Review this week’s Learning Resources, including the Focused SOAP Note Template.
Select a patient who you saw at your practicum site during the last 3 weeks. With this patient in mind, consider the following:
Subjective: What details did the patient provide regarding his or her personal and medical history?
Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities and psychosocial issues.
Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 code for the diagnosis. What was your primary diagnosis and why?
Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?
77 year old Hispanic female presented to clinic with complaint of generalized weakness and blood in urine x 2 days and headache and neck pain.
Patient has a past medical history of Congestion Heart Failure, Diabetes Mellitus Type 2, Hypertension, and Hyperlipidemia.
Medication List:
Atorvastatin 20 mg PO daily
Aspirin EC 81 mg Daily
Isosorbide mononitrate 60mg twice daily
Lantus 15 units SQ Nightly
Ciprofloxacin 500 mg twice daily x 7 days for ( UTI)
Diagnostic: Urine dipstick positive for Urinary tract infection (pending urine culture) and COVID- 19 positive test