Soap note discussion
60 yr old female with history of COPD, DM type 2, and HTN presents to clinic with increasing SOB X 5 days. She has 30 pkd smoking history and currently smokes 20 cigs/ a day. She was recently hospitalized 3 months ago for PNA.
A. Write a hypothetical SOAP note based on the data given:
See Patient’s Medication list below:
1. Symbicort 80 mcg/4.5 mcg 2 puff inhaled BID
2. Spiriva 18 mcg 2 puff inhaled qd
3. Advair HFA 115 mcg/ 21 mcg 2 puff q 12 hr
4. Lisinopril 20 mg one tab po qd
5. Metformin 500 mg one tab twice a day
6. Losartan 100 mg one tab daily.
7. Lasix 20 mg one tab at bed time
B. Review medications list. Any red flags with this medication list ? Any medications that is contraindicated here?
Review UpToDate for Medication Management and Treatment Plan.
C. Document detailed PE of Respiratory and Cardiac system on SOAP Note.
D. Write a substantive response to a minimum of two different students. Is objective and subjective data included in the right format? Please be specific to information related to the SOAP note format.
- Would you agree with your peers differentials listed? Are there any diffs you would add/remove, if so explain your rationale.
- Does HPI have relevant information related to CC?
- Medication listed with right timing, dosing, and number of tablets specified? Any red flags with medication list?
- PMH, FH, and SH has all the appropriate information?
- Does information in ROS correlate to CC?
- Is there any information lacking in physical exam documentation of CC (Students often get confused between ROS and objective findings)?
- Includes assessment, plan, follow up information, and patient education?
See attached SAMPLE SOAP Note: Sample_ SOAP_ Note
20 points will be deducted for combining subjective and objective information. Please see example below:
ROS:
Example 1.
General: Alert and oriented, denies fatigue and chills.
( subjective and objective information is combined above. ” Alert and oriented” is part of PE general and not ROS.
Example 2.
ROS:
Resp: denies cough, wheezing, lungs sounds CTA bilaterally.
( subjective and objective is combined above;” lungs sounds CTA bilaterally” is part of PE
PE:
Example 1:
PE: Denies fatigue and chills. Alert and oriented.
” Denies fatigue and chills” is part of ROS and not PE.
Example 2:
PE: Bowel sounds present all quadrants. Denies abdominal pain.
” Denies abdominal pain” is part of ROS and not PE
