Episodic and Comprehensive SOAP Note Write-Up Samples

Episodic and Comprehensive SOAP Note Write-Up Samples

Write Ups

The written History and Physical (H&P) serves several important purposes:

1. Reference Document: It serves as a reference document, providing concise information about a patient’s history and examination findings at the time of admission.

2. Issue Resolution Plan: It outlines a plan for addressing the issues that prompted hospitalization. This information should be presented logically, emphasizing data immediately relevant to the patient’s condition.

3. Communication Tool: It serves as a means of communicating information to all providers involved in the patient’s care.

4. Educational Opportunity: It offers students and house staff a chance to demonstrate their ability to gather historical and examination-based information, apply their medical knowledge, and create a logical plan.

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The H&P is not:

– Medical Student Torture: It’s not designed to torment medical students and interns.

– Irrelevant Information: It should not include unimportant or unrelated information.

– Time-Consuming: It shouldn’t take so much time to write that the information becomes obsolete upon submission.

Understanding what to include and omit depends largely on experience and understanding of illness and pathophysiology. For example, knowing that chest pain is often associated with coronary artery disease will influence what you mention in the history. As experience grows, write-ups become more focused, and seeking feedback and reviewing samples from experienced physicians can speed up this process.

Chief Concern (CC):

This is a single sentence covering the primary reason for hospitalization, sometimes referred to as the Chief Complaint. However, “Chief Concern” may be a better term as it’s less pejorative.

History of Present Illness (HPI):

The HPI should provide sufficient information to understand the symptoms and events leading to admission. It covers everything that contributed to the patient’s arrival in the hospital, and events after admission can be summarized separately.

A useful mnemonic for exploring core elements of chief concerns is OLD CARTS, which stands for Onset, Location, Duration, Characteristics, Aggravating/Alleviating factors, Related symptoms, Treatments, and Significance.

While some HPIs are straightforward, others, especially for patients with pre-existing conditions, require giving relevant past history upfront to provide context for the acute issue.

Past Medical History (PMH):

This includes past or present illnesses, ideally supported by objective data. If something was mentioned in the HPI, you can refer to it without restating details. Otherwise, list all other relevant historical information.

Past Surgical History (PSH):

List all past surgeries, along with approximate dates. Include major traumas if applicable.

Medications (MEDS):

List all current medications, including prescription, over-the-counter, and non-traditional therapies. Note dosages, frequencies, and adherence.

Allergies/Reactions (All/RXNs):

Identify specific reactions for each medication.

Social History (SH):

This category covers various aspects of the patient’s social life, including alcohol intake, smoking history, other drug use, marital/relationship status, intimate partner violence screening, sexual history, work history, and other relevant details like travel, pets, hobbies, healthcare maintenance, and military history if applicable.

Family History (FH):

Focus on illnesses within the immediate family, especially cancer, vascular disease, or other potentially heritable conditions among first-degree relatives.

Obstetrical History (where appropriate):

Include the number of pregnancies, live births, duration of pregnancies, complications, spontaneous and/or therapeutic abortions, and birth control if relevant.

Review of Systems (ROS):

This section generally contains a more extensive review of all organ systems, including pertinent positives and negatives related to the chief concern. It’s important for diagnosing the patient’s primary issue.

Physical Exam:

Begins with a brief sentence describing the patient’s appearance.

Vital Signs:

HEENT: Includes head, eyes, ears, nose, throat, oro-pharynx, and thyroid.

Lymph Nodes:

Lungs:

Cardiovascular:

Abdomen:

Rectal (as indicated):

Genitalia/Pelvic:

Extremities, Including Pulses:

Neurologic: This section includes assessing mental status, cranial nerves, motor function, sensory perception, reflexes, coordination, and observed ambulation.

Lab Results, Radiologic Studies, EKG Interpretation, Etc.:

Assessment and Plan:

It’s important to note that the provided format is meant for structure and guidance, and there is room for variation. When exposed to different styles, consider whether the proposed structure or elements make sense and adapt them into your own evolving style over time.

Sample Write-Up #1 – Admission Note:

Chief Concern (CC): Mr. B is a 72-year-old man with a history of heart failure and coronary artery disease, presenting with increasing shortness of breath, lower extremity edema, and weight gain.

History of Present Illness (HPI): Mr. B’s history of heart failure includes:

– A first MI in 2014, a STEMI related to an LAD lesion, treated with a stent.
– A subsequent MI in 2016 with occlusions in LAD, OMB, and circumflex arteries.
– Heart failure symptoms of DOE and lower extremity edema developed in 2017, managed medically.

In the past six months, he required increasing lasix doses for edema control. Two weeks ago, he saw Dr. Johns, his cardiologist, who increased his lasix dose to 120 mg bid without relief. Over the past week, his lower extremity edema worsened, with a 10lb weight gain in two days, decreased exercise tolerance, and dyspnea upon rising.

Denies CP/pressure, palpitations, diaphoresis. Occasional nausea, no vomiting. Normal food intake, no excessive salt/fluid. Increased urinary frequency, decreased total urine. No urinary urgency, dysuria, or hematuria. No cough, sputum, fever, or chills. Takes most prescribed meds but occasionally misses 2-3 doses a week.

Past Medical History (PMH):
– Congestive Heart Failure (CHF) – as mentioned above
– Myocardial Infarctions (MIs) in 2014 and 2016
– Hypertension (HTM)
– Chronic renal insufficiency due to Diabetic Nephropathy: Creatinine level of 1.8 in January 2018
– Diabetes: Well-controlled with Metformin – A1c was 6.8 in February 2018

Past Surgical History (PSH):
– Appendectomy in 1992
– Cholecystectomy in 2004

Medications (MEDS):
– Lasix 120 mg twice daily
– Correg 25 twice daily
– Lisinopril 40 once daily
– Potassium Chloride (KCl) 40 meq once daily
– Dabigatran 200 mg once daily
– Metformin 1g twice daily
– Aspirin (ASA) 81mg once daily
– Atorvastatin 40 mg daily

Allergies:
– No known drug allergies

Social History:
– Married for 45 years, sexually active with wife. Three children, 2 grandchildren, all in good health and living within 50 miles.
– Retired school teacher who enjoys model car building. Engages in occasional walks around home and shopping but is not physically active otherwise.
– Non-smoker and non-drinker with no history of substance use.
– Military service: Marine Corps for 4 years in a non-combat role, worked in logistics.

Family History:
– Sister and mother with Diabetes Mellitus (DM), father with Coronary Artery Disease (CAD) with onset at age 50, and brother with leukemia.

Review of Systems (ROS):
– General: Denies fatigue, fever, chills, weight loss; reports weight gain as mentioned above.
– HENT (Head, Eyes, Nose, Throat): Denies oral sores, neck masses, nasal discharge, hearing problems.
– Vision: Denies changes in vision, eye pain, redness, or discharge.
– Cardiac: As mentioned above.
– Pulmonary: As mentioned above.
– GI (Gastrointestinal): Denies heartburn, difficulty swallowing, abdominal pain, diarrhea, or constipation.
– GU (Genitourinary): As per History of Present Illness (HPI).
– Neuro: Denies seizures, weakness, or numbness.
– Endo (Endocrine): Denies heat/cold intolerance, weight changes, polyuria, or polydipsia.
– Heme/Onc (Hematology/Oncology): Denies unusual bleeding, bruising, or clotting.
– MSK (Musculoskeletal): Denies joint pain, swelling, or muscle aches.
– Mental Health: Denies anxiety, depression, or mood changes.
– Skin/Hair: Denies rashes, non-healing wounds, ulcers, or hair loss.

Physical Exam:
– Vital Signs: Temperature 97.1°F, Pulse 65 bpm, Blood Pressure 116/66 mm Hg, Oxygen Saturation 98% on 2L nasal cannula, Weight 187 lbs.
– General: An elderly man lying in bed with head elevated, no acute distress.
– HENT: Normal cranial nerves, multiple telangiectasias on face and nose, extraocular movements intact, pupils equal, round, and reactive to light, oropharynx without lesions, moist mucous membranes, non-palpable thyroid, no adenopathy.
– Pulmonary: Dullness to percussion at right base, crackles heard halfway up chest bilaterally posteriorly.
– Cardiac: Regular rate and rhythm, a 2/6 holosystolic murmur at apex radiating to axilla, an S3 heart sound, no S4; point of maximal impulse (PMI) displaced laterally toward axilla; 2+ carotid pulses, no bruits; jugular venous pressure (JVP) at 12 cm.
– Abdomen: Bowel sounds present, non-distended, non-tender, no hepatomegaly.
– Extremities: 3+ edema noted in sacrum, abdominal wall, and scrotum; no clubbing, cyanosis, or skin breaks distally.
– Pulses: 2+ femoral pulses, 1+ posterior tibial/dorsalis pedis pulses bilaterally.
– Neuro: Alert and appropriate mental status, 5/5 strength in all extremities, intact distal sensation to light touch and pinprick, normal proprioception in toes bilaterally, intact vibration sense at interphalangeal joint of great toes bilaterally.
– Reflexes: 2+ and symmetric bilaterally in biceps, triceps, brachioradialis, patellar, and Achilles; no observation of gait.

Labs and Data:
– Sodium (Na) 128, Chloride (Cl) 96, Blood Urea Nitrogen (BUN) 59, Glucose 92, Potassium (K) 4.4, Carbon Dioxide (CO2) 40.8, Creatinine (Cr) 1.4, White Blood Cell Count (WBC) 7.9, Platelet Count (PLT) 349, Hematocrit (HCT) 43.9, Alkaline Phosphatase (Alk phos) 72, Total Protein 5.6, Albumin (Alb) 3.5, Total Bilirubin (T Bili) 0.5, Alanine Aminotransferase (Alt) 17, Aspartate Aminotransferase (Ast) 52, Troponin <0.01, Brain Natriuretic Peptide (BNP) 1610.

Electrocardiogram (EKG):
– Sinus rhythm at 74 bpm, q-waves noted in leads V1-V5, no ST-T wave changes. No significant change compared to a study 6 months ago.

Chest X-Ray (CXR):
– Prominent pulmonary vessels with moderate interstitial edema and a right pleural effusion. Cardiomegaly observed. No parenchymal infiltrates.

Assessment and Plan:
– A 72-year-old man with a history of heart failure with reduced ejection fraction (HFrEF) following multiple myocardial infarctions (MIs), admitted with sub-acute worsening edema and dyspnea on exertion (DOE). Symptoms are most consistent with worsening heart failure, likely due to dietary indiscretion and poor medication adherence.
– Considering strict intake and output monitoring, daily weight checks, fluid restriction to 2 liters/day, a low-salt diet, intravenous Lasix 80mg with IV metolazone now and every 8 hours to achieve a goal diuresis of 2-3 liters/day.
– Continuing lisinopril 40 once daily, correg 25 twice daily, and monitoring electrolytes and renal function twice daily.
– Providing education about an appropriate diet through a nutrition consult.
– Repeating an echocardiogram and comparing it with a prior study for evidence of a drop in left ventricular (LV) function.
– Initiating a cardiology consult for further management and considering the use of Entresto and other interventions to improve symptoms.
– Managing pulmonary congestion by maintaining oxygen saturation above 95% and treating cardiac disease as mentioned above.
– Addressing renal function with daily chem 7 and diuresis.
– Adjusting diabetes management by holding metformin and using a low-intensity sliding scale insulin regimen along with an ADA 2100 calorie diet and frequent blood sugar monitoring.
– Anticipating discharge home in 3 days with close follow-up from the heart failure service to prevent readmissions and maintain clinical stability.

Admission Note

Chief Complaint (CC): Mr. S, a 65-year-old male, presents with two main concerns:

1. Sudden and painless decline in vision.
2. A persistent cough for the past three days.

History of Present Illness (HPI):

1. Visual Changes: Yesterday, during lunch, the patient experienced an abrupt, painless decrease in vision in both eyes, with a more pronounced effect on the right eye. He first noticed this while at a restaurant when he couldn’t see the clock and had difficulty reading the numbers on his cell phone. He did not experience pain, double vision, or describe it as a “curtain dropping” over his eyes. He had nausea and vomiting twice yesterday, but these symptoms have resolved. Instead of seeking medical attention, he hoped the issue would resolve on its own. However, when he woke up today, the visual problems persisted unchanged, prompting him to seek medical care. The patient normally wears prescription glasses without any issues and has no chronic eye conditions. His last vision test was two years ago during an optometrist visit. He notes that he can improve his vision by moving his head to adjust his view. He denies experiencing dizziness, weakness, headaches, speech difficulties, chest pain, palpitations, or numbness. He has no known history of atrial fibrillation, carotid artery disease, or heart disease.

2. Cough: The patient has a history of Chronic Obstructive Pulmonary Disease (COPD) with a smoking history of over 60 pack-years. His most recent Pulmonary Function Tests (PFTs) in 2016 indicated moderate disease. Over the past few days, he has noticed increased shortness of breath, wheezing, and greenish sputum production. He regularly uses two inhalers, Formoterol and Tiotropium, without missing any doses. In the past, he received treatment with antibiotics and prednisone for shortness of breath, but he has had no other respiratory issues or hospitalizations. He denies coughing up blood, fevers, orthopnea (difficulty breathing while lying flat), paroxysmal nocturnal dyspnea (sudden shortness of breath during sleep), chest pain, or edema.

Emergency Department (ED) Course: Due to concern over acute visual loss and a known history of vascular disease, a stroke code was activated when the patient arrived in the Emergency Room (ER). The Neurology service evaluated the patient, and a CT head was performed, revealing findings consistent with an occipital stroke that occurred more than 24 hours ago. Further details about management are described below.

Past Medical History (PMH):
– COPD (moderate) with PFTs in 2014 indicating FEV1/FVC ratio of 0.6 and FEV1 at 70% of predicted.
– Hypertension diagnosed in 2012.
– Gastroesophageal Reflux Disease (GERD).
– Hyperlipidemia with a 12% ASCVD (Atherosclerotic Cardiovascular Disease) risk.
– Obstructive sleep apnea diagnosed in 2014, for which he uses a Continuous Positive Airway Pressure (CPAP) machine.

Past Surgical History (PSH):
– Right orchiectomy at age 5 due to traumatic injury.
– Right cataract removal and lens implant placement in 2014.

Medications (MEDS):
– Aspirin 81 mg once daily.
– Lisinopril 40 mg once daily.
– Atenolol 50 mg once daily.
– Pantoprazole 20 mg orally once daily.
– Tiotropium 2 puffs once daily.
– Formoterol 2 puffs once daily.
– Atorvastatin 40 mg once daily.

Allergies:
– No known allergies.

Social History:
– The patient lives with a roommate in Encinitas.
– He is heterosexual and not currently sexually active.
– He has never been married and has no children.
– He worked as an architect in the past but is currently on disability.
– He enjoys walking and reading.

Family History:
– His brother and father have Coronary Artery Disease (CAD).
– His brother had Coronary Artery Bypass Grafting (CABG) at age 55.
– His father has a history of multiple strokes.
– His mother has Diabetes Mellitus (DM).

Military Service:
– The patient has no history of military service.

Review of Systems (ROS):
– General: Denies fatigue, fever, chills, weight loss, or weight gain.
– HENT (Head, Eyes, Nose, Throat): Denies oral sores, neck masses, nasal discharge, or hearing problems.
– Vision: As described in HPI.
– Cardiac: As described in HPI.
– Pulmonary: As described in HPI.
– GI (Gastrointestinal): Denies heartburn, difficulty swallowing, abdominal pain, diarrhea, or constipation.
– GU (Genitourinary): Denies hematuria, dysuria, nocturia, urgency, or frequency.
– Neuro: Denies seizures, weakness, or numbness.
– Endocrine: Denies heat/cold intolerance, weight changes, polyuria, polydipsia.
– Hematology/Oncology: Denies unusual bleeding, bruising, or clotting.
– MSK (Musculoskeletal): Denies joint pain, swelling, or muscle aches.
– Mental Health: Denies anxiety, depression, or mood changes.
– Skin/Hair: Denies rashes, non-healing wounds, ulcers, or hair loss.

Physical Exam (PE):
– Vital Signs: Temperature 99°F, Pulse 89 bpm with irregular rhythm, Blood Pressure 139/63 mm Hg, Respiratory Rate 20, Oxygen Saturation 98% on Room Air.
– General: The patient is obese and appears to be turning his head to the right side to improve his view. He is not in acute distress.
– HENT: No abnormalities noted.
– Neck: No enlarged lymph nodes, no jugular venous distension, bilateral carotid pulses are 2+.
– Pulmonary: Equal chest rise bilaterally, wheezes heard on auscultation throughout.
– Cardiovascular: Irregularly irregular heart rhythm, a grade II/VI systolic crescendo-decrescendo murmur at the left upper sternal border radiating to carotids. No S3 or S4. Point of maximal impulse (PMI) is not displaced.
– Abdomen: Obese, normal bowel sounds, soft, non-tender, non-palpable liver, liver span 8 cm at mid-clavicular line on percussion.
– Rectal: Brown stool, negative for occult blood.
– Pulses: Femoral pulse 2+ on the right, 1+ on the left; dorsalis pedis pulse 2+ on the right, absent on the left; posterior tibial pulse 1+ bilaterally.
– Extremities: No cyanosis, clubbing, or edema. Extremities are warm and well-perfused.
– Neurological Examination:
– Mental Status: Alert and oriented to person, place, and time.
– Cranial Nerves: Detailed examination findings provided.
– Motor: Full strength in all muscle groups.
– Rapid Alternating Movements: Symmetric and equal.
– Gait: Appears normal, although somewhat unsteady due to visual issues.
– Sensory: Intact sensation to light touch, pinprick, vibration, and proprioception in the feet bilaterally.
– Reflexes: Deep tendon reflexes are 2+ and symmetric bilaterally.
– Romberg test is negative.

Laboratory and Imaging Data:
– Detailed laboratory values provided.
– Head CT scan shows several new, well-demarcated infarcts in the right occipitoparietal region with no evidence of hemorrhage or midline shift.
– Chest X-ray (CXR) reveals no infiltrates and flattened diaphragms bilaterally, consistent with COPD.
– Electrocardiogram (EKG) shows atrial fibrillation with a heart rate of 72 bpm. No acute ST-T wave changes or differences compared to a study six months ago.

Assessment and Plan:
– A 65-year-old male with acute visual field deficits consistent with an embolic stroke, most likely cardioembolic in origin. The patient’s presentation and imaging findings are consistent with an embolic event affecting the visual cortex. As the last known normal was more than 24 hours ago, thrombolytic therapy (tPA) or device-driven therapy is not indicated.
– Neurological management:
– Admit to a step-monitored unit for close observation.
– Elevate the head of the bed by 30 degrees to monitor for increased intracranial pressure (ICP).
– Start unfractionated heparin to prevent additional events, targeting a partial thromboplastin time (PTT) of 80-100.
– Perform an MRI/MRA promptly to fully characterize the extent of the infarct and arterial anatomy.
– Continue aspirin 81 mg once daily.
– Initiate occupational therapy to manage deficits.
– Arrange for a physical therapy evaluation to assess gait safety.
– Refer for ophthalmology evaluation to formally assess visual fields and explore vision correction options.
– Pulmonary management:
– Treat as an acute COPD exacerbation presumed to be of bacterial origin.
– Continue inhalers.
– Prescribe doxycycline 100 mg twice daily for 7 days.
– Administer prednisone 40 mg once daily for 5 days.
– Monitor for clinical changes and discuss smoking cessation options during the hospital stay.
– Cardiovascular management:
– Address newly identified atrial fibrillation.
– Continue Norvasc and atenolol for hypertension.
– Continue atenolol for rate control of atrial fibrillation.
– Initiate anticoagulation with unfractionated heparin and transition to a Direct Oral Anticoagulant (DOAC) as appropriate.
– Perform echocardiography to assess left ventricular function, left atrial size, and potential etiologies for atrial fibrillation.
– Infectious Disease (ID) management:
– Treat as an acute COPD exacerbation presumed to be associated with acute bronchitis.

Disposition:
– Anticipate discharge in 3-4 days.
– Consider the need for a rehabilitation stay based on functional status and safety during stroke recovery.