SOAP NOTE

SOAP NOTE

 

Writer whatever is not here you can make it up.

 

Assignment Prompt

Patient type: Adult Diabetes Type 2

ID: 35 yo, female, Hispanic, hixtory of DM, Depression

Case# 3231608

Comes to the office with c/o of R flank pain for the last 7 days due to lifting her big 50 pound dog, pain has been persistent on R flank, does not radiates, non-tingling, ache/discomfort debilitating. Has been unable to do house shores do to pain. Patient appears to be in pain and discomfort, breathing non labor, non-jaundice, making eye contact, historian.

Straight leg test : Positive

Has taken Medrol pack, Ibuprofen 600 as need with minor relieved.

Vitals: weights, 158, height 5’5, B/P 148.88, HR 84, temp 98.0, resp 18, pain scale 1-10 states a 7. Glucose 200 fasting.

NKA

Social: no smoking, no drugs, no alcohol intake, exercises 3 times a week x1 hr.

Family history :

Patients’ parents/ grand parents

Mother: 65 alive, DM no allergies

Maternal Grandparents: mother die at age 80 unknown reason; G parent die at 86 of stroke

Father: 66 alive- smokes, HBP

Paternal Grandparents: mother die at age 64 car accident unknow is any chronic disease, Parent alive age 87 has HBP and DM.

Patient was prescribed : Metformin 500 BID X30 days, Toradol shot 15 mg/1ml injection x1.  Flexeril 10 mg 3 times a day as need for muscle stiffness for 7 days.

Tylenol regular 650mg every 6 hrs as need for pain.

Educated s/e such as …. of medication/purpose

Be back in 1-2 weeks if condition does not improve or worsen. If SOB call 911.

Monitor glucose closely and keep a log. Educated the Medrol pack might has spike her glucose along.

Ibuprofen can lead to acute renal failure

Please see all other instructions below. 

asure there is 3 diferential dx with ICD10 codes for the cause of pain.

Patient end up having a: M54.59 – Other low back pain

 

 

 

 

(SAMPLE as per institution- This is just for your reference)

SOAP Note Week Two

ID: M M, DOB 1/1/2000, age 20, Hispanic male presents to the clinic unaccompanied and appears to be a reliable historian.

 

Subjective:

CC: “Cough, runny nose, and sore throat for 7 days”

 

HPI:

28 year old Hispanic male presents to the clinic unaccompanied, complaining of non-productive cough, runny nose and sore throat x 7 days (1/7/2020). Currently, he reports his symptoms are controlled with Dayquil and Nyquil. He reports his cough as mild, worsened when lying flat. Reports intermittent chills with highest temp at home was 99 degrees. Patient is here to see if he needs antibiotics. He rates his pain in his throat as 4/10, described as “aching, swallowing makes it worse”, relieved by Dayquil/nyquil but returns when that wears off after an hour. Denies headache, denies being around any other sick contacts and denies recent travel.

 

Past Medical History:

●        Medical problem list

  Asthma until high school,

  Chickenpox at age 2

  Sinus infections-chronic, GERD

●        Surgical:

  Tonsillectomy (1998),

  Wisdom Teeth Removal (2005)

Allergies:

No known drug allergies.

Food allergies:Strawberries (rash),

Denies seasonal allergies

Medications:

1. Dayquil 15ml 3-4 times daily
2. Nyquil 15ml HS
3. No prescription medications, denies NSAID use or Tylenol

Vaccinations:

Received all childhood vaccines

Last flu shot given Oct 2019.

Social History:

Chemical history:

Denies tobacco/e-cigarette use.

Occasional beer once every 2-3 months. Last drink 2 months ago

Engaged, works in IT, Hobbies include archery.

Family History:

    Mother age 60-Diabetes II (deceased)

    Father age 61, HTN, DM     Sister 42yo HTN     Maternal Grandma Dementia Deceased age 67

ROS:

General: Denies weight change, weakness, fatigue, (+)fevers..

Eyes: no vision change, corrective lenses, pain redness, excessive tearing, double vision, blurred vision, or blindness. EarsNose/Throat/mouth: no hearing changes, tinnitus, earaches, infection, discharge.

       (+) FOR RHINORRHEA. No sinus pain or epistaxis. (+) SORE THROAT, 

       (+) HOARSE VOICE. No bleeding gums, dentures, sore tongue, dry mouth.

       Last dental exam was 4 months ago.

C/V: Denies chest pain, palpitations. Pulmonary:(+)NON-PRODUCTIVE COUGH, denies hemoptysis, dyspnea, wheezing, pleuritic pain Neuro: Denies headache, dizziness, focal numbness/weakness, nausea, vomiting.

Lymph: Denies swollen lymph nodes in neck.

Allergy/immunology: Denies seasonal or environmental allergies (+) chronic sinus

     infections

 

Objective

VS: T – 98 P – 80 R – 16 BP – 128/72 O2 sat – 99% – 4/10 pain in throat. Wt: 205 Ht: 72 in BMI: 27.8

Labs, radiology or other pertinent studies: Rapid strep negative this visit

Skin: Natural in color, warm, smooth and dry. Good skin turgor, no lesions, rashes, ecchymosis or moles. Nails without clubbing or cyanosis.

HEENT:     Ears: pinna clean, no exudate noted. TM intact and pearly gray with cone of light bilat.     Nose: nasal mucosa reddened. Inferior turbinates with bilateral erythema with

      clear exudate. Nares patent bilat. No sinus pain upon palpation. Septum midline.    Throat: oral mucosa with erythema, tongue mobile without lesions, tonsils absent.    Neck: non-tender cervical area, no lymph nodes palpable. Non-enlarged thyroid

     palpated. Trachea midline. Neuro: Alert and oriented x 4. Appropriate, answers all questions. Cardio: RRR. Crisp S1 S2 without clicks or murmurs.

Thorax and lungs: Thorax is symmetric with good expansion. Respirations are even and unlabored. No use of accessory muscles, stridor, grunting, or nasal flaring. Lungs CTA Bilaterally.

(***notice not all systems are in the PE when doing a focused exam on a problem) 

A:

Differential DDX:               INCLUDE AT LEAST 3 DIFFERENTIALS

1. Viral pharyngitis – most likely as evidenced by clear exudate in nares, sore throat, cough, low grade fever (Stead, 2019). (←←←←←that is a practice treatment guideline)
2. Strep Throat – not as likely; low grade fever could be higher but Nyquil/Dayquil contains Tylenol but appearance and 7 days duration, lack of sick contacts and negative rapid strep test performed here in office this visit (Stead, 2019).
3. Allergic rhinitis – no report of sx increasing with outdoor activity or exposure to allergens, sx with sore throat are less likely for allergies. 
4. Sinusitis- he has chronic infections with current erythema in turbinates, however he has no pain on palpation of sinus cavities, exudate is clear, his nares are patent, and he reports no pressure.  

 

DX: Viral pharyngitis

 

Plan:

●        Diagnostics

               In house throat swab for rapid strep – negative.

               Chest Xray, CBC, BMP (Stead, 2019).

●        Treatment (specific medication with dosages here if this applies)

   – Continue to rest and drink lots of fluids (Cash & Glass, 2017; Stead, 2019).

               – Continue OTC Dayquil/Nyquil 15ml PRN per directions on the box 

●        Education

                – Safe dosing discussed, sedation may occur with Nyquil, avoid driving or

                   operating heavy machinery after taking. Do not exceed 4000 mg tylenol in

                   a day or take additional products with Tylenol.

               – Do not drink alcohol while taking these medications.

               – Encourage tea with honey and lemon to help with cough and sore throat.

               – Gargle with warm salt water 2-3 times a day for 30 sec, swish and spit.

               – Do not drink alcohol while taking these medications. 

               – Cover mouth when coughing, do not drink after other people

●        Follow-up

               Return to office in 3-4 days if symptoms do not start to improve, or the

               emergency room.                Call 911 or go to ER for trouble breathing or any other emergent concern

             (Stead, 2019).