Submit a full SOAP note using provided bellow template, main diagnosis should be a chronic medical condition. Use attached SOAP Note template which is in the WORD format. Review the video on how to write a SOAP Note.

https://us-lti.bbcollab.com/collab/ui/session/playback

Thank you

SOAP NOTE

Name:  DB

Date: 1/13/2017

Time: 10:33AM

 

Age: 33

Sex: Female

SUBJECTIVE

CC: 

“My back hurts”. 

HPI:  (Use OLDCART)

She reports feeling pain in her lower back that started yesterday while at work. Last night she went to sleep as usual, when she woke up this morning she was in a lot of pain and was very stiff. The pain is described as a 7/10 on the pain scale, feels like burning. Pt states pain is worse in the R lumbo-sacral area. Pain radiated to her R buttock. It hurts her to stand up or to find a comfortable position. Pain worsens after bending or lifting. Her back hurts even at rest, but gets worse with movement. Taking Tylenol 500mg 2 caplets with no relief of the pain. Denies hx of UTI symptoms; Denies vaginal discharge or dyspareunia; denies change in bladder or bowel habits; denies weight loss or fever. Denies hx of previous back pain, injury or trauma. States she works as a cashier at the grocery store where she stands most of the day. Yesterday was her second day of working over time at work and she thinks since she works standing up, this might have cause for her to feel pain in her lower back. Denies muscle weakness, paresthesia, loss of sensations, and no severe or progressive neurological deficit in lower extremity. 

Medications:
(list with reason for med )

Tylenol Extra Strength 500 mg Caplets, 2 tabs q4-6 hr for back pain with no relief

Metformin 500mg 1 PO QD for Type 2DM

Lisinopril 10mg 1 po QD for HTN

PMH

Allergies:   NKDA, denies food allergies

Medication Intolerances: Denies

Chronic Illnesses/Major traumas: HTN (2016), Type 2 NIDDM (2017)

Hospitalizations/Surgeries: Appendectomy (2001) 

Family History

States her parents (mother 59, father 63), siblings (sister 34, brother 27) and daughter- 4y/o are healthy and both sets of grandparents are alive and live in Colombia (doesn’t know age or if they have any medical problems).

Social History

General: Born and raised in Cali, Colombia, moved to the US with her parents when she was 17 years old.

Marital status: Single Mom of a 4-yr/old girl. Ex-husband not involved financially or physic

SOAP NOTE

Name: 

Date:

Time:

 

Age:

Sex:

SUBJECTIVE

CC: 

Reason given by the patient for seeking medical care “in quotes”

 

HPI:  Use OLDCART acronym

Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness.

 

Medications:
(list with reason for med ) write medicine the same way you write a Rx

 

PMH (list approximate year of Dx of the disease or when surgical procedure performed)

Allergies:  

 

Medication Intolerances:

 

Chronic Illnesses/Major traumas

 

Hospitalizations/Surgeries

 

 

Family History (list immediate family, age, disease, and whether is dead or alive)

Does your mother, father or siblings have any medical or psychiatric illnesses?  Anyone diagnosed with: lung disease, heart disease, htn, cancer, TB, DM, or kidney disease.

 

Social History

Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, marijuana.  Safety status

 

ROS (Start each sentence with words such as “Denies, admits, complains, reports”, do not use the words “No, positive for, negative for”. Do NOT list physical exam findings here. If the body system not assess write “Non-Contributory”

General

 

Cardiovascular

 

Skin

 

Respiratory

 

Eyes

 

Gastrointestinal

 

Ears

 

Genitourinary/Gynecological

 

Nose/Mouth/Throat

 

Musculoskeletal

Breast

Neurological

Heme/Lymph/Endo

Psychiatric

OBJECTIVE- this is where you document phy