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 evaluatio
- Patient
- CC: Eric is a 46 y/o AA male for new a New Patient visit and to establish care with the practitioner. The pt c/o generalized abdominal pain and cramping. The pain started a few months ago. The pain is aggravated by food. He states he sometimes feels like he is bloated. He takes omeprazole and pepcid and gets temporary relief from these medications. He is also concerned about his prostate and wants a check-up for his prostate. Otherwise, his over health is good
- HistoryLAST UPDATEDLAST UPDATEDPast Medical History (PMHx)
- Abdominal Pain – pain/cramp
- GERD
- 21 Apr 202301:21 PMPast Surgical History (PSHx)
- Cholecystectomy/bile duct surgery – 2021
21 Apr 202301:23 PMFamily History (FHx)
brother (first): Alive, +No Health Concern
father: Deceased
mother: Deceased at 57, +Hypertension, +Diabetes
sister (first): Alive, +No Health Concern
21 Apr 202301:31 PMSocial History (SHx)
Alcohol: Do not drink
Birth Gender: Male
Cardiovascular: Regular exercise
Others: Caffeine – 2 cups a day
Safety: Household Smoke detector / Wear seatbelts
Sexual Activity: Sexually active
- Tobacco: Never smokerVitals List
RECORDEDBPHRRRTEMPHEIGHT/LENGTHWEIGHTBMISPO2INHALED O2HEAD CIRCCOMMENTRECORDEDBPHRRRTEMPHEIGHT/LENGTHWEIGHTBMISPO2INHALED O2HEAD CIRCCOMMENT21 Apr 202301:08 PM136/94782098.26′ 0″278 lbs 2 oz37.7298.0%
- CCEric is a 46 y/o AA male for new a New Patient visit and to establish care with the practitioner. The pt c/o generalized abdominal pain and cramping. The pain started a few months ago. The pain is aggravated by food. He states he sometimes feels like he is bloated. He takes omeprazole and pepcid and gets temporary relief from these medications. He is also concerned about his prostate and wants a check-up for his prostate. Otherwise, his over health is good. SubjectiveConst: Denies weakness or night sweatsHead: Denies headache, confusion, or lightheadednessNeuro: Denies syncope, slurred speech, or numbness/tinglingEyes: Denies changes to visionENT: Denies rhinorrhea sore throat, or hearing loss.Cardiac: Denies CP or palpitationsPulm: Denies cough, shortness of breath, or wheezingHeme: Denies bruising or petechiaeSkin: Denies itching, rashes, or lesionsGI: Denies diarrhea, constipation, or indigestionGU: Denies any problemsMSK: Denies any musculoskeletal painPsych: Denies thoughts of self harm or SIMedicationsAllergiesNo allergy history has been documented for this patient.Mental/FunctionalThe patient was sitting upright, and eyes contact and facial expression were appropriate. Grooming hygiene and dress code were appropriate for age and season. The patient is friendly and cooperative. Mood and affect were appropriate. Though process was significant. The patient is alert to person, place, time, and current situation and responds appropriately to questions, and physical and environmental stimuli.Vitals21 Apr 2023 – 01:08 PM – recorded by Faith StaggersBP:136.0 / 94.0HR:78.0 bpmRR:20.0 rpmTemp:98.2 °FHt/Lt:6′ 0″Wt:278 lbs 2 ozBMI:37.72SpO2:98.0%ObjectiveGENERAL: No weight loss, fever, chills, weakness, or fatigue.HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss; no sneezing, congestion, runny nose, and itching throatSKIN: No rash or itchingCARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.RESPIRATORY: No shortness of breath, cough, or sputum.GASTROINTESTINAL: Admit to abdominal pain. No anorexia, nausea, vomiting, or diarrhea. No blood in stool.NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.HEMATOLOGIC: No anemia, bleeding, or bruising.LYMPHATICS: No enlarged nodes. No history of splenectomy.PSYCHIATRIC: No history of depression or anxiety.ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or polydipsia.GENITOURINARY/REPRODUCTIVE: Denies Burning on urination.ALLERGIES: No history of asthma, hives, eczema, or rhinitis.AssessmentGeneralized abdominal pain (finding) (R10.84/789.07) Generalized abdominal pain (acute) started 17 Jan, 2023 modified 21 Apr, 2023Encounter for general adult medical exam w abnormal findings (Z00.01/V70.0) Encounter for general adult medical exam w abnormal findings (acute) started 21 Apr, 2023 modified 21 Apr, 2023Disorder of vitamin D (disorder) (E55.9/268.9) Vitamin D deficiency, unspecified (chronic) modified 21 Apr, 2023PlanCBC, CMP, TSH, lipid panel, A1c, Vit-D, and PSA level Abdominal ultrasound Maalox 15cc before each meal x1 week Return in 1 week for lab review and consultation Will discuss health maintenance and disease prevention on F/U visit Generalized abdominal pain (finding)Encounter for general adult medical exam w abnormal findingsDisorder of vitamin D (disorder)
Expert Solution Preview
Introduction:
In this answer, I will analyze the Comprehensive SOAP Note provided for a patient named Eric, who is a 46-year-old African American male. The patient presents with generalized abdominal pain and cramping, which started a few months ago and is aggravated by food. He also expresses concerns about his prostate and requests a check-up for it. The patient reports taking omeprazole and pepcid for temporary relief. Additionally, I will provide a differential diagnosis, including the CPT and ICD-10 codes, and discuss the primary diagnosis, treatment plan, and management options.
Answer:
Subjective:
According to the patient’s subjective information, he complains of generalized abdominal pain and cramping, which began a few months ago. The pain is worsened by food intake and occasionally accompanied by a bloated sensation. Eric reports obtaining temporary relief from omeprazole and pepcid. He also expresses his concerns about his prostate and desires a check-up. Apart from these complaints, the patient considers his overall health to be good.
Objective:
During the physical assessment, no significant abnormalities were observed. The patient’s weight was recorded at 278 lbs 2 oz, and his height was measured at 6′ 0″. The calculated BMI was 37.72. Vital signs were within the normal range, with a blood pressure of 136/94 mmHg, heart rate of 78 bpm, respiratory rate of 20 rpm, and SpO2 of 98%. The patient’s general appearance and mental/functional status were assessed as appropriate, with no remarkable findings.
Assessment:
Based on the patient’s history and physical assessment, the following differential diagnoses can be considered:
1. Generalized abdominal pain (R10.84/789.07): This diagnosis would encompass the patient’s primary complaint of abdominal pain and cramping.
2. Encounter for general adult medical exam w abnormal findings (Z00.01/V70.0): This code describes the encounter for a general adult medical exam in which abnormal findings were identified.
3. Disorder of vitamin D (E55.9/268.9): Considering the patient’s other risk factors and the potential impact of vitamin D deficiency on abdominal pain, this diagnosis is worth considering.
Among these differential diagnoses, the primary diagnosis would be generalized abdominal pain (R10.84/789.07) due to its relevance to the patient’s chief complaint and its higher priority compared to the other two diagnoses.
Plan:
To confirm and further evaluate the diagnosis, several diagnostic tests are recommended. These include a complete blood count (CBC), comprehensive metabolic panel (CMP), thyroid-stimulating hormone (TSH) test, lipid panel, A1c test, vitamin D level measurement, and prostate-specific antigen (PSA) level examination. Additionally, an abdominal ultrasound is advised as an imaging study.
For treatment and management, Maalox (15cc before each meal) is recommended for one week to provide symptom relief for the abdominal pain. The patient should return in one week for a review of the lab results and consultation. During the next follow-up visit, health maintenance and disease prevention topics will be discussed with the patient.
Reflection notes:
During the evaluation of this patient, the “aha” moment was recognizing the potential importance of assessing the vitamin D status due to its association with abdominal pain. In future similar patient evaluations, I would consider discussing the importance of vitamin D levels in patients presenting with abdominal pain, especially when risk factors such as obesity and darker skin complexion are present. This would help ensure comprehensive care and management strategies.
Note: The content of the SOAP Note and the medical information provided is fictional and does not represent real patient data.
