night sweats.

Skin:Warm and dry. Good turgor. No surgical scars.

HEENT: No sore throat or earache. No blurry vision or double vision.

Thorax & Lungs:Equal thoracic expansion. Breath sounds clear to auscultation bilaterally, unlabored respirations, no accessory muscle use or retractions. No rhonchi, wheezing, or rales. No tenderness on palpation or percussion of chest wall or spine. Upon percussion, there is tympani bilaterally and symmetrically.

Cardiovascular: No chest pain or palpitations.

Gastrointestinal: Denies abdominal pain, nausea, vomiting, diarrhea, or constipation. Patient reports having daily bowl movements.

Abdomen:Soft to palpation, non-distended. No rebound, guarding or tenderness. Bowel sounds present x four quadrants. No hepatic or spleen enlargement. No masses palpated.

Genitourinary: No hematuria or dysuria..

Nervous System:Gross sensation intact. Coordination is intact. Gait is stable and grossly intact.

MS: left shoulder pain. Cap refill <3 seconds. Upper extremities with Radial pulses 2+/4 noted bilaterally, strength testing 5/5 bilaterally, ROM intact. Lower Extremities with Dorsalis pedals pulses 2+/4.

Psych: Patient cooperative, denies history of depression, and anxiety.

Lymphadenopathy: No palpable lymphadenopathies.

Diagnostic Findings:

* Physical examination. * R shoulder x-Ray.

Diagnosis:

* Shoulder osteoarthritis.

Differential diagnoses:

1) Degenerative joint disease.

2) Osteoarthritis.

3) Rheumatoid Arthritis.

Treatment and Educational plan:

1) Ibuprofen 800 mg one tablet q 12 hrs PO PRN if pain.

2) Gabapentin 300 mg twice daily.

3) Proper lifting technique, abdominal wall/core strengthening.

4) Shoulder MRI.

5) Occupational and Physical Therapy to evaluate and treat.

6) Follow up in one week.