Can you please fill out this paper make up this SOAP notes for 30 years old female complain of heart burn.
The plan should include: What test and lab work you will order, what medications you will prescribe,
I sent the rubric to fallow also. APA style with rubric.
SOAP NOTE
Name: |
Date: |
Time: |
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Age: |
Sex: |
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SUBJECTIVE |
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CC: Reason given by the patient for seeking medical care “in quotes” |
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HPI: Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness. |
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Medications: (list with reason for med ) |
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PMH Allergies: Medication Intolerances: Chronic Illnesses/Major traumas Hospitalizations/Surgeries
“Have you every been told that you have: Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.” |
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Family History Does your mother, father or siblings have any medical or psychiatric illnesses? Anyone diagnosed with: lung disease, heart disease, htn, cancer, TB, DM, or kidney disease. |
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Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, marijuana. Safety status |
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ROS |
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General Weight change, fatigue, fever, chills, night sweats, energy level |
Cardiovascular Chest pain, palpitations, PND, orthopnea, edema |
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Skin Delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles |
Respiratory Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB |
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Eyes Corrective lenses, blurring, visual changes of any kind |
Gastrointestinal Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools |
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Ears Ear pain, hearing loss, ringing in ears, discharge |
Genitourinary/Gynecological Urgency, frequency burning, change in color of urine. Contraception, sexual activity, STDS Fe: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx Male: prostate, PSA, urinary complaints |
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Nose/Mouth/Throat Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain |
Musculoskeletal Back pain, joint swelling, stiffness or pain, fracture hx, osteoporosis |
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Breast SBE, lumps, bumps or changes |
Neurological Syncope, seizures, transient paralysis, weakness, paresthesias, black out spells |
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Heme/Lymph/Endo HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance |
Psychiatric Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx |
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OBJECTIVE |
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Weight BMI |
Temp |
BP |
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Height |
Pulse |
Resp |
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General Appearance Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first, then brighter later. |
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Skin Skin is brown, warm, dry, clean and intact. No rashes or lesions noted. |
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HEENT Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair. |
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Cardiovascular S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema. |
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Respiratory Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally. |
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Gastrointestinal Abdomen obese; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly. |
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Breast Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin. |
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Genitourinary Bladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness. No adnexal masses or tenderness. Ovaries are non-palpable. (Male: both testes palpable, no masses or lesions, no hernia, no uretheral discharge. ) (Rectal as appropriate: no evidence of hemorrhoids, fissures, bleeding or masses—Males: prostrate is smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm). |
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Musculoskeletal Full ROM seen in all 4 extremities as patient moved about the exam room. |
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Neurological Speech clear. Good tone. Posture erect. Balance stable; gait normal. |
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Psychiatric Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately. |
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Lab Tests Urinalysis – pending Urine culture – pending Wet prep – pending |
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Special Tests |
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Diagnosis |
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Differential Diagnoses
Diagnosis
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Plan/Therapeutics |
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Evaluation of patient encounter |
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