Episodic/ Focus SOAP Note Example

, ,

Outcome of:

Cardiac appt due to dizziness.

Labs for dizziness

Pylori labs

– Ambulatory referral to Vascular Surgery due to change in skin of lower legs and varicosities

Outcome of cardiac referral due to inc. HR and abnormal EKG

Outcome of GI referral for colonoscopy

Outcome of mammo, pt will have test done

Outcome of referral to Dr. Camacho for psyche thereapy

See if Tdap and Shingrix taken

Outcome of SSA and SSB

Outcome of endo referral

Outcome of x-ray of right feet and right ankle

Outcome of thoracic spine x-ray due to thoracic pain-not done

Outcome of GI referral for colonoscopy-pt had cancelled before

Outcome of Pulmonology referral due to Latent TB

Chief Complaint: C S evaluated for Dizziness

Pleasant 57 y.o. year old female .

PAST MEDICAL HISTORY: has Strain of thoracic region, initial encounter; Essential hypertension; Scoliosis, unspecified scoliosis type, unspecified spinal region; Latent tuberculosis; HDL deficiency; Other kyphosis of thoracic region; Other constipation; Vitamin B12 deficiency; Vitamin D deficiency; Obesity (BMI 30-39.9); Anemia, unspecified type; Right foot pain; Situational stress; Dependent edema; and Hyperlipidemia, unspecified hyperlipidemia type on their problem list.

ALLERGIES: Patient has no known allergies..

SOCIAL HISTORY: reports that she has never smoked. She has never used smokeless tobacco. She reports that she does not drink alcohol.

CURRENT MEDICATIONS:

Current Outpatient Medications:

alclomethasone (ACLOVATE) 0.05 % ointment, Apply 1 Application topically 2 (two) times daily., Disp: , Rfl:
ascorbic acid, vitamin C, (VITAMIN C) 100 mg tablet, Take 100 mg by mouth daily., Disp: , Rfl:
azithromycin (ZITHROMAX) 250 mg tablet, Take 2 tablets now, then take 1 tablet daily day 2-5., Disp: 6 tablet, Rfl: 0
cholecalciferol, vitamin D3, 50 mcg (2,000 unit) tablet, TAKE 1 TABLET BY MOUTH EVERY DAY, Disp: 90 tablet, Rfl: 1
cyanocobalamin 1,000 mcg/mL injection vial, Inject 1 mL (1,000 mcg total) into the muscle every 30 (thirty) days. For three months, Disp: 3 mL, Rfl: 0
lidocaine (ZTLIDO) 1.8 % patch, Apply 1 patch topically daily., Disp: 30 patch, Rfl: 2
LOTEMAX 0.5 % ophthalmic suspension, Apply 1 drop to eye as needed for dry eyes., Disp: , Rfl:
olmesartan-amLODIPine-hydrochlorothiazide (TRIBENZOR) 20-5-12.5 mg tablet, TAKE 1 TABLET BY MOUTH EVERY DAY, Disp: 90 tablet, Rfl: 2

SURGICAL HISTORY:

Past Surgical History

Past Surgical History:

Procedure Laterality Date

BREAST SURGERY Bilateral 10 years ago

lumpectomies

ovarian cysts Bilateral 8 years ago
SHOULDER SURGERY

FAMILY MEDICAL HISTORY: family history includes Alzheimer’s disease in her father; Diabetes in her father and mother; Heart disease in her mother; High cholesterol in her mother; Hypertension in her father and mother; Mult sclerosis in her brother; Skin cancer in her mother.

Immunization History:

There is no immunization history on file for this patient.

Does not want Flu vaccine or Shingles vaccins

Exercises regularly: No

Compliant with diet : No

Patient evaluated today for Dizziness

hx of latent TB, completed treatment x 4 months

Hx of anxiety

Hx of dry eyes

Labs

Lab Results

Component Value Date

K 4.0 07/08/2021

CREATININE 0.79 07/08/2021

CALCIUM 9.5 07/08/2021

GLU 93 07/08/2021

ALT 9 07/08/2021

AST 9 (L) 07/08/2021

HDL 54 07/08/2021

TRIG 73 07/08/2021

LDL 116 (H) 07/08/2021

WBC 8.5 07/08/2021

HGB 14.9 07/08/2021

HCT 44.6 07/08/2021

LYMPHOCYTES 34.9 07/08/2021

VITAMINB12 571 07/08/2021

IRON 50 12/10/2020

No components found for: URINALYSIS

No results found for: ANA, RF, SEDRATE, CRP

Lab Results

Component Value Date

HEPCAB NON-REACTIVE 02/23/2019

HPI:

Patient seen in office with complains of dizziness which began yesterday. States that she did experience some nausea along with dizziness yesterday, but it has subsided. Still feeling dizzy. Denies any vision problems. Reports poor water intake.

Reports acid reflux episodes.

Dizziness Sub

New Problem/Exacerbation of existing one (3-4)/HPI

Dizziness reported

Current episode: yes

Duration: since yesterday

Meds taken: no

Associated symptoms

Palpitation (order Event monitor if present): no

Chest pain (refer to cardiology, orderECHO etc): no

Dyspnea (order ECHO if present): no

Room Spinning (vertigo-hallucination of motion): no

Occurs with sudden change in position (consider Benign Paroxsymal Positional Vertigo): yes

Feels like is going to fall (imbalance-can be due to vit B12 deficiency, DM2 damage to Proprioception): yes

Issues addressed:

Hx of HTN, compliant with medication

Hx of hyperlipidemia per labs. No medication

Hx of HDL deficiency in previous labs. Resolved.

Hx of vit D, taking supplements

Hx of vit B12. Taking medication

Hx of anemia, no recent labs.

ISSUES ADDRESSED LAST VISIT:

Hx of dry eyes, being followed by eye doctors. Had Sjoegren’s testing done.

9/17/18 2/23/19 3/7/20 12/10/2020 7/8/2021

K+:4.0

Create: 0.62

GFR:

Ca+:9.3

FBS: 92

HA1c:

Albuminuria:

ALT: 7

AST: 11

HDL:

TG:

LDL:

WBC:

Hgb:

Hct:

Iron:

Vit B12:

Folate:

Ferritin:

TSH: 2.75

U/A: normal

Vit D:

PTH:

K+:

Create:

GFR:

Ca+:

FBS:

HA1c:

Albuminuria:

ALT:

AST:

HDL: 40

TG: 75

LDL: 84

WBC: 4.1

Hgb: 12.3

Hct: 36.9

Iron:

Vit B12:

Folate:

Ferritin:

TSH:

U/A:

Vit D:

PTH:

Quant Gold: Positive

Hep B: Neg

Hep C: Neg

Sjogren: Neg

HIV: Neg K+: 4.0

Createnine: 0.65

GFR:

Ca+: 8.8

FBS: 92

HA1c:

Albuminuria:

ALT:

AST:

HDL: 50

TG:

LDL:

WBC: 4.2

Hgb: 11.6

Hct: 34.2

Iron:

Vit B12: 301

Folate:

Ferritin:

TSH:

U/A:

Vit D: 24

PTH:

K+:

Createnine:

GFR:

Ca+:

FBS:

HgA1c:

Albuminuria:

ALT:

AST:

HDL:

TG:

LDL:

WBC:

Hgb:

Hct:

Iron: 50

Vit B12: 540

Folate: 15.7

Ferritin:

TSH:

U/A:

Vit D: 39

PTH: K+:

Createnine:

GFR:

Ca+:

FBS:

HgbA1c:

Albuminuria:

ALT:

AST:

HDL: 54

TG: 73

LDL: 116

WBC:

Hgb: 14.9

Hct: 44.6

Iron:

Vit B12: 571

Folate:

Ferritin:

TSH: 3.14

U/A: + leuko

Vit D:

PTH:

T3 110

Free T4 1.5

SSA ab neg

SSB neg

K+:

Createnine:

GFR:

Ca+:

FBS:

HgA1c:

Albuminuria:

ALT:

AST:

HDL:

TG:

LDL:

WBC:

Hgb:

Hct:

Iron:

Vit B12:

Folate:

Ferritin:

TSH:

U/A:

Vit D:

PTH:

K+:

Createnine:

GFR:

Ca+:

FBS:

HgbA1c:

Albuminuria:

ALT:

AST:

HDL:

TG:

LDL:

WBC:

Hgb:

Hct:

Iron:

Vit B12:

Folate:

Ferritin:

TSH:

U/A:

Vit D:

PTH:

STUDIES DONE

Study Date Results

U/S

MRI

Lab Results

Component Value Date

HGB 14.9 07/08/2021

HCT 44.6 07/08/2021

ALT 9 07/08/2021

AST 9 (L) 07/08/2021

K 4.0 07/08/2021

CREATININE 0.79 07/08/2021

Initial Encounter:

SPECIALTIES:

Cardiologist ACS

Rheumatologist

Urologist

GI Referred Dr. Castillo

Hematology

Neurology

Endocrinologist

GYN Dr. Ken Thomas

Eye Doctor

Podiatrist

Dentist

Psyche

Nephrology

Pulmonology referred

SCREENINGS: (goal of screening is to find dz before it begins)

Colonoscopy(age 50-75 every 10 yrs or as indicated)

Do not order in > 85 yr. old Referred to Dr. Castillo 3/22/2021

Fecal blood test (InSure Fit)

CPT 82272 (Yearly from 50-75 or as indicated),

Screening codes Z12.11 and Z12.12

Episodic/ Focus SOAP Note Example

Examines for blood antibodies in stool

Consider if:

Anemia D64.9

Melena K92.1

Abnormal wght loss R63.4

Abd pain R10.84

GERD K21.9

Mammography (40-49 every 2 yrs or start at age 50 for women at average risk of breast cancer and continue through at least age 74

4/28/2021

normal

Pap Smear Seen by Dr. Thomas

DEXA (female older than 65 or < 65 with risk factors):

DEXA Report date

2/5/20:

IMPRESSION: Osteoporosis: The lowest T-score is -3.3.

Lung cancer screening/Low dose CT (55-79 yrs old with 30 pack yr tobacco and smoked within past 15 yrs)

ABI screening

Intermittent claudication, paresthesia

(risk factors for PAD: DM2, HTN, hyperlipidemia, smoking, atherosclerosis, > 60)

Carotid Duplex (Carotid athresclerosis can inc. Risk of stroke-Goal is to assess before occurrence of stroke)

Screen if : + Bruit or > 55 and > 2 stroke risk factors including DM2, HTN, Hyperlipidemia, smoking, family hx of ischemic stroke or hx of PAD, CAD, AAA)

Carotid U/S guide

-Less than 69% occlusion, recheck every eyar

-70-79% occlusion, recheck every 6 months

-80% or > occlusion, send for surgical consult

EKG

ECHO

Hx of HTN, abnormal heart sounds e.g. Extra beat, Atypical chest pain, chest pain, dyspnea, murmur, edema, muffle heart beat, abnormal EKG-r/o wall motion abnormality, hx of sleep apnea, hx of stroke, known or suspected Marphan Syndrome.

1/22/20:

Normal left ventricular size, thickness and systolic function. EF 50-55%.
Normal right ventricular size and function.
Normal atria.
No significant valve abnormalities.
No pericardial effusion.
No previous study for comparison.

Stress test

HOLTER MONITOR

Cardiac Nuclear Imaging

HIV screening (All adults at least once) l

Hep C screening (IVDU hx , blood transfussion, and born b/w 1945-1965 without risk ICD # Z11.59) l

Sexual active screen (Chlamydia/gonorrhea, Hep B, RPR- sexually active) i

DM screening (HgbA1c/FBS) (any adult with BP > 135/80) l

Hyperlipidemia screening (all adults at risk, especially male > 35 yrs old) l

Prevnar 13 (one and done) > 65,

< 65 Spleen dysfunct, hx CA, CKD, Immunocomp, Chochlear implant Then PPSV 23 6-12 month later

Pneumovax (PPSV 23)

>65, or < 65 with smoking, DM2, Heart/lung dz-COPD,asthma, cirrhosis Immunocompromised, radiation, no spleen Revaccinate after 65 if initial vaccination given before 65 and 5 yrs have elapsed since first dose.

Td booster (q 10 yrs) l

Shingrix (herpes Zoster vaccine)

> 50 (60, hx of varicella

Don’t if immunocompromised (ie. Lupus, RA, HIV, leukemia, Lymphoma)

Immunosuppression, allergy to neomycin, pregnancy l

Influenza vaccine l

Tdap (once)

(don’t give if hx of Gillian Barre syndrome) l

Quantiferon Gold

Review of Systems:

2-9

Review of Systems

Constitutional: Negative for chills and fever.

Respiratory: Negative for cough, shortness of breath and wheezing.

Cardiovascular: Positive for leg swelling. Negative for chest pain and palpitations.

Baseline finding for patient, chronic edema

Gastrointestinal: Negative for diarrhea, nausea and vomiting.

Genitourinary: Negative for dysuria and urgency.

Objective:

Vital Signs:

Vitals:

06/02/22 1153

BP: 118/76

Pulse: 89

Resp: 18

Temp: 98.6 °F (37 °C)

Weight: 75.8 kg

Body mass index is 30.54 kg/m².

LABS:

Lab Results

Component Value Date

WBC 8.5 07/08/2021

HGB 14.9 07/08/2021

HCT 44.6 07/08/2021

PLT 203 07/08/2021

CHOL 187 07/08/2021

TRIG 73 07/08/2021

HDL 54 07/08/2021

ALT 9 07/08/2021

AST 9 (L) 07/08/2021

NA 139 07/08/2021

K 4.0 07/08/2021

CL 105 07/08/2021

CREATININE 0.79 07/08/2021

BUN 21 07/08/2021

CO2 25 07/08/2021

GLU 93 07/08/2021

Lab Results

Component Value Date

ALKPHOS 78 07/08/2021

BILITOT 0.3 07/08/2021

Lab Results

Component Value Date

VITAMINB12 571 07/08/2021

No results found for: ANA, RF, SEDRATE

No results found for: URICACID

No results found for: HIV

Physical Exam:

Physical Exam

Constitutional:

Comments: Looks tired

HENT:

Head: Normocephalic and atraumatic.

Right Ear: External ear normal.

Left Ear: External ear normal.

Eyes:

Conjunctiva/sclera: Conjunctivae normal.

Pupils: Pupils are equal, round, and reactive to light.

Cardiovascular:

Rate and Rhythm: Normal rate and regular rhythm.

Heart sounds: Normal heart sounds.

Pulmonary:

Effort: Pulmonary effort is normal.

Breath sounds: Normal breath sounds.

Abdominal:

General: Bowel sounds are normal.

Palpations: Abdomen is soft.

Musculoskeletal:

General: Normal range of motion.

Cervical back: Normal range of motion and neck supple.

Comments: Scoliosis/Khyphosis

Skin:

General: Skin is warm and dry.

Neurological:

Mental Status: She is alert and oriented to person, place, and time.

Gait: Gait is intact. Episodic/ Focus SOAP Note Example

Psychiatric:

Mood and Affect: Mood and affect normal.

Cognition and Memory: Memory normal.

Judgment: Judgment normal.

Assessment and Plan:

Dizziness

Dizziness Teaching

-Slow body changes/avoid falls

-Good water intake/good hydration

-Small frequent meals/avoid skipping meals

-EKG done

Asked for cardiac appt.

– Comprehensive metabolic panel; Future

– TSH; Future

– Urinalysis with culture reflex (GH L Q); Future

– Vitamin B12; Future

– Vitamin D, 25-hydroxy; Future

– Comprehensive metabolic panel

– TSH

– Urinalysis with culture reflex (GH L Q)

– Vitamin B12

– Vitamin D, 25-hydroxy

Vitamin D deficiency

– Vitamin D, 25-hydroxy; Future

– Vitamin D, 25-hydroxy

Vitamin B12 deficiency

levels

– Vitamin B12; Future

– Vitamin B12

Risk for falls

Fall risk teaching

-slow body changes

-avoid sudden movements

Anemia, unspecified type

– CBC and differential; Future

– CBC and differential

Gastroesophageal reflux disease, unspecified whether esophagitis present

– famotidine (PEPCID) 20 mg tablet; Take 1 tablet (20 mg total) by mouth 2 (two) times daily. Dispense: 90 tablet; Refill: 1

– H. pylori breath test; Future

– H. pylori breath test

Pt education:

-labs/tests reviewed

-Instructed on which symptoms to report

-Med teaching completed

-Disease teaching completed

-Diet and exercise discussion

-Safety discussed

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