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46-year-old Caucasian female with complaints of pain to right shoulder. She states she was carrying a grill up her stairs when the grill began to fall. She states she did not hit her shoulder but was also drug down the steps with the grill. She states the pian is 10/10 if she moves her right arm and radiates to her neck. She reports the pain is 6/10 if she remains still. Shoulder x-ray in office reveals no abnormalities. Patient referred to orthopedic for further evaluation.

 

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BP 132/78, HR 88, Respirations 18, Ht 5 ft 6 in., Weight 182

History of HTN treated with Amlodipine 5mg daily

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·  Review the Comprehensive SOAP Note Template.

·  With this patient in mind, consider the following: 

  • Subjective: What details did the patient provide regarding the personal and medical history?
  • Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities and psychosocial issues.
  • Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their CPT and ICD-10 codes for the diagnosis. What was your primary diagnosis and why? Provide at least 4 scholarly articles as references. No older than 5 years
  • Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Provide at least 2 scholarly articles as references no older than 5 years
  • Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?

 

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