Instructions

Over the course of the semester you will choose 10 patient encounters to document an extended SOAP note for.

It is expected that you vary the primary focus of each note to ensure you are receiving quality feedback for several types of patient encounters to include acute, chronic and wellness encounters. You are not to utilize the same type of encounter, acute/chronic health condition or wellness exam, more than once unless you have received approval to do so from your clinical faculty person.

Each SOAP note carries a 15-point value.

SOAP notes will be evaluated using a standardized rubric. Please review the evaluation criterion to ensure that your SOAP notes are constructed to address the required elements and desired level of achievement.

For planned weekly clinical experiences submission of the 10 SOAP notes would be accomplished by submitting one SOAP note weekly for weeks 4 through week 13.

For planned and approved condensed, compressed or alternate clinical experiences, submission of the 10 SOAP note would be dependent on the approved clinical schedule. This may mean that more than 1 SOAP note would need to be submitted on a weekly basis. If you are not in clinical for weeks where a SOAP note is due a 0 will be input into the Grade Center as a place holder until you have submitted the required assignment.

PATIENT INFORMATION:

Age: 54-year-old female

Date: [Insert Date]

Provider: PCP Clinic

Chief Complaint: Worsening acid reflux

S Subjective

HPI:

54-year-old female presents to clinic with complaints of worsening gastroesophageal reflux symptoms. Patient reports burning sensation in the chest and epigastric region consistent with reflux. She states symptoms have worsened over the past several weeks despite taking omeprazole 20 mg daily as prescribed.

Patient reports reflux symptoms are worse after meals and when lying down. She states symptoms have woken her from sleep over the last few nights, causing difficulty resting.

Patient denies nausea, vomiting, hematemesis, melena, dysphagia, or unintended weight loss.

Review of Systems

General: Denies fever, chills, weight loss.

GI: Reports heartburn and acid reflux. Denies vomiting, diarrhea, hematemesis, or melena.

Respiratory: Denies shortness of breath.

Cardiac: Denies chest pain unrelated to reflux.

O Objective

Vital Signs

Height: 56

Weight: 147 lbs

BMI: 23.7

BP: 122/82

HR: 71

Temp: 98.2F

O2 Sat: 99% RA

Physical Exam

General:

Alert, oriented, no acute distress.

HEENT:

Normocephalic, atraumatic.

Cardiovascular:

Regular rate and rhythm. No murmurs.

Respiratory:

Clear to auscultation bilaterally.

Abdomen:

Soft, non-distended. Mild epigastric tenderness noted. No rebound or guarding.

Past Medical History

• Hypertension
• Anxiety
• Insomnia
• Arthritis
• Migraines / headaches
• Neuropathy
• Irritable bowel syndrome
• Sinus conditions

Surgical History

• ENT surgery (Dr. Albright June 2025)

Allergies

• Penicillin (PCN)

Social History

• Current smoker 2 packs per day
• Smoking history: 41 years
• Started smoking at age 15
• Alcohol use: Moderate
• Illicit drug use: Denies
• Exercise: Moderate (57 times/week)
• Occupation: Office manager
• Reports high stress

Current Medications

• Albuterol sulfate HFA inhaler 90 mcg inhale 2 puffs every 4 hours PRN
• Alprazolam 2 mg take 1 tablet twice daily PRN
• Amlodipine 10 mg take 1 tablet daily
• Losartan 25 mg take 1 tablet daily
• Methylprednisolone dose pack follow package directions
• Omeprazole 20 mg daily (previous dose)
• Omeprazole 40 mg daily (new dose prescribed today)
• Prednisone 10 mg daily
• Trelegy Ellipta inhaler inhale 1 puff daily
• Triazolam 0.25 mg take prior to procedure as directed
• Varenicline tartrate dose pack follow package directions

A Assessment

1. Gastroesophageal reflux disease (GERD) worsening symptoms despite PPI therapy
2. Hypertension
3. Anxiety disorder
4. Tobacco dependence
5. Chronic respiratory disease requiring inhalers

P Plan

Medication Adjustment

• Increase omeprazole to 40 mg PO daily

Referral

• Referral to Gastroenterology for evaluation of persistent GERD and possible EGD.

Lifestyle Modifications

• Avoid spicy, acidic, and fatty foods
• Avoid eating within 23 hours of bedtime
• Elevate head of bed
• Reduce caffeine and alcohol intake

Smoking Cessation

• Discussed smoking as contributing factor for GERD
• Patient currently on varenicline for smoking cessation

Education

• Reviewed GERD management and medication use
• Discussed warning signs requiring immediate evaluation:
• dysphagia
• GI bleeding
• persistent vomiting
• unexplained weight loss

Follow-Up

• Follow up with GI specialist
• Return to clinic if symptoms worsen or do not improve.