Create a focused exam SOAP note based on a case during your clinicals. This same case will be used for your Unit 6 presentation video. References should be guidelines that support the treatment plan and related condition/s.
Subjective
· Opener presentation of the patient (age/sex/presentation of issue with key past DX)
· History of present illness (HPI) (OldCarts)
· Other related past medical history
· Review of systems (ROS)
Objective
· Vital signs and physical exam on pertinent body systems
Assessment
· Assessment including differentials and specific labs or X-rays reviewed
Plan
· Explain the plan that you are suggesting or that was done, including any education, further work-up, specific medications with doses and frequency, consultations/referral, and follow-up.
Here is one of my soap notes from clinical. You can add/change as needed to make it work for the assignment please and give the references. Thanks!
I26.99 | Other pulmonary embolism without acute cor pulmonale Z71.87 | Encounter for pediatric-to-adult transition counseling
Patient Age:
45 Years
Patient Sex:
F
Patient Ethnicity:
White
Chief Complaint:
follow up s/p hospitalization
Mini-SOAP Note:
Pt presents today for follow up. She was hospitalized 3.4.24-3.5.24 for pulmonary embolism. Pt was seen here in the office by another provider in early Feb for leg pain. She had an ultrasound which showed superficial phlebitits. She was started on Naproxen. She was also seen by vascular for her varicose veins and was scheduled for another US however before she had that completed she became acutely SOB and went to the ER. Imaging in ER showed saddle PE and RLE DVT. Coag studies have been collected but are still pending. She was started on Eliquis. She had also been taking oral birth control which was discontinued. She reports her SOB has improved, especially in the last 1-2 days she is feeling much better. Her menses returned last week, as she previously had not been getting a period. She has a follow up scheduled with GYN in April. She denies CP. Denies any signs of bleeding including blood in stool, easy bruising. Notes some ongoing soreness in her right thigh. She is using heat. She has a follow up with hematology in 3 months. She is now taking Eliquis 5mg daily. VS 97.2-87-18-122/74-98% Reviewed hospital discharge summary, labs, imaging reports. Alert and oriented, normal affect. HEENT normal exam. Lungs clear, normal effort. Regular heart rate and rhythm, normal S1, S2 without murmur. No peripheral edema. +varicosities noted bilat LE. No swelling, redness. Abdominal exam benign. Plan: continue Eliquis 5mg daily. Follow up with GYN, vascular and hematology as scheduled. We discussed bleeding precautions, signs of bleeding. She had questions regarding foods to avoid which were answered. She was advised to schedule next available appointment for annual PE as she has not been seen in several years.
Create a focused exam SOAP note based on a case during your clinicals
Subjective:
– Patient Age: 45 years
– Patient Sex: Female
– Chief Complaint: Follow-up post-hospitalization for pulmonary embolism
History of Present Illness (HPI):
– Patient presents for follow-up after hospitalization from March 4th, 2024, to March 5th, 2024, for pulmonary embolism (PE).
– Patient previously seen for leg pain in early February, underwent ultrasound showing superficial phlebitis, and was started on Naproxen.
– Patient also had varicose veins evaluated by vascular, scheduled for ultrasound, but acutely developed shortness of breath (SOB) before completion and went to the emergency room (ER).
– Imaging in the ER showed saddle PE and right lower extremity (RLE) deep vein thrombosis (DVT).
– Coagulation studies pending.
– Started on Eliquis, discontinued oral birth control.
– Reports improved SOB, return of menses, denies chest pain (CP) or bleeding symptoms.
– Follow-up scheduled with gynecology (GYN) in April, and hematology in 3 months.
Past Medical History:
– No significant past medical history provided.
Review of Systems (ROS):
– Denies CP, bleeding symptoms except ongoing soreness in right thigh, using heat.
– Menses returned last week after previously absent.
Objective:
– Vital Signs: Temperature 97.2°F, Heart Rate 87 bpm, Respiratory Rate 18 bpm, Blood Pressure 122/74 mmHg, Oxygen Saturation 98%.
– Physical Exam: Alert and oriented, normal affect. HEENT normal, lungs clear, regular heart rhythm, no peripheral edema, +varicosities bilaterally, no swelling or redness, benign abdominal exam.
Assessment:
– I26.99 | Other pulmonary embolism without acute cor pulmonale
– Z71.87 | Encounter for pediatric-to-adult transition counseling
– Differential Diagnosis: Pulmonary embolism, superficial phlebitis, deep vein thrombosis.
– Labs: Coagulation studies pending.
Plan:
– Continue Eliquis 5mg daily.
– Follow-up with GYN, vascular, and hematology as scheduled.
– Education on bleeding precautions, signs of bleeding.
– Answered patient’s questions regarding foods to avoid.
– Advise scheduling next available appointment for annual physical examination.
References:
– American College of Chest Physicians. (2016). Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest, 149(2), 315-352. doi:10.1016/j.chest.2015.11.026
– National Institute for Health and Care Excellence. (2020). Venous thromboembolic diseases: diagnosis, management, and thrombophilia testing. Retrieved from https://www.nice.org.uk/guidance/ng158
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