SOAP NOTE Patient Initials: Pt. Encounter Number: Date: Age ✓ Solved

```html

SOAP NOTE Patient Initials: Pt. Encounter Number: Date: Age:

Patient Initials: Pt. Encounter Number: Date: Age: Sex: Allergies: Advanced Directives:

SUBJECTIVE

CC: In quotation marks indicate the patient's complaint Follow the example. You must address the fundamental aspects of the patient, such as age, complaint, symptoms, time with symptoms, health problems ... HPI: Mr. FG is 71 years old male patient who presents today for the annual wellness visit. He was well oriented in time, place and person. He did not report any kind of illness except occasional lower back pain, after all he is suffering from a number of chronic conditions but he is taking proper guidelines and working on them. He denied any type of mentally or behavioral illness. He denied fever and chills, nausea and vomiting. The patient is living with his family happily.

Current Medications: Indicate if the patient is consuming any medication. Follow the lead according to the disease PMH Medication Intolerances: None Chronic Illnesses/Major traumas: Cardiac cath, “Operated 2007. Screening Hx/Immunizations Hx: No history of immunization. Rheumatoid factor. Urinary analysis. Angiography. Chest X-rays. Dexa scan. Ekg, Dental exam, eye exam, colonoscopy, spirometry. Hospitalizations/Surgeries: Hernia repair 1975, RT knee replacement 2004, fistulectomy 1975, partial prostatectomy 2014.

Family History: Father died of hemorrhage, Ulcer, gastric Mother died of kidney disease. Social History: Ex-smoker, drink on and off. In this case, the symptoms should focus on "Genitourinary / Gynecological" and other related systems- symptoms that the patient refers to their disease. You must use different wording to complete "ROS."

ROS General Alert no change in physical appearance, strength, weight and no fever and chills Cardiovascular No chest pain, no palpitations, no orthopnea. Regular rhythm, pulse rate normal Skin Normal, in color, no lesion, no rash. Respiratory No cough, sputum, chest normal in shape, no abnormal breathing sound. Eyes Normal vision, denied any pain and blurred vision Gastrointestinal Normal appetite, normal bowel habit. Ears Denied from vertigo, change in hearing, tinnitus. Genitourinary/Gynecological Nose/Mouth/Throat Nose: No obstruction. No discharge, denied bleeding, no epistaxis. Mouth: normal mucosal lining. Throat: Normal in shape, no abnormal mass found. Musculoskeletal Occasional lower back pain, denied any joint or muscle pain. Breast Normal Neurological Intact sensory and motor system, normal DTR Heme/Lymph/Endo Normal, no swelled lymph nodes. Normal thyroid gland. Psychiatric Normal, denied any type of psychiatric issue.

OBJECTIVE

Weight 174 lb. BMI 30.82 Temp 97.90 F BP 139/78 mmHg Height 63” Pulse 64 bpm Resp 18 bpm.

PHYSICAL EXAMINATION: General Appearance: Alert and oriented x 3. The patient is well-groomed, who responds to questions quickly and appropriately. She is dressed appropriate to the occasion and has a normal posture. Skin Normal in color and texture HEENT Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. No aphasia receptive or expressive. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movement intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without lesions. Lids non-remarkable and appropriate for race. Neck negative for masses, no noticeable or palpable swelling, redness or rash around throat or on face. No thyromegaly. No JVD distention. Teeth are in good repair. Cardiovascular No splitting of the heart sounds heard. No murmur. No S3 or S4. No friction rubs. Patient denies chest pain. S1, S2 with regular rate and rhythm. No extra heart sounds. No SOB, no JVD, no carotid bruits. Respiratory Symmetric chest walls. Respirations regular and easy. Clear to auscultation, no use of accessory muscles, no crackles or wheezes. Gastrointestinal Abdomen flat, soft, no painful palpation. BS active in all 4 quadrants. No hepatosplenomegaly Breast No mass noted, no full sensation, pain, or discharge reported. No prior history of breast biopsy, lesions, pain, or discharge. Genitourinary Musculoskeletal No history of falls reported, denies weakness, muscular pain, swollen, or any other inflammatory symptoms in the joints. Denies joint pain, limited ROM, difficulty walking, or trouble reaching above head. Neurological Denies history of seizure disorder, stroke, head injury, tremors, or involuntary movements, vertigo, spinal cord injury, meningitis, blackouts, paralysis, fainting, dizziness, numbness, or loss of sensation. Memory is good. Psychiatric Patient states no changes in mood, denies anxiety, depression, or insomnia. Denies low self-esteem, feeling sad, social isolation, or attention deficit, no change in thought patterns.

Lab Tests Follow the lead according to the disease MRI of back, X-ray of spine, CBC, Urinary analysis, Lipid profile. Special Tests: Follow the lead according to the disease X-ray of Spine, MRI of lumbar spine.

Diagnosis

Primary Diagnosis Follow the lead according to the disease Abscess of Bartholin's gland (ICD 10-N 75.1): Bartholinitis occurs when the ostium duct of Bartholin’s gland is blocked, and it becomes infected. If the cyst is small and there is not infection usually it is asymptomatic but, ones the cyst increases in size, or becomes infected, patients start to feel a tender, painful lump near the vaginal opening. Usually the pain and discomfort increase with walking and sitting, and patients also present dyspareunia and fever. Based on the patient’s subjective assessment, I suspect that the patient is the holder of this condition (Charleton, Otero, Giorgi & Tyndall, 2016).

Differential Diagnosis (minimum 3 differential diagnosis and 3 references) Follow the lead according to the disease Trichomoniasis (ICD 10-A59.01): Sexually transmitted infection of the urogenital tract is a common cause of vaginitis in women, while men with this infection can display symptoms of urethritis. 'Frothy', greenish vaginal discharge with a 'musty' malodorous smell is characteristic. Herpes viral infection of the urogenital tract. (ICD 10-A60.09): It is a sexually transmitted disease caused by the infection of Herpes Simplex Virus Type 2. It is characterized by the development of sores that look like blisters around the genitals or the skin surrounding the rectum with pain and itching. Usually, patients present flu-like symptoms such as fever, weakness, and cough before the lesions appear. After the primary infection, most cases suffer sporadic episodes of viral activation or outbreaks, the frequency and severity of the outbreaks are related with the patient’s immune status and the efficacy of the treatment (Lee, Dalpiaz, Schwamb, M., Miao, Waltzer & Khan, 2015). Gonorrhea (ICD 10-A54.9): The clinical presentation in the female patient is characterized by yellowish or gray-brown, purulent vaginal discharge, accompanied by itching and dysuria; may be accompanied by abdominal pain. May be accompanied by mild dysuria and urethral itching. On physical examination of the female patient, findings are usually scant to copious purulent vaginal discharge, and this patient has symptomatology that suggests this condition, although she does not have the complementary exams at hand to establish the diagnosis (Kessous, et al., 2018).

PLAN including education Follow the lead according to the disease. Plan: Further testing X-ray of D spine after 1 month. Medication Vitamin C 500mg oral OD. Vitamin D and Calcium supplement 500mg OD. Acetaminophen 50mg TD. Education Discussed risk factors and complications of deformity with the patient. Non-medication treatments Asked him to start physical activity. Referrals Physiotherapist. Follow-up visits After one month in OPD.

Paper For Above Instructions

The SOAP note is a critical component in documenting patient encounters in a structured manner. In this particular case, Mr. FG, a 71-year-old male, presents for his annual wellness visit. His extensive history, including chronic conditions and various surgical interventions, shapes the focus of the note. The subjective portion of the SOAP note documents Mr. FG's current health status, emphasizing his complaint of occasional lower back pain while reassuring that he remains mentally alert.

Current medications were discussed, notably he has no intolerances or major chronic illnesses aside from those previously mentioned. An insightful part of the visit was the review of his hospitalizations and surgical history, notably his surgeries including a hernia repair, knee replacement, and prostatectomy, adding depth to his medical background.

Family history also provides vital context; the passing of his parents due to complications from hemorrhage and kidney disease suggests potential genetic predispositions that should be monitored. His social history indicates moderate alcohol use and a history of smoking, both of which are pertinent details for ongoing health management.

The review of systems (ROS) offers an extensive overview across multiple systems, affirming stability in most areas while highlighting the ongoing issue of lower back pain and a complete urinary examination. The objective part of the note reiterates critical vital signs, with a BMI indicating overweight status, and a physical examination that reaffirms his general health conditions.

Diagnosis focuses on the primary issue of an abscess in Bartholin's gland, a pertinent concern as such infections require timely identification and treatment. The differential diagnoses include trichomoniasis, herpes, and gonorrhea—common STIs that could present similarly. Each condition warrants specific laboratory tests to confirm or rule out, emphasizing the importance of ongoing monitoring and preventative care.

The management plan outlines comprehensive steps including further imaging studies to assess the lumbar spine, supplement recommendations for vitamins, and the need for increased physical activity aimed at improving both physical and mental health. Education on risk factors associated with his conditions and their potential complications is crucial, fostering patient involvement in his care.

Referrals to a physiotherapist serve to provide additional support in managing his back pain, and setting a follow-up in a month is essential to reassess his condition and modify the plan as necessary.

In conclusion, the SOAP note for Mr. FG provides a well-structured and comprehensive evaluation for effective ongoing healthcare management. Attention to the details conveyed through subjective and objective findings allows for precise diagnostics and tailored interventions.

References

• Charleton, R., Otero, M., Giorgi, D., & Tyndall, J. (2016). Management of Bartholin gland cyst and abscess. British Journal of General Practice, 66(651), 650-651.
• Lee, C., Dalpiaz, A., Schwamb, M., Miao, A., Waltzer, S., & Khan, A. (2015). Herpes Simplex Virus: An Overview of its Epidemiology and Treatment. Southern Medical Journal, 108(11), 681-686.
• Kessous, R., et al. (2018). Gonorrhea: Challenges in the Diagnosis and Management. Infectious Diseases in Clinical Practice, 26(2), 121-126.
• Mayo Clinic. (2020). Kyphosis. Retrieved from Mayo Clinic.
• Mayo Clinic. (2020). Kyphosis - Diagnosis and Treatment. Retrieved from Mayo Clinic.
• WebMD. (2020). Anemia. Retrieved from WebMD.
• White, C. (2019). What is Kyphosis? Outlook, causes, and treatment. Healthline.
• Mayo Clinic. (2020). Overview of Osteoporosis Management. Retrieved from Mayo Clinic.
• American Urological Association. (2018). Guidelines on the Management of Urethral Strictures. Retrieved from AUA Journals.
• Centers for Disease Control and Prevention. (2021). Sexually Transmitted Infections Treatment Guidelines. Retrieved from CDC.

```