SOAP Notes

SOAP Notes

SOAP Note 1

Demographic Data

• Patient Name: J.W
• Age: 82 y/o
• Sex: Female

Subjective

Chief Complaint (CC): Patient transferred to the medical facility, requiring further assessment and possible interventions.

History of Present Illness (HPI): J.W, an 82-year-old female, was admitted with a diagnosis of brain edema . She reported a sudden onset of severe headaches and episodes of confusion that started approximately a week ago. The symptoms progressively worsened, prompting her family to seek medical attention.

Past Medical History (PMH): No known allergies.

Family History (FH): No known hereditary conditions.

Social History (SH): No known history of alcohol or tobacco use.

Review of Systems (ROS)

• Constitutional/Gen: No weight loss, fatigue, or fever.
• Neurological: Severe headache, episodes of confusion.
• Cardiovascular: No chest pain, palpitations.
• Respiratory: No shortness of breath or cough.

Objective

• Neurological: Alert but appears confused at times; Cranial nerves intact.
• Cardiovascular: Regular rate and rhythm; No murmurs.
• Respiratory: Clear to auscultation bilaterally.

Assessment

Differential Diagnosis:

1. Migraine (G43): Migraines are recurrent headaches often accompanied by nausea, vomiting, and sensitivity to light (Uysal 725). While J.W  reports a severe headache, she does not exhibit other common migraine symptoms.
2. Transient Ischemic Attack (TIA) (G45.9): TIAs are brief episodes of neurological dysfunction due to a temporary decrease in blood supply to the brain (Uysal 722). Given her  age, IIA could be considered, but her continuous symptoms render this less likely.
3. Brain Edema (G93.6): Brain edema refers to swelling due to an excess accumulation of fluid in the spaces of the brain (Uysal 726). Patient presentation, including severe headache and confusion, points towards this possibility.

Final Diagnosis:

• Brain Edema (G93.6): Based on J.W presentation of a severe headache and confusion, alongside the imaging findings, Brain Edema is diagnosed.

Plan

1. Continue monitoring neurological status.
2. MRI brain to further assess the extent of edema.
3. Consult with neurology for further management and interventions.
4. Keep patient comfortable and ensure safety measures are in place to prevent falls or injuries.

SOAP Note 2

Demographic Data
• Patient Name: A.K

• Age: 76 y/o
• Sex: Male

Subjective

Chief Complaint (CC): Patient presents to clinic with c/o weakness and fatigue. Referred for home health services due to physical deconditioning and need for physical therapy.
History of Present Illness (HPI): A.K, a 76-year-old male, was diagnosed with head and neck cancer. He is experiencing physical deconditioning as a result of his illness. The need for physical therapy arose due to difficulties in mobility and to prevent further decline.
Past Medical History (PMH): Head and neck cancer (HCC/RAF).
Family History (FH): No known hereditary conditions.
Social History (SH): No known history of alcohol or tobacco use.

Review of Systems (ROS)

• Constitutional/Gen: No reported weight loss, fever, or fatigue.
• Neurological: No reported cognitive deficits or headaches.
• Cardiovascular: No chest pain, palpitations.
• Respiratory: No shortness of breath or cough.
• Musculoskeletal: Physical deconditioning decreased mobility.

Objective

• Neurological: Alert and oriented.
• Cardiovascular: Regular rate and rhythm; No murmurs.
• Respiratory: Clear to auscultation bilaterally.
• Musculoskeletal: Limited mobility and strength in lower extremities.

Assessment

Differential Diagnosis:

1. Muscle Atrophy (M62.50): The decline in muscle mass and strength due to the lack of activity. A.K’s physical deconditioning could be linked to muscle atrophy.
2. Generalized Weakness (R53): Overall decreased strength and fatigue, which may arise from various underlying causes, including his primary diagnosis.

Final Diagnosis:

• Physical Deconditioning: Due to head and neck cancer and prolonged inactivity, Mr. Klein experiences a decline in physical strength and mobility.

Plan

1. Initiate home-based physical therapy services.
2. Focus on gait training and home safety evaluation.
3. Evaluate and provide necessary assistive devices for mobility.
4. Regular monitoring and adjustment of therapy based on progress.

SOAP Note 3

Demographic Data

Patient Name: H.D

DOB: 08/10/1955

Age: 66 Y/o

Sex: Male

Subjective

Chief Complaints: CAD (Coronary Artery Disease) and CHF (Congestive Heart Failure).

History of Present Illness (HPI)

• Doing well from a cardiac standpoint without symptoms.
• No chest pain, shortness of breath, palpitations, or dizziness.

Medications:

• NSTEMI TZ 6/2021.
• LHC= PCI LAD x 2, CX x 1, distal small vessel disease 6/2021.
• Echo 6/2021 EF45, mild MR, DM (Diabetes Mellitus).
• Nitroglycerin 0.4 mg/hr film, extended release.
• Metformin 500 mg tablet.
• Toprol-XL 50 mg tablet, extended release.
• Brilinta (ticagrelor) 90 mg tablet.
• Aspir 81 81 mg delayed release tablet.
• Rosuvastatin 20 mg tablet.

Review of Systems (ROS)

• Constitutional: No current complaints.
• HEENT: No headache, blurred vision, diplopia, or dysphagia.
• Chest: No COPD, asthma, wheezing, hemoptysis, or cough.
• Cardiac: No chest pain, palpitations, or shortness of breath.
• Abdomen: No pain or tenderness.
• Endocrine: No acute endocrine symptoms at this time.
• Neurological: No generalized or focal weakness.

Objective

• Constitutional/Gen: Elderly male appearing his stated age, alert and coherent.
• Neck: Jugular vein pulsation normal, no carotid bruits, supple
• Lungs: Clear to auscultation, no wheezes, no accessory muscle use
• Abdomen: Soft, non-tender, BS+, no guarding
• Extremities: No edema
• Head: Normocephalic/AT
• Heart: Regular rate and rhythm, no murmurs, gallops, s3, or s4
• Neurologic: Non-focal, symmetrical reflexes, no significant motor or sensory deficits
• Peripheral: 2+ pulses bilaterally

Assessment

1. Chronic Ischemic Heart Disease, Unspecified – 125.9: The patient has a history of coronary artery disease, which may have led to ischemic changes in the heart muscle. No acute ischemic symptoms have been reported recently.
2. Systolic CHF – 150.20: The patient has previously been diagnosed with systolic congestive heart failure, supported by the Echo from 6/2021 showing an EF of 45%. The patient is currently asymptomatic regarding CHF symptoms.
3. Hypertension (HTN) – 110: The patient’s blood pressure reading from 06/21/2021 was 144/84 mm/Hg, which indicates elevated blood pressure. The patient’s history also includes episodes of increased BP.
4. Diabetes – E11.9: Type 2 Diabetes Mellitus is supported by the patient’s medical history and current medications, including metformin.

Plan

Chronic Ischemic Heart Disease:

1. Continue asa, brilinta, crestor and toprol.
2. Increase physical activity as tolerated.  

Systolic CHF:

1. EF 45% post PCI.
2. Repeat echo in the near future.
3. Continue beta-blockers.

Hypertension (HTN):

1. Continue BP log and meds

Diabetes:

      1.  Management as per primary care physician

SOAP Note 4

Demographic Data

• Patient Name: F.B

• Age: 86 y/o

• Sex: Female

Subjective

Chief Complaint (CC): Follow up of diabetes and concern about the rising cost of Jardiance medication.

History of Present Illness (HPI): F.B, an 86-year-old female with a known medical history, is here for a follow-up regarding her diabetes. She was recently prescribed Jardiance and has experienced no adverse reactions. She has expressed concerns about the increased cost of the medication. Additionally, she mentioned suffering from insomnia, which is currently managed with Melatonin.

Past Medical History (PMH):

• Hyperlipidemia
• Migraine headaches
• Tinnitus
• Aortic sclerosis

Family History (FH): Brother has coronary artery disease

Social History (SH):

• Volunteer at Skirball
• Negative for Smoking
• 0-2 drinks of wine per week
• No drugs

Review of Systems (ROS)

• Constitutional: No current complaints.
• HEENT: No headaches, no blurred vision, no diplopia, and no dysphagia.
• Chest: No COPD, asthma, wheezing, hemoptysis, or cough.
• Cardiac: Patient denies chest pain, palpitations, or shortness of breath.
• Abdomen: No pain, nausea, vomiting, or tenderness.
• Endocrine: No acute endocrine symptoms at this time.
• Neurological: No generalized or focal weakness.

Objective

• Constitutional/Gen: Elderly female, appearing well.
• General: Patient appears well.
• Neurological: Alert and oriented.
• Cardiovascular: Regular rate and rhythm. No murmurs reported.
• Respiratory: No respiratory distress.
• Musculoskeletal: No visible deformities.

Assessment

Differential Diagnosis:

1. Diabetes Mellitus (E11): B.F has a known history of diabetes and is on Jardiance for management.
2. Insomnia (G47.0): The patient has been experiencing difficulty sleeping and is being managed with Melatonin.

Final Diagnosis:

Diabetes Mellitus: B.F is under management with Jardiance for her diabetes.

Insomnia: Currently managed with Melatonin.

Plan

1. Continue with current Jardiance medication while monitoring for any side effects.
2. Advise patient to discuss with the pharmacy about the deductible or look for potential assistance programs to manage costs.
3. Monitor the efficacy of Melatonin for insomnia and adjust as needed.
4. Schedule a routine follow-up visit to monitor diabetes control and overall health.

SOAP Note 5

Demographic Data

• Patient Name: S.J

• Age: 79 y/o

• Sex: F

Subjective

Chief Complaint (CC): Complaints of gastrointestinal discomfort and fatigue.

History of Present Illness (HPI): S.J, a 79-year-old female, was diagnosed with pancreatic adenocarcinoma. She has been experiencing gastrointestinal discomfort and episodes of fatigue. The discomfort and fatigue have been progressive over the last few months, making daily activities challenging.

Past Medical History (PMH): C25.9 – Pancreatic adenocarcinoma (HCC/RAF); Underwent hysterectomy.

Family History (FH): No family history of cancers or other significant illnesses.

Social History (SH): Non-smoker.

Review of Systems (ROS)

• Constitutional/Gen: No reported weight loss, fever, or fatigue.
• Neuro: Alert and oriented x3.
• Cardiovascular: Regular heart rhythm, no chest pain.
• Respiratory: Normal breathing, no respiratory distress.
• GI: Gastrointestinal discomfort, no vomiting.
• Musculoskeletal: No mobility issues noted.

Objective.

• Neurological: Alert and oriented x3.
• Cardiovascular: BP 120/68; Regular rate and rhythm.
• Respiratory: Clear to auscultation bilaterally.
• Respiratory rate: 18.
• Musculoskeletal: Normal strength in upper extremities.

Assessment

Differential Diagnosis:

1. Chemotherapy-induced neutropenia (D70.1, T45.1X5A): Decline in white blood cells due to chemotherapy, making the patient susceptible to infections.
2. Malabsorption (K90.9): Due to the gastrointestinal issues and pancreatic condition, she may have reduced nutrient absorption.

Final Diagnosis: Pancreatic adenocarcinoma (HCC/RAF) – Primary, and Chemotherapy-induced neutropenia (HCC/RAF).

Plan

1. Monitor chemotherapy effects and adjust dosage if required.
2. Focus on nutritional counseling and dietary modifications to address gastrointestinal discomfort.
3. Educate the patient on monitoring for signs of infections and precautions due to neutropenia.
4. Schedule regular follow-ups to monitor the progress and address any emerging issues.

SOAP Note 6

Demographic Data

• Patient Name: F.C

• Age: 64 y/o

• Sex: F

Subjective

Chief Complaint (CC): Chronic obstructive pulmonary disease symptoms and related discomforts.

History of Present Illness (HPI): F.C, a 64-year-old female, was diagnosed with chronic obstructive pulmonary disease (COPD). She has been facing difficulties due to this condition and requires ongoing medical support and interventions.

Past Medical History (PMH): J44.9 – Chronic obstructive pulmonary disease, unspecified (HCC/RAF).

Family History (FH): No significant family history. 

Social History (SH): Single. Catholic.

Review of Systems (ROS)

• Constitutional/Gen: No reported weight loss, fever, or fatigue.
• Neuro: Alert and oriented.
• Cardio: Regular heart rhythm.
• Resp: Respiratory distress associated with COPD.
• GI: No gastrointestinal complaints.
• Musculoskeletal: No mobility issues reported.

Objective

• Constitutional/Gen: Patient appears well-nourished and well-developed.
• Neurological: Alert and oriented x3.
• Cardiovascular: Regular rate and rhythm.
• Respiratory: Symptoms consistent with COPD diagnosis.
• Musculoskeletal: No noticeable weaknesses or limitations

Assessment

Differential Diagnosis:

1. Chronic Bronchitis (J42): Persistent cough and mucus production, which could be a manifestation of COPD.
2. Emphysema (J43.9): Damage to the alveoli in the lungs, leading to a reduced ability for oxygen exchange, a common feature in COPD patients.
3. Chronic Obstructive Pulmonary Disease, unspecified (J44.9): The generalized symptoms and history provided by the patient align with a non-specific COPD diagnosis.

Final Diagnosis: Chronic Obstructive Pulmonary Disease, unspecified (J44.9).

Plan

1. Regular monitoring of lung function and respiratory symptoms.
2. Educate the patient about COPD management techniques, including breathing exercises.
3. Prescribe and review medication regimen, which includes Hydroxyzine, Oyster shell calcium, Duloxetine, Vitamin D3, Omeprazole, Noritriptyline, Tramadol, and Diclofenac sodium gel.
4. Schedule follow-ups for lung function tests and symptom assessments.
5. Advise on lifestyle changes, including avoiding smoke and allergens.

SOAP Note 7

Demographic Data

• Patient Name: C.J

• Age: 61 y/o 

• Sex: M

Subjective

Chief Complaint (CC): Weakness for 5 days. 

History of Present Illness (HPI): C.J, a 61-year-old male, presented to the clinic with generalized weakness. He denies any fever and is unable to ambulate due to his weakness. No history of seizures or heart disease. He denies shortness of breath. 

Past Medical History (PMH): Arthritis.

Family History (FH): Non-contributory. 

Social History (SH): Unemployed.

Review of Systems

• Constitutional/Gen: No significant past health information, no recent weight changes, no recent illnesses, no recent injuries, no fevers, no chills, no diaphoresis, and no night sweats.
• General: No significant past health information, no recent weight changes, no recent illnesses, no recent injuries, no fevers, no chills, no diaphoresis, and no night sweats.
• Mouth/Throat/Neck: No significant past health information, no difficulty swallowing, no mouth sores, no hoarseness, and no neck swelling.
• Chest: No significant past health information, no lumps, no pain, and no masses.
• Cardiac: No significant past health information, no hypertension, no murmurs, no angina, no palpitations, no orthopnea, no paroxysmal nocturnal dyspnea, and no swelling to extremities.
• Respiratory: No significant past health information, no shortness of breath, no coughing, no phlegm, and no congestion.
• Gastrointestinal: No significant past health information, no abdominal pain, no nausea, no vomiting, no bloating, no distention, no diarrhea, no constipation, no change in stool color, and no dyspepsia.
• Musculoskeletal: Weakness is noted as per the past health information.
• Psychiatric: No significant past health information, no anxiety, no depression, no tension, and no memory issues.

Objective

• Constitutional/Gen: Patient appears well-nourished and in no distress.
• Neurological: Alert and oriented (based on presentation).
• Respiratory: No history of seizures. No known history of heart disease. 
• Musculoskeletal: Reported aching in joints.

Assessment

Differential Diagnosis:

1. General Weakness (R53): Can be due to a variety of underlying conditions.
2. Arthritic Pain (M00-M25): Pain or discomfort associated with arthritis.

Final Diagnosis: Generalized Weakness (tentative based on chief complaint).

Plan

1. Conduct comprehensive physical examination.
2. Possible blood work to determine underlying causes of weakness.
3. Monitor patient’s vitals and symptoms.
4. Educate the patient on managing symptoms of arthritis.
5. Schedule follow-ups for symptom assessments and to confirm the cause of the generalized weakness.

SOAP Note 8

Demographic Data

• Patient Name: J.M

• Age: 77 y/o

• Sex: F

Subjective

Chief Complaint (CC): Lumbar spinal stenosis causing numbness, paresthesias, and intermittent radiculopathy.

History of Present Illness (HPI): J.M, a 77-year-old female, presented with bilateral diffuse numbness to LT throughout her BLE, paresthesias, and left L4 and L5 dermatomal distribution pain. She also experiences difficulty in walking due to balance issues.

Past Medical History (PMH): Hypertension, Diabetes Mellitus.

Family History (FH): Father had lumbar spinal issues. Mother had osteoarthritis.

Social History (SH): Non-smoker.

Review of Systems

• Constitutional/Gen: Severe multilevel lumbar spinal stenosis secondary to facet and ligamentum hypertrophy.
• General: Severe multilevel lumbar spinal stenosis secondary to facet and ligamentum hypertrophy.
• Mouth/Throat/Neck: No significant past health information.
• Chest: No significant past health information.
• Cardiac: Regular rate and rhythm.
• Respiratory: No significant past health information.
• Gastrointestinal: No significant past health information.
• Musculoskeletal: Notable paresthesias throughout, as well as left L4 and L5 dermatomal distribution pain (intermittent); Mildly hyperreflexic in the lower extremities.
• Psychiatric: Patient described as a very pleasant but anxious individual.

Objective

• Neurological: CN II-XII grossly intact.
• Respiratory: Clear lungs, no signs of respiratory distress.
• Musculoskeletal: 5/5 strength in upper and lower extremities. Noted difficulty in tandem walking due to balance issues.

Assessment

Differential Diagnosis:

1. Lumbar Spinal Stenosis (M48.062).
2. L4-5 Spondylolisthesis.
3. Facet Hypertrophy.

Final Diagnosis: Severe multilevel lumbar spinal stenosis secondary to facet and ligamentum hypertrophy; Grade 1 L4-5 spondylolisthesis.

Plan

1. Decompressive laminectomies at L2-3, L3-4, L4-5 with bilateral foraminotomies.
2. 3V lumbar flex/extension xrays to assess for instability at listhesis 4-5.
3. CT lumbar spine to assess facet cysts and for pre-op planning.
4. Tentative surgery date: 2/23 at WHH.
5. Prescribe pain management medications as needed.
6. Follow-ups for symptom assessments and post-operative recovery.

SOAP Note 9

Demographic Data

• Patient Name: V.K
• Age: 62 y/o
• Sex: M

Subjective

Chief Complaint (CC): Impaired mobility post-injury with associated pain, decreased strength in extremities, and difficulty in bed mobility.

History of Present Illness (HPI): V.K, a 62-year-old male, presents with a reduced range of motion in both upper and lower extremities following a recent physical injury. He reports associated pain, particularly when trying to move or when shifting in bed. Victor has also noted difficulty in walking due to balance issues.

Past Medical History (PMH): Previous similar injury 10 years ago; treated with physiotherapy.

Family History (FH): Father had similar mobility issues in his later years; Mother had a history of arthritis.

Social History (SH): Occasional alcohol consumption.

Review of Systems

• General: Impaired mobility due to recent injury; Pain on movement.
• Mouth/Throat/Neck: No significant past health information.
• Chest: No significant past health information.
• Cardiac: Regular rate and rhythm.
• Respiratory: Clear lungs, no wheezing or shortness of breath noted.
• Gastrointestinal: No significant past health information.
• Musculoskeletal: Reduced strength noted, particularly in the lower extremities. Balance issues reported.
• Psychiatric: Patient described as cooperative and engaged, but showing signs of mild anxiety due to his condition.

Objective

• Constitutional/Gen: Patient appears well-nourished, in mild distress due to pain.
• Neurological: CN II-XII grossly intact.
• Respiratory: Clear lungs, no signs of respiratory distress.
• Musculoskeletal: Strength 3/5 in both upper and lower extremities.

Assessment

Differential Diagnosis:

1. Musculoskeletal Injury resulting from a physical accident.
   1. Degenerative Joint Disease.
   1. Age-related reduction in muscle mass and strength.

Final Diagnosis: Musculoskeletal injury with associated impaired mobility and pain.

Plan

1. Initiate a comprehensive physical therapy regimen focusing on strengthening exercises and mobility training, as indicated by the therapeutic exercises, gait training, home exercise program, and pain management listed in the supplementary physician’s order.
2. MRI to further assess the extent of injury and any underlying issues.
3. Consultation with an orthopedic specialist for further assessment.
4. Prescribe pain management medications as appropriate.
5. Frequent follow-ups to monitor progress and adjust treatment as necessary.

SOAP Note 10

Demographic Data

• Patient Name: A.M
• Age: 45 y/o
• Sex: F

Subjective

Chief Complaint (CC): Persistent migraines, light sensitivity, and nausea for the past 6 months.

History of Present Illness (HPI): A.M, a 45-year-old female, reports experiencing severe migraines that last for several hours. Notably, these headaches often come with light sensitivity and are sometimes accompanied by nausea. She has tried over-the-counter pain medications with minimal relief.

Past Medical History (PMH): Treated for hypertension and hyperthyroidism.

Family History (FH): Mother had migraines; brother diagnosed with epilepsy.

Social History (SH): Works as an editor and spends prolonged hours in front of a computer.

Review of Systems

• General: Reports general fatigue and occasional dizziness.
• Mouth/Throat/Neck: No significant past health information.
• Chest: Occasional chest tightness but no shortness of breath.
• Cardiac: Regular rate and rhythm.
• Respiratory: No significant past health information.
• Gastrointestinal: Reports occasional nausea, especially during severe migraines.
• Musculoskeletal: No complaints.
• Psychiatric: Patient describes mild anxiety due to her migraines affecting her work and personal life.

Objective

• Neurological: Alert, oriented x3. Pupils equal, round, and reactive to light.
• Respiratory: Clear lungs, no signs of respiratory distress.
• Musculoskeletal: Full strength in all extremities.
• Cardiovascular: Regular rhythm, no murmurs heard.

Assessment

Differential Diagnosis:

1. Chronic Migraine
   1. Tension-type Headache
   1. Cluster Headache

Final Diagnosis: Chronic Migraine associated with light sensitivity and nausea.

Plan

1. Start a trial of triptan medications for acute migraine attacks.
2. Begin a preventive migraine medication regimen.
3. Recommend minimizing screen time and taking regular breaks during work.
4. Advise on lifestyle changes, including regular sleep, hydration, and avoidance of known migraine triggers.
5. Schedule a follow-up in 4 weeks to assess the effectiveness of the treatment.
6. Consider referring to a neurologist if no improvement is seen.

Work Cited

Uysal, Suzan. “ICD-10-CM Diagnosis Coding for Neuropsychological Assessment.” Archives of Clinical Neuropsychology, vol. 34, no. 5, 2019, pp. 721-730.