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Patient SOAP Note For Writing Help essay paper

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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

Patient SOAP Note For Writing Help essay paper

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Patient SOAP Note For Writing Help

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PRACTICE CASE 2

 

Chart Information

Chief complaint: A 31-year-old man comes to the clinic with chest and stomach pain.

Vital signs: T: 98.6 F (37 C), BP: 130/85 mm Hg, HR: 108/min, RR: 16/min

Patient SOAP Note For Writing Help

 

History

For approximately a year, this patient has suffered a burning, epigastric pain (4/10). The pain is located in the center of his stomach, occasionally in his lower chest, and seems to spread through to his back. The pain occasionally wakes the patient at night, although it does not seem to be associated with any constitutional symptoms. He has not suffered any night sweats, fevers, chills, or significant weight loss, nor has he had any recent diaphoresis, shortness of breath, nausea, or vomiting. He does, however, occasionally suffer from a burning sensation and foul taste in his throat. Recently, the pain has become more frequent and more painful, and the patient has had some episodes of dark stools, although he has never noticed any blood in his stool. Eating seems to help with the pain, as do over-the-counter antacids.Patient SOAP Note For Writing Help The pain does not appear to be related to exertion. Aside from over-the-counter antacids, the patient takes no medications, prescriptions, or otherwise, and specifically denies taking any nonsteroidal anti-inflammatory medications.Patient SOAP Note For Writing Help He is single and works as an investment banker. He has an erratic diet, eating when he can (usually fast food), and admits to a 20-pack-year history of tobacco and a near-daily consumption of one to two gin and tonics to help him relax from the stresses of work. He denies using illicit drugs. Occasionally, the alcohol may worsen his symptoms. Aside from his current symptoms, which he has not suffered before this year, he has no other medical problems and is unaware of any medical problems in his family. He specifically denies any history of diabetes, heart disease, or elevated lipid levels in himself or close family members.

Patient SOAP Note For Writing Help

Physical Examination

His chest is clear to auscultation bilaterally, and tactile fremitus is within normal limits. His cardiac exam demonstrates normal sounds, rate, and rhythm, without any murmurs, rubs, or peripheral edema. His jugular venous pressure is about 7 cm H20. On abdominal exam, his liver and spleen are not enlarged. He has normal active bowel sounds, and his abdomen is tympanic to percussion in all four quadrants. He is mildly tender to palpation in the mid-epigastric area, but displays no rebound tenderness or guarding. He has a negative Murphy sign. Of note, the patient states he normally is much darker skinned than he is currently.

Patient SOAP Note For Writing Help