S.O.A.P. Note Template CASE ID# Tina Jones Abdomen
Subjective Objective
Assessment (diagnosis [primary and differential diagnosis])
Plan (treatment, education, and follow up plan)
Chief ComplaintWhat brought you here
today (eg. headache)“I’ve been having stomach pain for a while.”History of
Present
IllnessChronological order of events, state of health before onset of CC, must include OLDCARTS in paragraph form
OnsetPatient is a 28-year-old African American woman who presented to the clinic with complaints of upper stomach pain after eating. She reports the pain started about a month ago. She states that she experiences pain daily starting after meals usually lasting “a few hours.” She reports pain is a 5/10 in her upper stomach after eating. She reports pain is a 7/10 when lying down. She describes the pain similar to heartburn. She notes it to increase with consumption of food. She states pain is worse after fast food and spicy
food. She reports decreased appetite and not wanting to eat because of anticipation of pain. She denies any recent changes to her diet besides an increase in water intake. She denies coffee intake but does drink diet cola daily. She states that the pain usually goes away several hours after eating but that she does treat the pain “every few days” with an over the counter antacid with some relief. She reports burping after meals and denies any recent weight loss. She denies any gastrointestinal history but does report her grandfather passed away from colon cancer. Location
Duration
Character
Aggravating/associate
d factors
Relieving factors
Temporal factors –
other things going on
SeverityPast
Medical
HistoryAdult Illnesses, childhood illnesses, immunizations, surgeries, allergies, Adult illness: diabetes, asthma Childhood illness: asthma at 2.5 years old Immunizations: up to date, received annual flu shotFamily
HistoryInclude Parents, siblings; grandparents if applicable/known, cause of death, age, Mother: Alive 59 y.o., High blood pressure, high cholesterol Father: Deceased at 58 due to car accident Type II Diabetes, high blood pressure, high cholesterol Paternal grandmother: Alive 84 y.o., High blood pressure, high cholesterol Personal/Social
HistoryEducation, marital status, occupation, alcohol/drug use, smoking status, sexual history if relevant, exercise, nutrition, religious preference if Education: Current Student Marital Status: Single
Occupation: supervisor at Mid-American Copy and Ship Religion: Christian
Social History: Denies drug use, non-smoker, denies vaping, social drinking- no more than 4 drinks a month This study source was downloaded by 100000812546443 from CourseHero.com on 02-22-2023 01:40:50 GMT -06:00
https://www.coursehero.com/file/66475733/Gastrointestinal-Tina-Jones-SOAPdocx/
Subjective Objective
Assessment (diagnosis [primary and differential diagnosis])
Plan (treatment, education, and follow up plan)
Chief ComplaintWhat brought you here
today (eg. headache)“I’ve been having stomach pain for a while.”History of
Present
IllnessChronological order of events, state of health before onset of CC, must include OLDCARTS in paragraph form
OnsetPatient is a 28-year-old African American woman who presented to the clinic with complaints of upper stomach pain after eating. She reports the pain started about a month ago. She states that she experiences pain daily starting after meals usually lasting “a few hours.” She reports pain is a 5/10 in her upper stomach after eating. She reports pain is a 7/10 when lying down. She describes the pain similar to heartburn. She notes it to increase with consumption of food. She states pain is worse after fast food and spicy
food. She reports decreased appetite and not wanting to eat because of anticipation of pain. She denies any recent changes to her diet besides an increase in water intake. She denies coffee intake but does drink diet cola daily. She states that the pain usually goes away several hours after eating but that she does treat the pain “every few days” with an over the counter antacid with some relief. She reports burping after meals and denies any recent weight loss. She denies any gastrointestinal history but does report her grandfather passed away from colon cancer. Location
Duration
Character
Aggravating/associate
d factors
Relieving factors
Temporal factors –
other things going on
SeverityPast
Medical
HistoryAdult Illnesses, childhood illnesses, immunizations, surgeries, allergies, Adult illness: diabetes, asthma Childhood illness: asthma at 2.5 years old Immunizations: up to date, received annual flu shotFamily
HistoryInclude Parents, siblings; grandparents if applicable/known, cause of death, age, Mother: Alive 59 y.o., High blood pressure, high cholesterol Father: Deceased at 58 due to car accident Type II Diabetes, high blood pressure, high cholesterol Paternal grandmother: Alive 84 y.o., High blood pressure, high cholesterol Personal/Social
HistoryEducation, marital status, occupation, alcohol/drug use, smoking status, sexual history if relevant, exercise, nutrition, religious preference if Education: Current Student Marital Status: Single
Occupation: supervisor at Mid-American Copy and Ship Religion: Christian
Social History: Denies drug use, non-smoker, denies vaping, social drinking- no more than 4 drinks a month This study source was downloaded by 100000812546443 from CourseHero.com on 02-22-2023 01:40:50 GMT -06:00
https://www.coursehero.com/file/66475733/Gastrointestinal-Tina-Jones-SOAPdocx/
