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.

  1. Would you agree with your peers differentials listed? Are there any diffs you would add/remove, if so explain your rationale.
  2. Does HPI have relevant information related to CC?
  3. Medication listed with right timing, dosing, and number of tablets specified? Any red flags with medication list?
  4. PMH, FH, and SH has all the appropriate information?
  5. Does information in ROS correlate to CC?
  6. Is there any information lacking in physical exam documentation of CC (Students often get confused between ROS and objective findings)?
  7. 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:


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.


Resp: denies cough, wheezing, lungs sounds CTA bilaterally.

( subjective and objective is combined above;” lungs sounds CTA bilaterally” is part of 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

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