Samuel Merritt University Back Pain SOAP Note Discussion

60-year-old male with diabetes comes to your clinic with back pain that is not relieved with OTC analgesics. He denies recent history of trauma. 

Medications:

Metformin 500 mg one tab PO BID for diabetes

Glipizide 5 mg one tab PO BID for diabetes 

Rosuvastatin 20 mg one tab PO at bed time for hyperlipidemia

Lantus 14 units at bed time

1. Write a SOAP note of above presentation. Your information in the subjective and objective data can be based on a hypothetical case. 

2. Document Red Flags of pertinent negatives and positives in HPI of SOAP note.

3. Document pertinent special tests in PE of SOAP Note.

4. Write a substantive response to a minimum of two different students. Is objective and subjective data included in the right format? Please be specific to information related to the SOAP note format.

1. Would you agree with your peers differentials listed? Are there any diffs you would add/remove, if so explain your rationale.
2. Does HPI have relevant information related to CC?
3. Medication listed with right timing, dosing, and number of tablets specified? Any red flags with medication list? 
4. PMH, FH, and SH has all the appropriate information?
5. Does information in ROS correlate to CC?
6. Is there any information lacking in physical exam documentation of CC (Students often get confused between ROS and objective findings)?
7. Includes assessment, plan, follow up information, and patient education?

See sample SOAP Note: Sample_ SOAP_ Note 

20 points will be deducted for combining subjective and objective information. Please see example below:

ROS:

Example 1. 

General: Alert and oriented, denies fatigue and chills.

( subjective and objective information is combined above. ” Alert and oriented” is part of PE general and not ROS.

Example 2.

ROS:

Resp: denies cough, wheezing,  lungs sounds CTA bilaterally.

( subjective and objective is combined above;” lungs sounds CTA bilaterally” is part of PE

PE:

Example 1:

PE: Denies fatigue and chills. Alert and oriented.

” Denies fatigue and chills” is part of ROS and not PE.

Example 2:

PE: Bowel sounds present all quadrants. Denies abdominal pain.

” Denies abdominal pain” is part of ROS and not PE