Running head: SOAP NOTE 1

Soap Note
SOAP NOTE 2

SOAP NOTE UNIT THREE

I. Subjective Data

A. Chief Complain (CC): “I am still depressed, but doing better. I am having

trouble sleeping through the night.”

B. History of Present Illness (HPI): 49 year old white male recently hospitalized for
getting intoxicated and then asking police to shoot him. Patient has been
depressed for several years, started to increase alcohol use. Wife left him earlier
this year and this is what precipitated the event with the police. Patient was
injured in car accident prior the hospitalization with injuries including
pneumothorax. Patient now living at The Haven and has an escort with him until
January due to suicide attempt. Patient is now sober and attending meetings at
AA as well as other counseling and group meetings. Still has trouble sleeping
through the night and some left over pain from the motor vehicle accident. Has
tremors in hands when waking in the morning. Denies being suicidal at this time.

C. Last Menstrual Period (LMP- if applicable) – Not applicable.

D. Allergies: aspirin (GI bleeding), quibron (hot flashes/nervous).

E. Past Medical History: bronchitis, pneumonia, insomnia, alcoholism, depression,

anxiety, hypertension, attention deficit disorder, diabetes.

F. Family History: Father – high cholesterol, stroke, coronary arteriosclerosis.

Mother – mental disorder, thyroid disorder.

G. Surgery History: greenfield filter placement, bariatric surgery, tonsillectomy,

saliva duct cleaned duct, hernia..

H. Social History (alcohol, drug or tobacco use): Denies drug use. Quit alcohol use
77 days ago.

I. Health Maintenance: Last eye exam 2014. Has not had colonoscopy yet.

J. Lifestyle Patterns: Attends group meetings including AA. Believes in God but
does not attend church at this time.

K. Current medications: Abilify 5mg PO at bedtime. Folic Acid 1 mg PO daily.

Lopressor 25mg PO BID. Losartan 25mg PO daily. Metformin 1000mg PO BID.
Prozac 40mg PO daily. Thiamine 100mg PO daily. Vivitrol 380mg IM, one
injection every 28 days.
SOAP NOTE 3

L. Review of Systems (ROS):

System Areas discussed Negative/positive

General Wgt change; weakness; fatigue; fevers Denies weight loss, denies

weakness, denies fevers;

denies weight changes;

increased fatigue over last

several months

Skin Rash; lumps; sores; itching; dryness; color Denies change in skin, no new

change; change in hair/nails moles or lesions; no c/o of

lumps; denies change in hair

or nails
Head Headache; head injury; dizziness or vertigo Denies dizziness or syncope;

denies headache; no head

injury
Eyes Vision Δ; eye pain, redness or swelling, No c/o of changes in vision;

corrective lenses; last eye exam; excessive no eye complaints; last eye

tearing; double vision; blurred vision; exam in 2014.

scotoma
Ears Hearing change; tinnitus; earaches; Denies changes in hearing;

infections; discharge, hearing loss, hearing denies new ear infections; no

aid use use of hearing aid; denies

tinnitus
Nose/ Colds; congestion; nasal obstruction, Denies cold/congestion; denies

Sinuses discharge; itching; hay fever or allergies; allergies or nosebleeds; no

nosebleeds; change in sense of smell; sinus change in smell; denies sinus

SOAP NOTE 4

pain pain
Throat/ Bleeding gums; mouth pain, tooth ache, Denies bleeding gums; denies

Mouth lesions in mouth or tongue, dentures; last dental pain or lesions of mouth

dental exam; sore tongue; dry mouth; sore or tongue; no dentures; last

throats; hoarse; tonsillectomy; altered taste dental exam 2013; denies sore

throat
Neck Lumps; enlarged or tender nodes, swollen Denies neck stiffness, no

glands; goiter; pain; neck stiffness; complaints of lumps or

limitation of motion swollen glands, denies range

of motion issues
Breasts Lumps; pain; discomfort; nipple discharge, Deferred

rash, surgeries, history of breast disease;

performs self-breast exams and how often,

last mammogram; any tenderness, lumps,

swelling, or rash of axilla area

Pulmonary Cough—productive/non-productive; Denies cough; denies being

hemoptysis; dyspnea; wheezing; pleuritic short of breath; no c/o of

pains; any H/O lung disease; toxin or wheezing or chest discomfort;

pollution exposure; last Chest X-RAY, TB no history of lung disease or

skin test toxin exposure; unknown last

TB test and chest x-ray

Cardiac Chest pain or discomfort; palpitations; Denies chest pain or

dyspnea; orthopnea; edema, cyanosis, discomfort; denies

nocturia; H/O murmurs, hypertension, palpitations; no dyspnea with

anemia, or CAD exertion; hx of hypertension,

denies anemia or cardiac

SOAP NOTE 5

disease
G/I Appetite change; jaundice; nausea/emesis; Good appetite, denies

dysphagia; heartburn; pain; nausea/emesis, denies

belching/flatulence; change in bowel habits; heartburn; no complaints of

hematochezia; melena; hemorrhoids; constipation or diarrhea; no

constipation; diarrhea; food intolerance known food intolerances;

denies hemorrhoids
GU Frequency; nocturia; urgency; dysuria; Denies incontinence, urinates

hematuria; incontinence once per night; denies urinary

Females: Use of kegal exercises after urgency or frequency

childbirth; use of birth control methods;

HIV exposure; Menarche;

frequency/duration of menses;

dysmenorrhea; PMS symptoms: bleeding

between menses or after intercourse; LMP;

vaginal discharge; itching; sores; lumps

Menopause; hot flashes; post-menopausal

bleeding;

Peripheral Claudication; coldness, tingling, and Denies leg cramps or swelling;

Vascular numbness; leg cramps; varicose veins; H/O denies current blood clots or

blood clots, discoloration of hands, ulcers ulcers; has greenfield filter; no

complaints of leg cramps or

varicose veins
Musculo- Muscle or joint pain or cramps; joint Has frequent pain in bilateral
SOAP NOTE 6

skeletal stiffness; H/O arthritis or Gout; limitation hips; denies back pain or other

of movement; H/O disk disease joint pain

Neuro Syncope; seizures; weakness; paralysis; No c/o of syncope, weakness,

stroke, numbness/tingling; tremors or tics; involuntary movements or

involuntary movements; coordination coordination problems; denies

problems; memory disorder or mood memory problems; depression

change; H/O mental disorders or improving

hallucinations
Heme Hx of anemia; easy bruising or bleeding; No history of bleeding or

blood transfusions or reactions; lymph node bruising; has never had blood

swelling; exposure to toxic agents or transfusion; unknown

radiation exposure to toxins

Endo Heat or cold intolerance; excessive Denies being intolerant of

sweating; polydipsia; polyphagia; polyuria; heat/cold; denies thyroid

glove or shoe size; H/O diabetes, thyroid problems; no hormone

disease; or hormone replacement; abnormal replacement or abnormal hair

hair distribution distribution

Psych Nervousness/anxiety; depression; memory Has loss interest in doing some

changes; suicide attempts; H/O mental normal activities, but

illnesses improving; complaints of

depression but feeling better

control of it; recent suicide

attempt
SOAP NOTE 7

II. Objective Data

Vital Signs/ Height/Weight: 140/78, HR 68, Resp 16, temp 98.6, weight 272 lbs,
height 73, BMI 35.88.

General:
49 year old white male appears relaxed and comfortable. He is alert, oriented and appropriate.
Speech is clear and concise; well dressed, even fat distribution, nourished and hydrated. Skin
tone consistent with race. Hearing appears intact with facial expressions appropriate for
conversation.

Skin:
Skin is warm, dry and consistent with ethnicity. Good skin turgor.
No discoloration.

HEENT & Sinuses:

Skull is round, symmetrical and proportionate to rest of body. Scalp is smooth, symmetrical;
no lumps or deformities. Temporal mandibular joint moves freely. Face is symmetrical, no
abnormalities. Ears equal in size. Pinna non painful when palpated. Auditory meatus clear
with no redness or drainage. Eardrum shiny, clear, flat and gray in color. Eyes symmetrical
on face. Eyebrows symmetrical and equal height. Eyelashes distributed evenly. PERRLA
with brisk 3mm bilaterally. Cornea smooth with no opacities. Iris flat. Red reflex present.
Conjunctiva were clear and pink, no drainage. Optic disc was yellowish, no AV nicking seen
and no lesions. Macula observed. Diagnostic positions test performed with smooth eye
movement, no lid lag. Nose symmetrical with no deformity. Nostrils patent. Nasal mucosa
smooth, moist, pinkish red with no swelling or nodules. Inferior and middle turbinates moist
and pink with no nodules. Septum intact with no deviation. Paranasal and maxillary sinuses
nontender upon palpation. Lips pink, moist and symmetrical. Teeth white, straight and spaced
evenly. No signs of decay. Gums with defined margins, no swelling. Tongue moist. Buccal
mucosa pink, moist with no lesions. Hard palate has irregular transverse rugae. Soft palate
smooth and pink. Uvula midline, pink and cranial nerve X intact.

Neck & Regional Lymph Nodes:

Neck is midline, no visual lymph nodes or swelling present. No tenderness upon palpation of
lymph nodes in face, head and neck which included: re-auricular, post auricular, occipital,
tonsillar, submaxillary, submental, superficial cervical, posterior cervical, deep cervical chain,
and supraclavicular. Neck supple with good range of motion. No jugular vein distention. No
carotid bruits. Trachea midline, nontender. Thyroid palpable, no lumps or masses present.
No bruit.

Breasts:
Not examined. Deferred
SOAP NOTE 8

Lungs & Thorax:

Lungs clear to auscultation anterior and posterior. No deformities noted to thorax. Skin intact
with no lesions. Chest symmetrical. No CVA tenderness.

Heart:
S1 and S2 heard, regular rhythm with no murmur or extra sounds. Pulse sites assessed
include: radial, brachial, femoral, popliteal, dorsalis pedis, posterior tibial, carotid and
abdominal aorta. No bruits heard over carotid or aorta.

Gastrointestinal:
Abdomen is soft and round. Umbilicus is midline and inverted. Skin is smooth and even.
Bowel sounds present in all four quadrants. Non tender upon palpation. No masses felt.

Genitourinary:
Bladder non tender upon palpation. External genitalia – not examined.

Extremities (Peripheral Vascular):

Extremities warm to touch. Capillary refill less than three seconds. No edema. No
deformities or abnormalities with extremities. Freely moving.

Musculoskeletal:
Steady gait with normal balance. Coordination intact. Spine aligned. Good range of motion
with spine and joints. Normal strength, no muscle atrophy. Joints freely movable. No
crepitus.

Neurological:
Alert and oriented to person, place, time and events. Speech is clear. Short and long term
memory intact. Deep tendon reflexes intact. No tremors or weakness.

A. Assessment

Differential Diagnosis

1. Depression – Depression isn’t just being sad, it involves much more including
loss of interest in normal activities, inability to concentrate, loss of pleasure in
things that would normally be pleasurable, and much more. Not all people
present the same. Other symptoms or complaints a patient may say he or she
is experiencing are fatigue, anger, irritable, and slow thinking (Dunphy,
Winland-Brown, Porter, & Thomas, 2011). Depression can include thoughts
SOAP NOTE 9

of suicide or suicide attempts which this patient did after he crashed his car.
This patient more than meets the criteria for depression.

2. Thyroid disorder - Certain thyroid disorders can cause many symptoms that
mimic anxiety or depression. Hyperthyroidism can cause depression, anxiety,
palpitations, weight loss, weakness, apathy, irritability and trouble
concentrating (Dunphy, Windland-Brown, Porter, & Thomas, 2011). The
easiest way to rule this out is to do blood work to confirm a diagnosis. This
patient’s lab work was done previously which did not indicate a thyroid
disorder, so this diagnosis can be ruled out at this time but should be checked
periodically.

3. Alcoholism – This involves not only consuming alcohol in access or multiple

times a day or week, but encompasses the fact the person continues to drink
even though it has disrupted social roles (Papadakis & McPhee, 2014).
Alcoholism usually involves a lack of judgment by the person drinking.
Clinical guidelines suggest at least one clinically significant impairment
which can include failure to fulfill work or home obligations or risk of bodily
harm (Uphold & Graham, 2013). This particular patient drank daily and
ended up losing his job and marriage because of alcohol. The patient also
risked bodily harm by driving under the influence and asking police to shoot
him. This patient had a drinking problem which involved bouts of depression
and anxiety with it. The patient is currently in remission.

Medical Diagnosis

1. Depression (ICD9 - 311.) and Other and unspecified alcohol dependence in

remission (ICD9 - 303.93).

B: PLAN

1. Patient to continue taking medications as prescribed. Not skip any doses.

2. To attempt to exercise more frequently because this will help with energy
levels and mood. Continue to eat a balanced diet and increase water intake.
3. To continue with group therapy and AA meetings.
4. Prescription given for Neurontin 600mg PO TID to help with bilateral hip
pain and generalized pain from motor vehicle accident. Was recently taken
off of pain medications.
5. Patient has no cultural or spiritual beliefs that would hinder treatment.
The patient’s spiritual beliefs are what keep him moving forward and prevent
thoughts of suicide. The patient is in middle adulthood phase of life and does
mention the many regrets he has with losing him previous job, failed marriage
and drinking problem. He realizes that he must learn from his past mistakes
and move forward. Will continue to monitor patient’s mood and energy level
SOAP NOTE 10

and also his desire to drink alcohol again. Patient will get yearly labs drawn
today.

Follow-Up Plans: Patient is to follow up in one month for a re-check of energy levels, mood,
and pain. If lab work comes back abnormal will follow up sooner to discuss results and further
plan of care. Will re-check blood pressure at this next visit as well to see if medications need
adjusting.

CPT Code: 99396

SOAP NOTE 11

References

Dunphy, L. M., Windland-Brown, J. E., Porter, B. O, & Thomas, D. J. (2011). Primary care:

The art and science of advanced practice nursing (3rd ed.). Philadelphia, PA: F. A.

Davis Company.

Papadakis, M. A., & McPhee, S. J. (2014). Current medical diagnosis & treatment 2014. New

York, NY: McGraw Hill Education.

Uphold, C. R., & Graham, M. V. (2013) Clinical guidelines in family practice (5th ed.).

Gainesville, FL: Barmarrae Books Inc.