SOAP Note Template
Encounter date: ________________________
Patient Initials: _KL_____ Gender: M/F/Transgender _F___ Age: _72____ Race: _Caucasian____ Ethnicity ____
Reason for Seeking Health Care: _Patient came with a history of chest pains and hemoptysis for a period of three weeks._____________________________________________
HPI:_Patient was well until three weeks ago; when she presented with a history of left-sided chest pains. There is an associated history of difficult breathing for an unknown period of time. The history of hemoptysis is related to regular coughing. According to the patient, there was no prior history of chest trauma._____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Allergies(Drug/Food/Latex/Environmental/Herbal): __The patient mentions that she has a history of lactose/gluten allergy._________________________________
Current perception of Health: Excellent Good Fair Poor
Past Medical History
Major/Chronic Illnesses: The patient had a prior history of COPD (Chronic Obstructive Pulmonary Disease) through which the diagnosis presented seven years ago.__________________________________________________
Trauma/Injury _Patient had a history of fall which happened eight years ago.__________________________________________________________
Hospitalizations __She had an admission thirty years ago due to a myomectomy procedure for the removal of fibroids.________________________________________________________
Past Surgical History: Has had a prior history of a myomectomy procedure for the management of symptomatic fibroids. _________________________________________________________
Medications: _The patient has been taking Seretide 50/500 and Duovent inhalers for the management of the COPD as a way of preventing of bronchoconstriction._________________________________________________________________
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Family History: _According to the patient, there’s a familial history of asthma and convulsive disorder both among the maternal relatives.___________________________________________________________
Social history:
Lives: Single family House/Condo/ with stairs: _Condo with stairs__________ Marital Status:_Married_______ Employment Status: _Self-Employed_____ Current/Previous occupation type: __Businesswoman_______________
Exposure to: ___Smoke_Has a 10-pack history.___ ETOH _No alcohol history___Recreational Drug Use: _There’s no recreational drug history._________________
Sexual orientation: _Straight______ Sexual Activity: _N/A___ Contraception Use: ___None_________
Family Composition: Family/Mother/Father/Alone: __Also stays with her mother in the same house.___________________________
Health Maintenance
Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc __Patient has had a mammogram taken last year which was non-remarkable.___
Exposures: There is an exposure history of mammograms plus a chest X-ray which was done during the diagnosis of COPD.
Immunization HX: The immunization history was non-remarkable.
Review of Systems:
General: This system is non-remarkable.
HEENT: Patient presented with a positive history of hemoptysis.
Neck: This system is non-remarkable.
Lungs: There is a positive history of chest pains and dyspnea.
Cardiovascular: This system is non-remarkable.
Breast: This system is non-remarkable.
GI: This system is non-remarkable.
Male/female genital: This system is non-remarkable.
GU: This system is non-remarkable.
Neuro: This system is non-remarkable.
Musculoskeletal: Power on the left lower limb is 4/5 due to a recent history of a prior fall.
Activity & Exercise: Patient tries to do elliptical exercises three times a week.
Psychosocial: Assessment of the history tries to depict that the patient has a non-remarkable psychosocial history.
Derm: This system is non-remarkable.
Nutrition: Patient has a non-remarkable nutritional history with a good nutritional status.
Sleep/Rest: The patient sleeps eight hours a day with a stable sleeping cycle.
LMP: The patient is post-menopausal.
STI Hx: This system is non-remarkable.
Physical Exam
BP_131/74_______TPR_37.4____ HR: _75____ RR: _24___Ht. _5’8”____ Wt. _72kg_____ BMI (percentile) _24____
General: Patient had a history of finger clubbing and cyanosis after the examination of the nails.
HEENT: Analysis of the oral mucosa elicits the presence of stained teeth and tongue.
Neck: This system is non-remarkable.
Pulmonary: There was no deviation of the trachea. Palpation elicits no pulmonary masses. Auscultation portrayed that there were decreased lung sounds on the left side. Percussion sounds on the left side elicited stony dull percussion sounds.
Cardiovascular: This system is non-remarkable.
Breast: This system is non-remarkable.
GI: This system is non-remarkable.
Male/female genital: This system is non-remarkable.
GU: This system is non-remarkable.
Neuro: This system is non-remarkable.
Musculoskeletal: This system is non-remarkable.
Derm: This system is non-remarkable.
Psychosocial: This system is non-remarkable.
Misc. This system is non-remarkable.
Plan:
Differential Diagnoses
1. Lung Malignancy
2. Interstitial Lung Disease
3. Acute COPD exacerbation
Principal Diagnoses
1. Lung Malignancy
2. Interstitial Lung disease
Plan
Diagnosis Lung Malignancy
Diagnostic Testing: CXR, Chest CT scan
Pharmacological Treatment: Carboplatin plus docetaxel; plus Seretide 50/500 plus Duovent inhalers.
Education: The patient needs to comprehend that the type of management depends on the stage and grade of the malignancy.
Referrals: They might be a need for referral to an oncologist.
Follow-up: Pulmonologist and oncologist follow-up is crucial.
Anticipatory Guidance: Assessment of the therapeutic success is critical in the prognosis of the patient.
Diagnosis Interstitial Lung Disease
Diagnostic Testing: Spirometry, CXR, Bronchoscopy with biopsy.
Pharmacological Treatment: Prednisolone 10 mg OD on alternate days plus Seretide 50/500 plus Duovent inhalers.
Education: The patient should be counselled on the adverse effects of steroid medications.
Referrals: They might be a need for referral to a pulmonologist.
Follow-up: Pulmonologist follow-up is crucial.
Anticipatory Guidance: The patient might need to understand that the pulmonologist follow-up would be long term.
Signature (with appropriate credentials): __________________________________________
Cite current evidenced based guideline(s) used to guide care (Mandatory)_Kubota et al., (2020) depicts the fact that the combination of carboplatin plus docetaxel is highly effective in the management of lung malignancy. Sahu (2016) elicits the fact that prednisolone is effective in the management of interstitial lung disease.______________
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Tel: (000) 555-1234 FAX: (000) 555-12222
Patient Name: (Initials)________KL______________________ Age ___72________
Date: _______________
RX ______________________________________
SIG:
Dispense: ___________ Refill: _________________
No Substitution
Signature: ____________________________________________________________
Kubota, K., Kunitoh, H., Seto, T., Shimada, N., Tsuboi, M., Ohhira, T., ... & Watanabe, K. (2020). Randomized phase II trial of adjuvant chemotherapy with docetaxel plus cisplatin versus paclitaxel plus carboplatin in patients with completely resected non-small cell lung cancer: TORG 0503. Lung Cancer, 141, 32-36.