SOAP Note: Acute Immune Thrombocytopenia

SOAP Note: Acute Immune Thrombocytopenia

Acute Immune Thrombocytopenia: The SOAP note should contain the history of the present illness, which in our 2-year old patient’s case entails, bruising and low blood platelets.

Describe the PMH, surgeries, social history, immunization, allergies, review of system (ROS), physical examination, diagnostic test, differential diagnosis, medication, referral and education. SOAP Note: Acute Immune Thrombocytopenia.

Acute Immune Thrombocytopenia Template

Subjective – The “history” section HPI: include symptom dimensions, chronological narrative of patient’s complains, information obtained from other sources (always identify source if not the patient). Pertinent past medical history. Pertinent review of systems, for example, “Patient has not had any stiffness or loss of motion of other joints.” Current medications (list with daily dosages). Objective – The physical exam and laboratory data section Vital signs including oxygen saturation when indicated. Focuses physical exam. All pertinent labs, x-rays, etc. completed at the visit. SOAP Note: Acute Immune Thrombocytopenia.

Assessment/Problem List – Your assessment of the patient’s problems Assessment: A one sentence description of the patient and major problem Problem list: A numerical list of problems identified All listed problems need to be supported by findings in subjective and objective areas above. Try to take the assessment of the major problem to the highest level of diagnosis that you can, for example, “low back sprain caused by radiculitis involving left 5th LS nerve root.” Provide at least 2 differential diagnoses for the major new problem identified in your note.

Plan – Your plan for the patient based on the problems you’ve identified Develop a diagnostic and treatment plan for each differential diagnosis. Your diagnostic plan may include tests, procedures, other laboratory studies, consultations, etc. Your treatment plan should include: patient education, pharmacotherapy if any, other therapeutic procedures. You must also address plans for follow-up (next scheduled visit, etc.). Also see your Bates Guide to Physical Examination for excellent examples of complete H & P and SOAP note formats. SOAP Note: Acute Immune Thrombocytopenia.

SOAP Note: Acute Immune Thrombocytopenia

URGENT CARE VISIT
Patient Name:
Age/Sex:
DOB:

CHIEF COMPLAINT:

HPI:

PMH:

ROS:
-General: Denies wt. changes, fever/chills, fatigue.
-HEENT: Denies any changes in vision, nasal discharge/epistaxis, sore throat/hoarseness or hearing problems.
-CV: Denies chest pain, dyspnea, palpitations, edema.
-Pulmonary: Denies cough, hemoptysis, wheezes, SOB.
-G.I: Denies anorexia, N/V/D, abd. pain, constipation, heartburn.
-GU: Denies urinary symptoms at this time. Denies erectile dysfuntion.
-MS: Denies Decreased ROM, arthralgias, swelling, pain
-Neuro: Denies weakness, numbness, HAs, seizures, dizzines/vertigo.
-Skin: Denies rashes, erythema, skin breakdown, itching.

SH:

Allergies:

MEDICATIONS:
Active Outpatient Medications (including Supplies):

Active Outpatient Medications Status
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MEDICATION RECONCILIATION:

Reviewed medications with patient, including over-the-counter and herbals.
Medications reconciliation was performed with the following results:
The patient was provided with a list of his/her medications?
Yes
If a medication list was not provided, please give the reason:

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PHYSICAL EXAM:

Blood Pressure:
Heart Rate:
Respiratory Rate:
Weight:
Temperature:
Pain:

GENERAL: Pleasant yo white male. NAD.

HEENT: TMs with sharp light reflex bilaterally. PERRLA. EOMS intact. Sclera white, conjunctiva non-swollen. Nares are patent, no exudates. Nasal mucosa is non-swollen and red. Throat is non-swollen, no pnd. Uvula moves midline.

NECK: Supple, no bruits or masses.

CARDIOVASCULAR: RRR, S1S2. Radial, brachial, femoral, DP and TP pulses are 2+/4.

RESPIRATORY: Clear sounds posteriorly to the bases bilaterally.

ABDOMEN: Active sounds in all quads. No bruits, masses, or organomegaly.

GU: External genitalia normal looking. Sphincter tone is normal. Prostate is smooth, small, no nodules.

MUSCULOSKELETAL: MAE. FROM. Strength is = side to side in the UE and LE.

SKIN: Warm and dry.

NEURO: OX3. CN II-XII intact. DTRs 2+/4 all around.

PSYCHIATRIC: Alert, interactive. Good eye contact. Appropriate responses.

HEME/LYMPH/IMMUNE: No nodal enlargement in the cervical chains, axillae, or groin.

ASSESSMENT AND PLAN:

HEALTH CARE MAINTENANCE:
Flex/sig:
Tetnus:
Pneumonia vax:
flu shot:
DRE/PSA:

Clinical Reminders:

DISPOSITION/FOLLOW-UP: