Comprehensive SOAP Note
Patient Information:
G.C., 55, Male, Caucasian
S.
CC: “Right Hip Pain”
HPI: G.C. is a 55-year-old-male who presents to the ED for right pain. Patient states
that “he has had hip pain in the past” but it has worsened over the past 3 days.
Patient has taken Tramadol with no relief of his symptoms. He rates his pain 9/10.
The pain comes on quickly especially with movement and continues as a burning
pain at rest. The patient is currently taking Amoxicillin for osteomyelitis of his
cervical vertebra in December 2018. He is following up with infectious disease
doctor later this month.
Current Medications:
Multivitamin – 1 Tab PO daily – maintenance, cirrhosis
Folic Acid – 1 mg PO daily – cirrhosis
Rifaximin – 550 mg PO daily – Liver disease
Amicar – 500 mg PO QIDPRN – Liver disease, low platelet count
Amoxicillin – 500 mg PO Q8H - osteomyelitis
Bumex – 1 mg PO BID – diuretic, hypertension, liver disease
Atarax – 25 mg PO Q8H PRN - itching
Afrin 0.05% - 2 spray BNOS BID PRN - decongestant
Thiamine – 100 mg PO daily – cirrhosis
Tramadol – 50 mg PO BID PRN - sleep
Zinc Sulfate – 220 mg PO daily – cirrhosis
Allergies: No Known Allergies
PMHx:
Hypertension
Hyperlipidemia
Hemorrhoids
Cirrhosis
BPH
Arthritis
Diabetes
Anemia
Obesity
CKD
PSHx:
Patient Information:
G.C., 55, Male, Caucasian
S.
CC: “Right Hip Pain”
HPI: G.C. is a 55-year-old-male who presents to the ED for right pain. Patient states
that “he has had hip pain in the past” but it has worsened over the past 3 days.
Patient has taken Tramadol with no relief of his symptoms. He rates his pain 9/10.
The pain comes on quickly especially with movement and continues as a burning
pain at rest. The patient is currently taking Amoxicillin for osteomyelitis of his
cervical vertebra in December 2018. He is following up with infectious disease
doctor later this month.
Current Medications:
Multivitamin – 1 Tab PO daily – maintenance, cirrhosis
Folic Acid – 1 mg PO daily – cirrhosis
Rifaximin – 550 mg PO daily – Liver disease
Amicar – 500 mg PO QIDPRN – Liver disease, low platelet count
Amoxicillin – 500 mg PO Q8H - osteomyelitis
Bumex – 1 mg PO BID – diuretic, hypertension, liver disease
Atarax – 25 mg PO Q8H PRN - itching
Afrin 0.05% - 2 spray BNOS BID PRN - decongestant
Thiamine – 100 mg PO daily – cirrhosis
Tramadol – 50 mg PO BID PRN - sleep
Zinc Sulfate – 220 mg PO daily – cirrhosis
Allergies: No Known Allergies
PMHx:
Hypertension
Hyperlipidemia
Hemorrhoids
Cirrhosis
BPH
Arthritis
Diabetes
Anemia
Obesity
CKD
PSHx:
