SOAP Note Template
Encounter date: __5th August 5, 2022______________________
Patient Initials: ____F__ Gender: M/F/Transgender ____ Age: __38___ Race: White Ethnicity: American
Reason for Seeking Health Care: Fatigue and flu-like symptoms for the past two weeks.
HPI: The patient is a 38-year-old female who comes to the clinic complaining of fatigue and flu-like symptoms for the past two weeks. She reports that her temperature has been elevated and has reduced energy levels, and has a poor appetite. She has also developed a rash on her chest, and her body feels especially achy. She is generally feeling quite unwell.
Allergies (Drug/Food/Latex/Environmental/Herbal): None reported
Current perception of Health: Poor
Past Medical History
Major/Chronic Illnesses, The patient has a history of major depressive disorder and anxiety.
Trauma/Injury She has no history of trauma or surgery.
Hospitalizations She has also been hospitalized for anorexia nervosa in the past.
Past Surgical History She has no history of surgery
Medications: The patient is currently taking sertraline (Zoloft) 50 mg daily for her depression and anxiety. She has no other medication allergies or intolerances.
Family History: The patient's father died of a heart attack at age 55. Her mother has a history of hypertension and is currently on medication. The patient has two sisters, both of whom are healthy. There is no history of cancer or other chronic illnesses in the family.
Social history:
The patient is a 38-year-old female who lives alone in a condo. Her family consists of her mother, father, and two sisters. She is divorced and currently unemployed. She has no history of smoking, alcohol use, or recreational drug use. She is heterosexual and sexually active but does not use contraception.
Health Maintenance
The patient is up to date on all her vaccinations. She has had a mammogram and a Pap smear within the past year, and both were normal. She has no known exposure to hazardous materials.
Review of Systems:
General: The patient has fatigue, flu-like symptoms, elevated temperature, reduced energy levels, poor appetite, and rash. She is generally feeling quite unwell.
HEENT: The patient's head is normocephalic and atraumatic. Her eyes are anicteric, and she has an intact vision. Her ears are clear, and she has no hearing loss. Her nose is clear, and she has no difficulty breathing. Her throat is clear, and she has no tenderness.
Neck: The patient's neck is free of any tenderness or lump. She reports no pain or tenderness in her breasts.
Lungs: She reports occasional shortness of breath but no chest pain.
Cardiovascular: She has no history of cardiovascular disease.
Breast: She reports no pain or tenderness in her breasts.
GI: The patient's appetite has been poor, and she reports some nausea and vomiting. She reports occasional heartburn. She has no abdominal pain or diarrhea.
Male/female genital: She has no history of sexually transmitted infections. She has no history of urinary tract infections.
GU: The patient reports no genitourinary symptoms. She has no pain or burning with urination.
Neuro: The patient reports no neurological symptoms. She has no history of head trauma. She has no record of seizures. She has no history of stroke.
Musculoskeletal: She has no joint pain or muscle pain.
Activity & Exercise: The patient reports reduced energy levels and fatigue. She reports no difficulty with activity or exercise.
Psychosocial: The patient has a history of major depressive disorder and anxiety. She has been hospitalized for anorexia nervosa in the past. She is currently unemployed and divorced. She reports no difficulty with social activities or interactions.
Derma: The patient has a diffuse red rash on her chest. She reports no other skin problems.
Nutrition: The patient has reduced energy levels and a poor appetite.
Sleep/Rest: She reports no difficulty with sleep or rest.
LMP: The patient's last menstrual period was two weeks ago. She has no menstrual problems.
STI Hx: She has no history of sexually transmitted infections.
Physical Exam
The patient's BP is 120/80 mmHg, TPR is 98.6°F, HR is 70 bpm, RR is 18 breaths/min, Ht is 5'6", Wt is 120 lbs, and BMI is 20.
General: The patient is generally feeling quite unwell and is distressed. She is ill-appearing and has developed a rash on her chest. She is well-nourished and hydrated.
HEENT: The patient's head is normocephalic and atraumatic. Her eyes are anicteric, and her pupils are equally round and reactive to light. Her ears are clear to aural inspection, and her hearing is intact to whispered voice. Her nose is patent and without discharge. Her throat is transparent and without lesions.
Neck: The patient's neck is free of any tenderness or lump.
Pulmonary: She has mild tenderness on examination of her chest. She has no signs of respiratory distress.
Cardiovascular: Her heart rate is regular, and her blood pressure is within normal limits.
Breast: She has no tenderness in her breasts, and no lumps are felt.
GI: Her abdomen is soft and non-tender
GU: There are no masses felt in the genital or urinary system.
Neuro: The patient is alert, straight in gait, and active in all reflexes.
Musculoskeletal: She has a full range of motion in her joints, and no tenderness or swelling is noted.
Derm: The patient's diffuse red rash on her chest is described as erythematous and maculopapular. It is non-blanching and covers most of her chest.
Psychosocial: She reports feeling anxious and fatigued.
Plan:
Differential Diagnoses
1. Diagnosis of influenza
2. Viral bronchitis
3. Pneumonia
Principal Diagnoses
1. Based on the information, it is likely that the patient has developed a viral infection. However, further testing may be required to confirm the diagnosis.
Order blood tests to confirm a diagnosis
Plan
Diagnosis
Diagnostic Testing: The patient appears to be in moderate distress. She has an elevated temperature, heart rate of 70bpm, and blood pressure of 120/80. She reports fatigue, body aches, and difficulty breathing.
Pharmacological Treatment: She is also given a prescription for an inhaler and antibiotics
Education: Get rest, drink fluids, and take over-the-counter medication for fever and pain.
Referrals: if the rash worsens, refer to a dermatologist
Follow-up: She is scheduled for a follow-up appointment in two weeks.
Anticipatory Guidance: Seek medical attention if the symptoms worsen or develop any new symptoms. Drink plenty of fluids, get plenty of rest, and take over-the-counter medications such as ibuprofen and acetaminophen as needed for fever and pain relief.
Signature (with appropriate credentials): __________________________________________
Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________
References
Mirza, S., Clay, R. D., Koslow, M. A., & Scanlon, P. D. (2018). COPD Guidelines: A Review of the 2018 GOLD Report. Mayo Clinic Proceedings, 93(10), 1488–1502. https://doi.org/10.1016/j.mayocp.2018.05.026
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