Case scenario:

Mr. X is a 42-year male with PMH of GERD who presents with a chief complaint of diffuse abdominal pain onset one day ago. The patient reported that he ate spicy yesterday, triggering the abdominal pain. He took OTC Prilosec 2 pills with no relief. He had one episode of NBNB vomiting since coming to the ED. He endorses subjective fever. He reports taking sucralfate as needed and just started on pantoprazole. Denies smoking, alcohol, and drug use.

Pertinent negative: fever, chills, CP, SOB, palpitations, headache, dizziness, orthopnea, diaphoresis, diarrhea, constipation and urinary symptoms.

Initial workup revealed lactate 2.7, WBC 12.8, neutros abs 10.24. UA with ketones. Unremarkable electrolytes, LFT. CT A/P with mild abdominal thickening and right lung sub-5 mm nodules. Pt was medicated with sucralfate, Zofran, Haldol, and NS bolus. Pt was admitted for the management of abdominal pain, intractable nausea, and vomiting.

You are working with your preceptor who is working with the admitting hospitalist team. Prepare a Problem-Focused SOAP Note based on the information given in the case scenario.

Problem-Focused SOAP Note Format

Demographic Data

• Patient initial (one initial only), age, and gender must be HIPAA compliant.

Subjective

• Chief Complaint (CC)
• History of Present Illness (HPI) in paragraph form (remember OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment)
• Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, Immunizations, and preventative health maintenance
• Family Hx
• Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc.
• Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)

Objective

• Physical findings listed by body systems, not paragraph form

Assessment (the diagnosis)

• Three (3) differential diagnosis (if applicable) with rationale
• Final diagnosis with rationale and pathophysiological explanation

Plan

• Dx Plan (lab, x-ray)
• Tx Plan (meds)
• Pt. Education, including specific medication teaching points
• Referral/Follow-up
• Health maintenance (including when screenings, immunizations, etc., are next due):

Reference

• Compare care given to the patient with the National Standards of Care/National Guidelines. Cite accordingly.