Problem-Focused SOAP Note. Utilize the SOAP template provided to you for the course.
Case scenario:
Mr. X is a 42-year male with PMH of GERD who presents with a chief complaint of diffuse abdominal pain onset one day ago. The patient reported that he ate spicy yesterday, triggering the abdominal pain. He took OTC Prilosec 2 pills with no relief. He had one episode of NBNB vomiting since coming to the ED. He endorses subjective fever. He reports taking sucralfate as needed and just started on pantoprazole. Denies smoking, alcohol, and drug use.
Pertinent negative: fever, chills, CP, SOB, palpitations, headache, dizziness, orthopnea, diaphoresis, diarrhea, constipation and urinary symptoms.
Initial workup revealed lactate 2.7, WBC 12.8, neutros abs 10.24. UA with ketones. Unremarkable electrolytes, LFT. CT A/P with mild abdominal thickening and right lung sub-5 mm nodules. Pt was medicated with sucralfate, Zofran, Haldol, and NS bolus. Pt was admitted for the management of abdominal pain, intractable nausea, and vomiting.
In this scenario, you are working with your preceptor who is working with the admitting hospitalist team. Prepare a Problem-Focused SOAP Note based on the information given in the case scenario.
ATTACHMENTS
agac_soap_note_template_060823_cf.docx
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