Patient SOAP Note For Writing Help essay paper

Patient SOAP Note For Writing Help

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CS Patient Note grading:

1. History (30%): CC and HPI (20%), ROS, PMHx, PSHx, FHx, SHx, Meds, Allergies (10%)
2. PEx: (20%)
3. Differential Diagnosis, most to least likely: (30%)
4. Initial Diagnostic Studies: (20%)

History (30%): A complete History must contain:

CC (At Top)Patient SOAP Note For Writing Help

HPI

Pertinent ROS: positive and negative symptoms associated with the CC

PMHxPatient SOAP Note For Writing Help

PSHx

FHx

SHx

Meds

Allergies

PEx (20%): Systems Approach:

Important: “Normal” is acceptable for NCAT, S1S2, skin turgor, tactile fremitus.

Avoid using “normal”, benign, or unremarkable in other parts of PEx.

PEX should be focused by system on the patient’s chief complaint, BUT ALSO complete enough to develop a comprehensive differential diagnosis based on physical examination of associated systems.Patient SOAP Note For Writing Help

Remember: Observe, Auscultate, Palpate

Systems are based on CC and positive associated symptoms.

Vital signs should be documented (2%): Temp, P, BP, RR, (RA ox): WNL is acceptable for normal Vital signs. Recommend writing them out.

General Appearance Statement (GAS) (must be documented) (2%)Patient SOAP Note For Writing Help

Skin: rashes, lesions, ulcers, masses (note dimensions of finding)

HEENT: NCAT, EOMI, PEERL, no papilledema, no nasal congestion, TMs without erythema, bulging, Throat no tonsillar erythema, exudates or enlargement, Mouth moist mucous membranes, good dentition, no lesions

Neck: supple, no JVD, no cervical LAD, no thyromegaly or nodules

CVS: RRR, S1S2 audible, no murmurs, rubs, gallops. PMI not displaced

Chest/Lungs: no tenderness, clear breath sounds bilaterally, no wheezing, rales, rhonchi

Abdomen: soft, non-distended, non-tender, BS +/present, no hepatosplenomegaly, no pulsatile mass or abdominal bruit, no CVA tenderness

Extremities: edema, pulses, cyanosis, clubbingPatient SOAP Note For Writing Help

MSK: musculoskeletal exam (including ROM), deformity, tenderness

Neuro: Mental status Alert, Oriented x 3, CN II-XII grossly intact, Motor strength 5/5 all muscle groups, Sensation intact to sharp and dull, DTRs 2+ intact and symmetrical, Babinski -, Cerebellar intact finger to nose, Romberg -, gait stable

• Note the difference between the Extremity exam, MSK exam, and Neuro exam.
• DRE, Genital, Pelvic, Breast, Inguinal Hernia, Corneal and Gag reflex are NOT listed in the PE section. These tests need to be ordered and put into the Initial Studies section of the note. These exams are only done to Confirm a diagnosis.

Patient SOAP Note For Writing Help

Differential Diagnosis (30%): Most likely to Least likely.

The Diagnosis should match the CC.

Diagnosis #1 (14%) is most supported by your history and physical exam.

Diagnosis #2 (10%)

Diagnosis #3 (6%)

If no supporting evidence given in the History/Symptoms and Physical Exam findings, only 2% received for correct diagnosis.

Associated symptoms and physical findings should support your differential diagnoses.

You must list physical findings that support each Differential Diagnosis.

You must know the difference between symptoms (historical) and signs (physical findings).

Patient SOAP Note For Writing Help

Initial Studies (20%): The objective is to confirm the diagnosis with the Initial Studies.

• Consider initial studies that will help you make the diagnosis, not secondary studies that may be performed later in the decision making process.
• Treatment Interventions and Consultations are not diagnostic studies.
• DRE, Genital, Pelvic, Breast, Inguinal Hernia, Corneal and Gag reflex are NOT listed in the PE section. These tests need to be ordered and put into the Initial Studies section of the note.
• XRays, US, and CT/MRI scans etc must indicate the specific anatomy.
• Blood tests must be specified: The only studies that can be written are CBC, Electrolytes and UA. Everything else must be broken down and specified. LFTs, TFTs are unacceptable for CS, must specify parts of each study. (BMP (Na, K, BUN, Cr, Ca, Mg) LFTs (t. bili, SGOT/SGPT (AST/ALT), alk phos, lipase amylase), TFTs (TSH, T4, etc.) Coags (PT/PTT/INR), pregnancy test (B-HCG), vaginal or urethral cultures (GC/Chlamydia, KOH wet prep), etc.
• Consider B-HCG in any woman of child-bearing age. It may influence your choice of diagnostic studies and choice of treatment/medications.

Patient SOAP Note For Writing Help

This assignment is to help prepare you for the patient note section of the USMLE CS exam.  It might be helpful to review the bulletin of information regarding the Patient Notes here: https://www.usmle.org/pdfs/step-2-cs/cs-info-manual.pdf

Advice:

1. Systematic Approach: Follow the Bullet Format (HPI and Physical Exam): so that you don’t miss a required component for the CS Exam.
2. Then think clinically: Focusing your History and Physical Exam should lead you toward a comprehensive Differential Diagnosis, Initial studies, and then an appropriate Assessment and Plan.

Patient SOAP Note For Writing Help