ANSWER
This Mini-SOAP Note Template is formatted in accordance with the specifications given:
Initial Demographic Information: J
45 years old
Male gender
Subjective Chief Complaint (CC): “For the past week, I’ve been feeling very exhausted and breathless.”
J, a 45-year-old man, presents with a history of current illness (HPI) that includes shortness of breath and exhaustion that started about a week ago. The symptoms get a little better when you relax and get worse when you strain yourself. He denies having a fever, cough, palpitations, or chest pain. He says it is rare that he wakes up at night feeling out of breath and that he has mild swelling in his lower legs.
Previous Health History (PMH):
Five years ago, hypertension (HTN) was identified and managed with medicine.
elevated cholesterol levels.
Present-day Drugs:
10 mg of lisinopril every day.
20 mg of atorvastatin each day.
Allergies to medications:
Reports of none. Social History:
Smoker: 20 years, 1 pack each day.
Alcohol: Used infrequently (1–2 drinks per week).
Employment: Sedentary lifestyle, office worker.
Family Background:
Father: Coronary heart disease; passed away at age 62.
Mom: Diabetes type 2.
System Review (ROS):
General: No weight loss, fatigue.
Cardiovascular: Swelling in the lower extremities, dyspnea.
Respiratory: No hemoptysis, wheezing, or coughing.
Gastrointestinal: No pain in the abdomen, nausea, or vomiting.
Signs of Objective Vitality:
Blood pressure: 145/88 mmHg
HR: 96 beats per minute
RR: 18 m/min
Temperature: 98.6°F
94% SpO2 on room air
Exam of Mental Status:
Vigilant and focused x3. System-specific physical findings:
General: There was some respiratory discomfort.
Cardiovascular: No murmurs; regular rhythm and pace. +2 bilateral edema of the lower extremities.
Respiratory: Crackles on both sides of the lungs. Don’t wheeze.
No organomegaly, non-tender abdomen.
Extremities: There is bilateral pitting edema.
Screenings:
PHQ-9: 3 (no discernible signs of depression).
(moderate anxiety) GAD-7: 2.
Evaluation (ICD10/Diagnosis Code)
I50.9: Congestive heart failure (CHF).
elevated blood pressure (I10).
Diagnosis Differential:
lung conditions that cause chronic obstruction (COPD) (J44.9).
Plan Dx Plan:
BNP, CBC, CMP, and TSH labs.
Imaging: echocardiography and chest X-ray.
EKG to evaluate rhythm in the clinic.
Plan Tx:
Start taking 20 mg of furosemide each day to alleviate the symptoms of fluid retention.
Keep taking atorvastatin and lisinopril.
Patient Instruction:
discussed the potential adverse effects of furosemide (e.g., dizziness, dehydration) and the significance of medication adherence.
taught about limiting fluid intake and eating a low-sodium diet to lessen edema.
Plan for Safety:
advised the patient to get help right away if their chest hurts, their shortness of breath gets worse, or their swelling gets noticeably worse.
Referral/Follow-Up:
Cardiology is consulted for assessment and treatment.
follow-up for imaging and lab findings in a week.
This template can be modified to accommodate new requirements or discoveries while still adhering to the format specifications. Please let me know if you require any other help!
QUESTION
Submit 1 Mini-SOAP note on a patient that you saw in clinic this week. Submit as a Word Document. See example template below for required format.
Review the rubric for more information on how your assignment will be graded.
Demographic Data
· Patient initial (one initial only), age, and gender must be Health Insurance Portability and Accountability (HIPPA) compliant.
Subjective
· Chief Complaint (CC)
· History of Present Illness (HPI) (symptoms) in paragraph format
· Past Medical History (PMH): Current problem-focused and document pertinent information only.
· Current Medications:
· Medication Allergies:
· Social History: For current problem-focused and document only pertinent information only.
· Family History: For current problem-focused and document only pertinent information only.
· Review of Systems (ROS) as appropriate:
Objective
· Vital signs
· Mental Status Exam
· Physical findings listed by body systems, not paragraph form.
· Patient Health Questionnaires, Screenings, and the results (PHQ-9, GAD 7, suicidal)
Assessment (Diagnosis/ICD10 Code)
· Include all diagnoses that apply to this visit.
· Include one differential diagnosis.
Plan
· Dx Plan (lab, x-ray)
· Tx Plan: (meds)
· Pt. Education, including specific medication teaching points.
· Safety Plan
· Referral/Follow-up
*Based on population focus, some additional details may be required by faculty Top of Form