Assignment: A SOAP Note Case Study

Assignment: A SOAP Note Case Study
Assignment: A SOAP Note Case Study
In this assignment, you will analyze a SOAP note case study that
describes abnormal findings in patients seen in a clinical setting.
You will consider what history should be collected from the
patients, as well as which physical exams and diagnostic tests
should be conducted. You will also formulate a differential
diagnosis with several possible conditions.
Abdominal Assessment
SUBJECTIVE:
· CC: “My stomach hurts, I have diarrhea and nothing seems to
help.”
· HPI: JR, 47 yo WM, complains of having generalized abdominal
pain that started 3 days ago. He has not taken any medications
because he did not know what to take. He states the pain is a 5/10
today but has been as much as 9/10 when it first started. He has
been able to eat, with some nausea afterwards.
· PMH: HTN, Diabetes, hx of GI bleed 4 years ago
· Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin
1000mg, Lantus 10 units qhs
· Allergies: NKDA

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