Raymond Pinkowski is an 18-year-old who presents to your outpatient clinic with a 3-day history of painful left ear. He has a recent history of swimming in a friend’s pond over this past weekend. He is generally in good health, no significant medical history other than seasonal allergies and has ADHD which was diagnosed when he was in middle school. He recently started a part time job at Target but doesn’t work enough hours to qualify for any health insurance, he will be paying out of pocket for the visit and any medications. HPI/PMH: as presented in the case.
Vital signs: BP 118/70 P 84 R 14 T 99.9 oral Pulse ox 98% on room air Allergies: NKDA Medications: Tylenol 500mg 1 or 2 PRN. Not taking medications for ADHD since completing his GED 1 year ago.
ROS: Occasional headaches, left ear pain, states it is 8-9/10 today. PE: Lungs clear, Heart regular rate and rhythm. Right ear shows clear ear canal, TM with normal light reflex, no fluid noted. Left ear canal red, swollen, unable to perform thorough ear exam due to edema and pain. Some greenish discharge noted from Left ear. Social History: Lives with his mother in an apartment, has one younger sister also at home. Obtained his GED last year. Drinks alcohol on weekends occasionally, smokes marijuana 1 or 2 times a month with friends, no other reported drug use, no use of tobacco or vaping. Drinks 2 – 3 energy drinks daily. No history of interaction with law enforcement, no DUI’s.
As you review the case and write your SOAP note please review the following questions and incorporate them into the note.
1. What is the likely cause of this issue for Raymond?
2. Write at least 3 differential diagnoses for this issue.
3. Describe in detail the physical exam you would complete for this visit.
4. What are some of the risk factors for individuals to develop this issue?
5. Name the pathogens most likely involved.
6. How would you describe the severity of Raymonds issue – mild, moderate or severe? 7. What treatment options would you prescribe?
8. List the cost of the medication you prescribe for Raymond – you can use sources like GoodRx or others available on the web to review costs in your area.
9. What other health promotion topics would you review with Raymond at this visit? 10. What social determinants of health (SDOH) are affecting Raymond’s care at this time?
11. What CPT code and E&M code would you use for this visit – this can be added to the? end of the SOAP note.
12. What is your follow up plan and any need for referral for Raymond after this visit, also are there any free clinics in your area – if so list them?
Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint): A brief statement identifying why the patient is here, stated in the patient’s own words (for instance “headache,” not “bad headache for 3 days”).
HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form, not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products
Allergies: include medication, food, and environmental allergies separately (A description of what the allergy is, i.e., angioedema, anaphylaxis, etc. This will help determine a true reaction as opposed to intolerance).
PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more information is sometimes needed. Soc & Substance Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren, if pertinent.
Surgical Hx: prior surgical procedures
Mental Hx: diagnosis and treatment. Current concerns: Anxiety and/or depression. History of self-harm practices and/or suicidal or homicidal ideation.
Violence Hx: concern or issues about safety (personal, home, community, sexual . . . current & historical)
Reproductive Hx: menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any sexual concerns
ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: 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, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, 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, cold, or heat intolerance. No polyuria or polydipsia.
REPRODUCTIVE: Not pregnant and no recent pregnancy. No reports of vaginal or penile discharge. Not sexually active.
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
O.
Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format, i.e., General: Head: EENT: etc.
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidence and guidelines)
A .
Differential Diagnoses: List a minimum of three differential diagnoses. Your primary, or presumptive, diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.
P.
Includes documentation of diagnostic studies that will be obtained, referrals to other healthcare providers, therapeutic interventions, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.
Include a discussion related to health promotion and disease prevention, taking into consideration patient factors such as age and ethnic group; PMH; and other factors, such as socio-economic and cultural background.
The reflection also is included in this section. Reflect on this case and discuss what you learned. Were there any “aha” moments or connections you made?
References
You are required to include at least three evidence-based, peer-reviewed journal articles or evidence-based guidelines that relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.
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