INSTRUCTIONS: Using the blank SOAP Note Template (found in the Learning Materials module), complete a comprehensive SOAP Note for a patient in your target patient population. (THIS IS A COMPREHENSIVE SOAP NOTE).
S- 62-year-old female presents with left arm pain localized under the left armpit, ongoing for approximately 1 year and progressively worsening. The pain is rated as 10/10 in severity and is most pronounced at night, making it difficult to move the arm or sleep on the affected side. The area is tender to palpation. The most comfortable position is with the arm resting down. The pain radiates from the left axilla down the arm and is tender to palpation in the axillary area. Lifting the arm overhead exacerbates the pain, while holding it at the side provides relief. The patient also reports intermittent shortness of breath. Vitals are stable at this time. The patient expresses feelings of depression and anxiety related to work stress. (PHQ-9 score:17), reporting a lack of support from management and negative interactions with coworkers. The patient has been employed at Costco for 34 years and plans to retire next year, but is currently experiencing significant emotional distress and a desire to take time off work. Past history is notable for a motor vehicle accident 4–5 years ago, resulting in a right shoulder fracture, for which physical therapy provided minimal improvement. The patient also has a history of sciatic nerve pain and reports that an X-ray taken at an urgent care visit about one year ago revealed an “extra vein” in the left axillary region. However, no further evaluation or treatment was completed.Pt denies SOB, chest, palpitations, N/V/D, fever/chills, or any acute changes to health status.
MEDICATIONS: Medications ibuprofen 600 mg tablet, 1 tab by mouth every 6 hours prn pain CeleXA 40 mg tablet, TAKE 1 TAB PO QD guaiFENesin 100 mg/5 mL oral liquid, Take 10ml PO every 4-6 hours as needed for cough Lopid 600 mg tablet, Take 1 tablet PO twice daily citalopram 40 mg tablet, TAKE 1 TAB PO QD Vitamin D2 1,250 mcg (50,000 unit) capsule, Take 1 capsule PO weekly for 8 weeks
Mental/Functional: PHQ-9 total score: 17 The patient’s speech was normal, sharing conversation with normal laryngeal efforts. Appropriate mood and affect were seen on exam. Thought processes were logical, relevant, and thoughts were completed normally. Thought content was normal. Thought content was normal with no psychotic or suicidal thoughts. The patient’s judgement was realistic with normal insight into their present condition. Mental status included: correct time, place, person orientation, normal recent and remote memory, normal attention span and concentration ability. Language skills included the ability to correctly name objects. Fund of knowledge included normal awareness of current and past events.
Allergies No known allergies
O- Vital Signs: BP 133/63, HR 59, RR 15, T 98.3 °F, Ht 5’2″, Wt 180.6 lbs, BMI 32.99, SPO2 92%. Alert and oriented. Objective GEN: NAD NECK: supple, NT, FROM RESP: lungs clear to auscultation bilaterally, no rales, wheezes or rhonchi, nonlabored breathing, no use of accessory of muscles of respiration CV: RRR, no m/r/g GI: +BS, nontender to palpation, no masses, no HSM DERM: skin warm and dry EXT: no cyanosis/clubbing/edema NEURO: AO x 3 PSYCH: judgment/insight intact, NL mood/affect
IMMUNIZATIONS: Influenza (LAIV, TIV) Pneumococcal (PCV, PPSV) Tetanus; Diphtheria; Pertussis (Tdap, Td) Zoster (Shingles)
Medical History (PMHx) Other skin condition(s): NO MEDICAL HISTORY
Past Surgical History (PSHx) REMOVAL OF A MASS IN ARMPIT
Family History (FHx) father: Deceased mother: Deceased, +cancer (unsure of type)
Social History (SHx) Alcohol: Do not drink Tobacco: Never smoker
Social Determinants of Health (SDOH) No social determinants of health data have been documented for this patient
OB & Pregnancy History:
A-
Body mass index (BMI) 32.0-32.9, adult (Z68.32) Body mass index (BMI) 32.0-32.9, adult
Mild depression (F32.A) Depression, unspecified
Mass of left axillary region (L02.412) Cutaneous abscess of left axilla
Prediabetes (R73.03) Prediabetes
Obesity (E66.9) Obesity, unspecified
Anxiety (F41.9) Anxiety disorder, unspecified
Plan
Plan
Rx:
-ibuprofen 600mg q6
Diagnostics:
-mammogram
-US Left axillary
-annual labs
-CTscan with contrast (after annual labs)
Referral(s):
-psych
-therapy
Follow-up:
in 1-2 weeks for LAB and US review
INSTRUCTIONS:
Patient Information and Chief Complaint Includes required identifying information and clearly states the chief complaint in concise, appropriate language.
Subjective Data Subjective section is complete, relevant, and well organized, including HPI, pertinent past medical/surgical/family/social history, allergies, immunizations, medications, and ROS as appropriate to the visit.
Objective Data
Objective section is complete, accurate, and focused, including vital signs, physical exam findings, and relevant labs/diagnostics interpreted during the visit as appropriate. : (FOR PHYSICAL ASSESSMENT (EXAMPLE): please review proper PE documentation (health assessment course). What does the rash look like? Provide specific location of the rash, upper arm, medial arm? See exams below: Chest: normal AP diameter, symmetrical expansion, normal tactile fremitus bilaterally, clear on percussion and auscultation. No wheezes, rales or rhonchi heard. Cardiovascular: S1 and S2 normal, physiologic splitting, a loud S4 is present at the cardiac apex, no murmurs or rubs Respiratory: Lung sounds are even and unlabored. No crackles, rhonci or wheezing to auscultation. Able to converse w/o SOB or tachypnea. No sign of respiratory distress or accessory muscle usages. O2 saturation at 98%).
Assessment and Clinical Reasoning Identifies 2-3 appropriate differential diagnoses, includes ICD-10 codes, and supports the primary diagnosis with sound clinical reasoning based on subjective and objective findings supported with one to two references in APA format. (There must have a clinical reasoning based on subjective and objective findings supported with references).
Plan of Care Reflection demonstrates meaningful clinical insight, and the SOAP note is organized, concise, professional, and written at the graduate level with appropriate clinical terminology. Includes at least one to two references beyond the course learning materials.
