QUESTION.

Maria is a 35 y/o female who is complaining of frequent vaginal yeast infections. She has had 4 in the last 6 months, and they have been treated with topical and oral antifungal medications which have initially worked, but the infections recur within 1-2 weeks. Maria reports increased thirst and urination for the last two to three months. Maria is an office manager in a bookstore who works full-time and has 4 children aged 5, 7, 10, and 12, who live with her 80% of the time. She has been divorced x 3 years and is struggling to make ends meet and reports she and her children frequently eat fast food because of the low cost and time constraints. Maria’s vital signs are 136/88, 98.8, 16, 80, Ht 5’3”, Wt 187 lbs,

COMPLETE THE SOAP NOTE

Template

Case Study Chosen: (List what case you have chosen)

Demographics: Age/Gender

SUBJECTIVE

• CC:
• HPI: (As listed from Case Study Information)

Subjective: (What questions will you ask? Must be listed by System, ONLY as it pertains to Chief Complaint/HPI. Should NOT be all systems or full head to toe unless pertinent).

OBJECTIVE

General:

• VS BP, HR, RR, Weight, Height, BMI
• Physical Exam Elements: (Must be listed by System, ONLY as it pertains to Chief Complaint/HPI. Should NOT be all systems or full head to toe unless pertinent.)

POC Testing (any Point of Care (POC) testing specifically performed in the office): What tests (if any) did you perform during the visit (urine dip, rapid strep, urine pregnancy test, Glucose finger-stick, etc.)? Leave blank if none.

ASSESSMENT

• Working

  Diagnosis

  : (Must include ICD 10) PERTINENT POSITIVES AND NEGATIVES

• Differential Diagnosis: (Must include ICD 10) PERTINENT POSITIVES AND NEGATIVES

PLAN

Diagnostic studies: If any, will be ordered (Labs, X-ray, CT, etc.). Only include if you will be ordering for your patient. Remember the importance of appropriate resource utilization. Remember you are managing this patient in the CLINIC setting, NOT THE HOSPITAL.

• Treatment: Must include full Sig/Order for all prescriptions and OTC meds (Name of medication, dosage, frequency, duration, number of tabs, number of refills). CANNOT only list drug class. Should follow evidence-based guidelines.
• Referrals: If Applicable
• Education:
• Health maintenance:
• RTC:

In addition to your SOAP note, you must also complete the following table.