Use the SOAP template

Use the SOAP template

A 49-year-old-male presents to the clinic for an annual physical exam.
The doctor dictates the following:
“Patient is a mildly obese 49-year-old-male with a history of moderate persistent asthma, benign
prostatic hyperplasia (PH) and high cholesterol. He works as an overnight security guard at the
local bank. His medical problems are currently managed on Spiriva, Albuterol nebulizer,
Tamsulosin 0.4 mg, and Crestor 10 mg. He has been a smoker for the past 20 years, smoking
about 1⁄4 ppd. He does not have any allergies. His father was diagnosed with lung cancer at age
68 and is now deceased. Patient has a history of vasectomy 2 years ago. He is married and has 3
children.”
The patient states the following:
“I’ve been doing pretty good. I still use my inhaler and nebulizer as prescribed and it allows me to
make it through my day without feeling short of breath. I know I shouldn’t be smoking, but you
know, it’s just so hard to quit. I’m going to try smoking less in this upcoming year. I do still get up
about once per night to urinate, but the Tamsulosin 0.4 mg daily has been helping. I used to get
up like 3-4 times per night before I started taking that. I don’t feel depressed or down. I haven’t
seen any blood in my urine or semen or anything like that. I haven’t felt my heart skipping beats
or any chest pain either. I take the medication you prescribed me for my high cholesterol every
day. My wife is trying to get us eating a Mediterranean diet, but I still grab fast food two or three
times a week. I don’t really have time to exercise anymore. I cut back on drinking, now I only have
a beer or two maybe once a month.”
The patient had diagnostic testing done before his visit. The doctor reviews the results of his
labs and MRI with patient:
“Looking at your chest X-ray from 12/10/21, it seems like your lungs have built-up scarring from all
of your years of smoking. This could be playing a role in your difficulty breathing.”
The doctor examines the patient and dictates the following:
“The patient is healthy appearing. Well developed. Mildly obese with BMI of 31.5. In no acute
distress. His pupils are equally round and reactive to light. Conjunctivae are non-injected.
Extraocular movements intact. There is no thyroid enlargement. Neck is supple with full range of
motion. No carotid bruits. Auscultating his heart, the patient is tachycardic. Regular heart rhythm.
No murmur. No rub. No gallop. S1 and $2 are normal. Listening to his lungs, there are some mild
expiratory wheezes of the upper lobes. No rales or rhonchi. Mild tachypnea. Some intercostal
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retraction observed. His abdomen is soft and nontender. No distension. Bowel sounds are
normal. No masses. No hepatosplenomegaly. Penis shows no lesions. No testicular masses.
Prostate is mildly enlarged without nodules. Skin is warm and dry. Grossly normal movements of
all extremities. No lower extremity edema. He is alert and oriented. Normal motor strength and
tone. Cranial nerves Il-XIl intact. He has a normal affect. Normal mood.”
The doctor reviews the findings with the patient:
“Well, I think you’re doing fine overall. Your vitals are stable today, but your heart rate is a little
elevated at 102 bpm. Blood pressure is 134/84 and oxygen saturation is 98% on room air. You’re
breathing a little fast too at 18, but that seems to be your baseline from the smoking. Since you’re
asthmatic, a smoker, and have a family history of lung cancer, we’ll order you a chest x-ray every
year to keep an eye on things. Since you just had yours done, you won’t be due until next year. I
want you to keep using your inhaler and nebulizer and really try to quit smoking this year. I can
give you some Chantix samples for you to try out, and if you want I’ll send in a prescription for
you. I noticed your prostate is slightly enlarged, which explains your nighttime bathroom trips, but
I’m glad the Tamsulosin is helping. I’ll keep you on that current dose and also check your PSA.
Make sure you avoid consuming any liquids before bedtime. As for your high cholesterol, I want
you to continue taking your Crestor and try to cut back on fast food. If you can do that and get in
30 minutes of exercise a few times a week, this should help. I’m going to order some labs today,
including a CBC, CMP, lipid panel, HgAIc, and PSA. I’ll review them with you when I see you back
in 3 months.”

Complete Answer:

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