SOAP note with the information given in the scenario. Use the SOAP note template for the note and imagine how this would look in an actual medical record. For any information not given, feel free to make up what a patient like this would say or what the exam could be like. You are given the 2 diagnoses for which you will create an evidence-based plan.

She is a new patient with at least two problems: HTN and cholecystitis/lithiasis. Although it says she needs a refill, she has never gotten this prescription from you, so it is new. She will need a new patient visit where you take care of the acute problems and establish care, then schedule her for a well-woman exam/physical where the preventive care would be addressed. What Social Determinants of Health could be affecting this patient?

Also, consider that this is a hospital/urgent care follow-up evaluation. Imagine what a patient such as this would say, and what exam findings she could potentially have.

For the GI exam, you want to document if there is contact guarding and/or rebound tenderness. Ensure you are using inspection, auscultation, percussion, and palpation for your examination (and document what the findings would be). What specialty exams would be used in a patient with abdominal pain?

Check out Evaluation of the adult with abdominal pain

Also, review Overview of gallstone disease in adults

For the ROS, you will review the problems or complaints system by system. The information that she went to the ER and findings would be good to summarize in her HPI.

You will come up with an evidence-based differential diagnosis and plan for care.

For a review of what the subjective portion and exam portion of the SOAP note should look like, check out:

Bates Electronic text pages 184 (history) and 215 (physical exam).

(you must change the note to reflect our current patient, Maria Alvarez, no figures or charts are needed)

Remember that every office visit is an opportunity for health promotion and preventive care! This is what NPs are all about.

SOAP Note Template

Complete the SOAP note template using the information provided within this week's patient visit scenario. Refer to the SOAP Note Structure Guide to develop your documentation.

Subjective

ID

First Name: Maria

Last Name: Alvarez

Gender: Female

DOB: 01/01/1980

Age: 45-years-old

Ethnicity: Hispanic

CC

The new patient presents to the clinicfor a refillon her blood pressure medication andepisodes of pain in her abdomen under her right rib cage.

HPI

History (including PMH, surgical, family, and social):

ROS (general, skin, HEENT, neck, breasts, resp, CV, GI, peripheral vascular, urinary, genital/LMP, MSK, psych, neuro, hematologic, endocrine):

Allergies:

Current Medications:

Objective

Vital signs

HR: 78

BP: 128/78

Pulse: 78

RR: 16

Pain:

LMP:

Height: 5'4"

Weight: 180

BMI: 30.9

Physical Exam (general, HEENT, neck/lymph, breasts, chest/respiratory, CV, GI/abdomen, GU/rectal, back, MSK, skin, neuro, psych):

Assessment

(Including differential diagnoses)

Problem list:

1.

2.

3.

Differential diagnosis:

Differential Diagnoses	How was this diagnosis ruled out?
1.
2.
3.

Plan

Include the following:

• Complete prescription information: drug, dose, directions, quantity, refills
• Instructions to continue, discontinue, or start medications including changes to routine medications
• Diagnostic tests in the proper order and reason for the order; for example, CT abdomen and pelvis with and without contrast, Dx, LLQ abdominal pain
• Labs including appropriate serum panels; for example, BMP, CBC with diff., TSH, T4, UA, C&S
• Patient education pertinent to health condition
• Follow-up plan
• Referrals

Plan	Rationale and EBP/Supporting Documentation

E&M Code

Maria lvarez, a 45-year-old Hispanic female who is a new patient, presents today for a medication refill.

She relocated to Arizona from Texas 6 months ago due to a job transfer and needs a refill on her blood pressure medication.

Early in the visit, Maria mentions that for the past year she has been having episodes of pain in her abdomen under her right rib cage, especially after she eats greasy foods. As of late, the episodes have been happening more frequently, and she feels bloated and nauseated at times. It seems the episodes are triggered with any kind of food now. Not eating seems to ease the pain a little. Maria had an ultrasound a couple of weeks ago at a local urgent care and was told she has gallstones and needs to have her gallbladder removed. She brought that report today and would like to know which surgeon you recommend she visit. Maria indicates she is having a flare of pain today in her right upper abdomen and took some Tylenol this morning for it, which helped a little. Her current level of pain is 5/10.

Maria had an appendectomy at age 10. Maria, who works as a call center manager, is married and has 2 kids. Her mother is 82 years old and has high blood pressure, high cholesterol, diabetes, and arthritis. Her father is deceased from a heart attack at age 63 and was a heavy smoker. Her sister is 53 years old with diabetes, high blood pressure, and breast cancer; her brother is 50 and doesn't speak to her; her maternal grandmother died of a stroke and had diabetes; her paternal grandmother died of lung cancer; her paternal grandfather died of old age. She does not drink alcohol (very rarely) or smoke.

Meds: losartan 50mg daily, multivitamin daily. Drug allergies: none known.

BP	P	R	T	HT	WT	BMI
128/78	78	16	98.8	5'4"	180	30.9

The abdominal u/s report's impression she brought with her is "gallbladder wall thickening with sludge and numerous stones noted in the gallbladder."

Diagnosis:

Hypertension

Cholelithiasis w/ cholecystitis