Posted: February 28th, 2022

Review the Comprehensive SOAP Note Template

In Week 3, you completed a focused SOAP note. This week, you will complete a comprehensive SOAP note. Both types of SOAP note provide a cognitive framework for diagnostic reasoning and treatment planning.

To prepare:

Review the Comprehensive SOAP Note Template.
Select a patient who you saw at your practicum site during the last 5 weeks. With this patient in mind, consider the following:
Subjective: What details did the patient provide regarding the 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 CPT and ICD-10 codes 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 Assessment?

(M1021) Primary Diagnosis Code:
E11.9
03
(M1021) Primary Diagnosis
Type 2 diabetes mellitus without
complications
Severity:
(M1023) Other Diagnosis Code:
I10
03
(M1023) Other Diagnosis
Essential (primary) hypertension
Severity:
(M1023) Other Diagnosis Code:
E87.1
02
(M1023) Other Diagnosis
Hypo-osmolality and hyponatremia
Severity:
(M1023) Other Diagnosis Code:
N39.0
02
(M1023) Other Diagnosis
Urinary tract infection, site not specified
Severity:
(M1023) Other Diagnosis Code:
R11.2
02
(M1023) Other Diagnosis
Nausea with vomiting, unspecified
Severity:
(M1023) Other Diagnosis Code:
F32.A
02
(M1023) Other Diagnosis
Depression, unspecified
Severity:
(M1023) Other Diagnosis Code:
M54.59
02
(M1023) Other Diagnosis
Other low back pain
Severity:
(M1023) Other Diagnosis Code:
E78.5
02
(M1023) Other Diagnosis
Hyperlipidemia, unspecified
Severity:
(M1023) Other Diagnosis Code:
G90.09
02
(M1023) Other Diagnosis
Other idiopathic peripheral autonomic
neuropathy

1 – Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)
✓
✓
2 – Diabetes Mellitus (DM)
3 – None of the above

Patient is a 82 years old hispanic
female presented due to health/medical condition being unstable
and genarlized weakness, and recent discharge from hospital after a acute episode of UTI. Patient
requires partial Help with transfer.
Patient with multiple DX: DM II,
HTN, Depression, chronic low back pain, and other comorbidities.
Patient for Admission to HHCS based upon medical necessity and homebound status and based on the
assessment of the patient’s rehabilitation potential, that D/T multiple and complex medical condition that could deteriorate at anytime, the condition of the patient will
improve with continued skilled SN teachings/Management/monitoring for optimal outcomes / goal attainment, and or the services are necessary to the establishment of a
safe and effective maintenance program, and to prevent and exacerbation. Live with daughter. Referral to home care Apex SN , HHA, PT services for strengthen . UTI cleared at this time

1. LISINOPRIL 20 MG ORAL TABLET
1 tab twice a day By mouth (PO) New cardiovascular agents
2. 12/19/2022 GABAPENTIN 300 MG ORAL CAPSULE
2 cap twice a day By mouth (PO) New anticonvulsants
3. 12/19/2022 SODIUM CHLORIDE 1 mg
1 tab day QHS By mouth (PO) New nutritional products
4. 12/19/2022 PREDNISONE4MG ORAL TABLET
1 tab x 5 days By mouth (PO) New glucocorticoids
5. 12/19/2022 CARVEDILOL 25 MG ORAL TABLET
1 tab twice a day By mouth (PO) New cardiovascular agents
6. 12/19/2022 METFORMIN 500 MG ORAL TABLET
2 tab twice a day By mouth (PO) New antidiabetic agents
7. 12/19/2022 HYDROXYZINE HYDROCHLORIDE 25 MG ORAL TABLET
1 tab as need By mouth (PO) New central nervous system agents
8. 12/19/2022 SIMVASTATIN 40 MG ORAL TABLET
1 tab day By mouth (PO) New antihyperlipidemic agents
9. 12/19/2022 novolog 70/30 flex pen
30 units AM subcutaneous (SQ) New insulin
10. 12/19/2022 novolog 70/30 flex pen
20 units PM subcutaneous (SQ) New insulin
11. 11/17/2022 Tylenol 8HRS ARTHRITIS 650MG
1-2TABS EVERY 6HRS AS NEEDED FOR PAIN By mouth (PO)
Heart Rate: Greater Than(>) 90 Less Than (<) 60
Temp: Greater Than (>) 100 Less Than (<) 95 Respirations: Greater Than (>) 24 Less Than (<) 12 Pain Level: Greater Than (>) 7 O2
Saturation: Less Than (<) 95 Systolic BP: Greater Than (>) 160 Less Than (<) 60
Diastolic BP: Greater Than (>) 90 Less Than (<) 60 Blood Sugar, Fasting: Greater Than (>) 200 Less Than (<) 60 Blood Sugar, Random:
Greater Than (>) 300 Less Than (<) 60

Subjective

The patient is an 82-year-old female who presents with a chief complaint of generalized weakness. She reports that she has been feeling weak and tired for the past few months. She also reports that she has been having trouble walking and climbing stairs. She denies any pain or other symptoms.

The patient has a past medical history of type 2 diabetes mellitus, hypertension, depression, and chronic low back pain. She is currently taking lisinopril, carvedilol, metformin, glyburide, hydrochlorothiazide, prednisone, gabapentin, sodium chloride, and lisinopril.

Objective

The patient’s vital signs are within normal limits. Her physical exam is unremarkable, except for decreased muscle strength in her lower extremities.

Assessment

The differential diagnosis for this patient includes:

Polymyalgia rheumatica
Myopathy
Hypothyroidism
Anemia
Medication side effect
The patient’s history and physical exam are most consistent with polymyalgia rheumatica. Polymyalgia rheumatica is a chronic inflammatory disorder that affects the muscles of the neck, shoulders, and hips. It is most common in people over the age of 50. The diagnosis of polymyalgia rheumatica is based on the patient’s symptoms and physical exam. There is no specific test for polymyalgia rheumatica.

Plan

The patient will be started on prednisone. Prednisone is a corticosteroid that is used to treat inflammation. The patient will also be referred to a rheumatologist for further Assessment and treatment.

The patient will be monitored for side effects of prednisone, such as weight gain, mood changes, and increased risk of infection. The patient will also be monitored for improvement in her symptoms.

Reflection

The most important thing I learned from this patient encounter is the importance of a thorough history and physical exam. The patient’s history and physical exam were very helpful in making the diagnosis of polymyalgia rheumatica. I also learned the importance of referring patients to specialists when they have complex medical conditions.

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