Cantellops, N. Soap Note #2 1.28.20

Acute Office Visit SOAP note – Student Template edited 1.7.
20
Patient Name: J.G.
Date: 01/28/20 Time: 9:00am
Faculty Evaluator: Dr. Canto
Small Group Leader: Dr. Lacombe
Medical Student name: Nicole Cantellops
Cueli
Subjective
Chief Complaint
“I feel exhausted, like whipped out”
History of Present Illness (include opening statement with Patient ID)

Patient J.G. a 70-year-old male with a significant past medical history of high cholesterol presented to the
office with symptom of tiredness, an itchiness on his skin and a dull, achy pain on his RUQ that started 2 weeks
ago. Patient states that nothing alleviates it or makes it worst. Had a pain of 3 in a scale from 1 to 10. Patient
mentioned travelling 3 weeks ago to Dominican Republic and eating some vegetables and fruits there.
Past History
Chronic Medical Illnesses (include duration of each illness):
- High cholesterol
Mental Health Issues (include duration of each illness):
- No mental health issues present
Hospitalizations/Accidents (include date, reason):
- No hospitalizations
Surgical History (include dates, indications, types of surgery, complications):
- No surgeries done
Health Care Maintenance (include dates of last PCP visit, age-specific screening tests and immunizations):
- Patient Hepatitis B vaccination; shingles vaccine at 60 yrs. old; pneumonia at 65 yrs. old; Flu shot a few
weeks ago and the tetanus vaccine
- Patient had colonoscopy and prostate examination approximately 9-10 months ago
Medications (include name, dose, route and frequency; also add duration if pertinent to case):
- Patient is taking atorvastatin, 10mg orally once a day for 20 years
Drug / Food Allergies

- No drug or food allergies
Social History
- Patient travelled 3 weeks ago to Dominican Republic
- Patient is married with 2 sons
- Patient drinks 1 beer occasionally
- Have been smoking for 45yrs, a pack and a half a day; 67.5 pack years
- Occupation: funeral director
Family History
- Mother is alive 92 yrs. with dementia
- Father died at 72 yrs. of a heart attack
- 1 brother with mild high blood pressure and diabetic
- 1 sister healthy with asthma
- Healthy wife
- 2 healthy sons
Review of Systems
- Patient denied any dizziness, vision changes, hearing changes, sore throat, edema, dyspnea,
constipation or vomiting.
- Patient had nausea, bowel changes; stool with a light color, also had darker urine and weight loss (5
pounds lost since last week)
Objective
Physical Exam (only include applicable exams)
Vital Signs & Body Measurements: T 99.0 ⁰ F BP120/80 mmHg RR 16 bpm HR 72 bpm Wt. 169
lbs. Ht 5 ft, 5 in
General survey Patient was well groomed with no distress
Skin Patient had mild jaundice; no edema
HEENT Patient had conjunctival icterus and normal oral pink mucous membranes
Thorax/Lungs Patient had normal vesicular breath sounds with no wheezes or rhonchi
CV Patient had normal S1 and S2 with no murmurs or bruits heard
Abd/Rectal: Upon auscultation patient had normal active bowel sound, with no masses felt upon
percussion and palpation. Also, upon palpation the tip of the spleen was palpable. The liver was 15cm
and enlarged with a positive murphy’s sign. Patient had pain in RUQ.
Office testing: include results of pregnancy test, strep test, EKG, Xrays done in the office.
Assessment
Case Summary
Patient J.G. a 70-year-old male with a significant past medical history of high cholesterol presented to
the office with symptom of tiredness, an itchiness on his skin and a dull, achy pain on his RUQ that
started 2 weeks ago. Patient presented with nausea, weight loss, change in bowel habits.
Problem List
1. Tiredness
2. Itchy skin
3. Pain in RUQ
4. high cholesterol
* Likely diagnosis (include supporting evidence)

1. Hepatitis A because of the recent travelling to Dominican Republic
* Differential Diagnosis (include supporting evidence for and against diagnosis)

1. Hepatitis B, but no history of sexually active
2. Alcoholic Hepatitis, but no history of alcohol abuse
Acute Office Visit SOAP note – Student Template edited 1.7.20
Plan
1. Diagnostic Plan
1. Viral hepatitis panel
2. CMP to check liver function
3. CBC
2. Therapeutic Plan
1. Self-resolved in approximately 3 moths
2. Hydrate
3. Stop atorvastatin medication
3. Patient Education
1. Hepatitis A vaccine to patient and people close to him
2. Don’t cook for any family members
3. Cut down smoking and avoid alcohol
4. Follow up
1. 3 months follow up
Signature
Print Name, Medical School Level (MS II) and UMHS
If the patient presents with multiple unrelated diagnoses (issues), include a likely diagnosis and differential
diagnosis discussion for each issue separately. You may, however, list the plan all together under a single
plan section.

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Acute Office Visit SOAP note – Student Template edited 1.7.

“I feel exhausted, like whipped out”

History of Present Illness (include opening statement with Patient ID)

Drug / Food Allergies

* Likely diagnosis (include supporting evidence)

* Differential Diagnosis (include supporting evidence for and against diagnosis)

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