Soap note
This will include three differential diagnoses with rationales for each, listed in order of likelihood or significance. The case study write-up should include at least 2 credible sources
- Title page
- Brief introduction to the patient
- Learning Issues- do you need more information in order to develop a plan? If so, what information do you need or want?
- Assessment in SOAP format:
- Subjective- include HPI, past medical history and medications
- Objective-physical exam findings, labs findings, or test results.
- Assessment- include 3 differential diagnoses including ICD-10 codes
- Plan- including what labs, tests are the next steps as well as the treatment plan for each diagnosis. Remember to include pharmacologic and non-pharmacologic treatments.
- Brief conclusion
- Reference page
Case 2
8:00 AM
Harold Baron
Age 56 years
Opening Scenario
Harold Baron is a 56-year-old African American man on your schedule for an annual health-care visit. He wants to start an exercise program. He has been seen in your practice for the past three years for episodic visits but has never been seen for health maintenance.
History of Present Illness
“I feel that I’m getting older and I’ve put on a few pounds, so I think I should start exercising. I’ll probably just start out with brisk walking, but I’d like to get up to running a few miles a day. I feel very healthy.”
Medical History
Denies chronic illness: No history of heart disease, HTN, or diabetes. Tonsillectomy and adenoidectomy as a child. Denies previous colonoscopy (screening or diagnostic)
Immunizations: Reports usual childhood immunizations; denies hepatitis A or B immunization; unsure of last tetanus immunization Has never received seasonal influenza immunization.
Last laboratory tests more than five years ago, per patient; unsure what was tested but were “all normal.”
Family Medical History
MGM: Died at age 82 (breast cancer)
MGF: Died at age 77 (myocardial infarction)
PGM: Died at age 80 (complications of type 2 DM)
PGF: Died at age 74 (stroke)
Mother: 81 years old (type 2 DM)
Father: Died at age 80 (stroke two years ago)
Brother: 58 years old (type 2 DM)
5
Daughter: 32 years old (A&W)
Son: 30 years old (A&W)
Four grandchildren: None with health problems
Social History
Married for 34 years; works full time as administrator in a post office, extensive computer use; no recreational exercise; quit smoking 15 years ago (25 pack-year history)
Alcohol: Three ounces per week (glass of wine)
Caffeine: Two cups of coffee per day
Safety: Wears seatbelt; does ride bicycle in summer on occasion and wears helmet; does not ride motorcycles; does not wear sunscreen
Medications
One multivitamin “for men” daily, last dose this AM
Vitamin D 1000 IU daily, last dose this AM
Acetaminophen 325 mg, two tablets once or twice daily for one to three days per week for knee pain, last dose two days ago
Allergies
NKDA
Review of Systems
General: Good energy level, denies fatigue; sleeps approximately seven hours a night; denies snoring, difficulty initiating or maintaining sleep; wakes rested and denies daytime drowsiness
Integumentary: Denies new lesions, itching, or rashes
HEENT: Denies history of head injury; denies eye pain, excessive tearing, blurring, or change in vision; denies tinnitus or vertigo; denies frequent colds, seasonal allergies, or sinus problems; dental examination with cleaning every six months; wears nonprescription glasses for reading only; eye examination (without dilation) 12 months ago
Neck: Denies lumps, swollen glands, goiter, or pain
Cardiovascular: Denies chest pain, shortness of breath, or elevated blood pressure; denies swelling in extremities. Denies excessive bruising, enlarged lymph glands; denies history of transfusions
Respiratory: Denies shortness of breath, cough, dyspnea, wheeze, orthopnea, snoring
Gastrointestinal: Denies nausea or vomiting, constipation, or diarrhea; denies heartburn, belching, bloating, stomach pain, black or clay-colored stools; denies having had a colonoscopy
6
Genitourinary: Denies dysuria, frequency, urgency, difficulty starting or stopping stream, and any sexual dysfunction; libido normal
Musculoskeletal: Right knee pain (4 out of 10) described as achy noted with prolonged walking, standing, climbing stairs; gradual onset present intermittently for past year; denies trauma to knee; denies swelling, redness, warmth; denies any other joint pain/ache; denies back pain
Neurological: Occasional (fewer than once per week) mild headache (bilateral frontal pressure) relieved by acetaminophen 325 mg; denies severe headaches; denies numbness/tingling, weakness; denies history of seizures, head trauma
Endocrine: No polyuria, polyphagia, polydipsia; denies history of thyroid disorder
Physical Examination
Vital signs: Temperature 98.4°
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