Background

Background - the SO parts of SOAP 

 

  • Pt Intro - A bulleted approach is more efficient (than paragraph narrative) for the fast pace ambulatory setting, describe the patient’s established medical conditions. For a new patient,  include inactive medical conditions and surgeries. For follow up visit presentations, list only the active and pertinent.
  • HPI: describe patient's chief concern and their perspective clearly, and explore +/- pertinents.  Conceptualize HPI in 2 parts, the first clearly conveys CLEARLY the patient's narrative and concerns, the second communicates relevant details (pertinents) you explored - relating to ddx you considered while hearing the patients' story.  After the chief concern, you can report on status of known chronic conditons (# of inhaler use of asthma, FSG log, BP logs..)
  • ROS these are symptoms UNRELATED to HPI-  functional status/exercise capacity is always helpful. 
  • Medications List: and list drug allergies when positive.
  • Family/Social history -present w details on initial visit, include when pertinent for follow up
  • Physical Exam:   #s are more helpful than "normal"  for BP and BMI  
    • Include any special and pertinent maneuvers performed for HPI, include pertinent negatives if explored
  • Data: list new and relevant results from labs and radiology

SBAP Case Example 

 

Situation: This is a known patient seen recently for hypertension medication changes, she is here on follow up with a new problem

Background:

PF is a 75 year old with:

  • Hypertension uncontrolled on 3 medicines with recent addition of lisinopril
  • Type 2 Diabetes with A1c of 7.8 a few months ago
  • Chronic low back pain improved with PT
  • CKD stage 3b with hx of longstanding NSAID use for pains
  • Allergic rhinitis seasonal coughs in the spring, uses flonase
  • Psoriasis well controlled
  • Intermittent benign positional vertigo since 2009

(inactive) Pmhx: childhood asthma, hepatitis A resolved 1990, diverticulitis admissions 2012, corneal abrasion 1994, MVA resulting in tibia fracture at age of 20

Psurghx: TAH for fibroids in 1980

CC Patient’s chief concern is coughing for over a month

HPI: Generally well since our last visit but she has noticed an intermittent “scratching, itchy” sensation of the throat which comes and goes but can trigger an annoying cough. The cough is dry, bothersome as it comes on some nites, when she is trying to sleep.  It resolves with sipping water or robitussin, which she started only last week. She is concerned that the cough persisting over a month, her friend with lung cancer presented with a chronic cough.   

There has been no sick contacts, she is not experiencing reflux, nor nasal congestions or itchiness. She has no fever, chills, hemoptysis or wt loss.

Otherwise she has been taking all 3 blood pressure meds, and home blood pressures  are doing better, running around 140s.  She remains very active babysitting her grandkids all day.

Allergies – NKDA

Medications

Amlodipine 5mg daily

Lisinopril 10 mg daily (new)

Atorvastatin 20mg daily

Metformin 850mg bid

Chlorthalidone 12.5mg daily qAM

Acetaminophen 325mg tablet q 6 hrs prn pains

Sochx: lives with daughter and helps to babysit in building, widowed, immigrated at age of 30 from Belize. No habits, worked previously in local bakery

Famhx: adopted

(review sochx fam hx on all new visits, mention pertinents on follow up)

Exam

Well appearing and younger than stated age, running after her 5 yr old grandson

BMI 27 afeb, HR of 72, blood pressure was 142/70 (repeated) down from 160/100 last time

Her weight  is the same

Heent anicteric, no conjunctival congestion, no nasal discharge, pharynx is wo exudate

Neck no LAN JVD

Cor rrr s1s2 no m

Lungs clear

Abd soft NT

Extrem nt calf, no edema

Neuro: nl gait, good recall

Lab this am with K  of 5.2 Cr of 1.5 her baseline,  A1c of 8.1