13 Oct Create a SOAP using the templates attached and the patient case also attached, No AI, plagiarism less than 20 %, two or more references with APA

(Student Name)

Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor:

Soap Note # ____ Main Diagnosis ______________

PATIENT INFORMATION

Name:

Age:

Gender at Birth:

Gender Identity:

Source:

Allergies:

Current Medications: (including OTC and vitamins)

·

PMH:

Immunizations:

Preventive Care: Preventive Screenings: (for results already obtained before this encounter) – Pap smear: ______ – Mammogram: ______ – Colonoscopy: ______ – Lipid panel: ______ – A1C: ______ – STI screen: ______ – Depression screen (PHQ-9): ______

Surgical History:

Family History:

Social History:

Sexual Orientation:

Nutrition History:

SUBJECTIVE DATE

Chief Complaint (which must be stated between “__”)

Symptom analysis/HPI:

Clinical Tools Used (if applicable), otherwise state N/A – PHQ-9: ___ /27 – GAD-7: ___ /21 – AUDIT-C / DAST:

Review of Systems (ROS) (This section is what the patient says, therefore it should state “Pt denies… or Pt states…”)

CONSTITUTIONAL:

NEUROLOGIC:

HEENT:

RESPIRATORY:

CARDIOVASCULAR:

GASTROINTESTINAL:

GENITOURINARY:

MUSCULOSKELETAL:

SKIN:

OBJECTIVE DATA

VITAL SIGNS: LABS / DIAGNOSTICS REVIEWED (if available): – CBC: – Lipid Panel: – A1C: – EKG: – Imaging (if done):

GENERAL APPREARANCE:

NEUROLOGIC:

HEENT:

CARDIOVASCULAR:

RESPIRATORY:

GASTROINTESTINAL:

MUSKULOSKELETAL:

INTEGUMENTARY:

ASSESSMENT

Red Flags / Reasons for Escalation: – [ ] None noted – [ ] Positive suicidal ideation – [ ] Unstable vital signs – [ ] Abnormal exam requiring urgent referral

Clinical Note

(In a paragraph you should state “your encounter with your patient and your findings (including subjective and objective data)

Example: “Pt came into our clinic today c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… On examination I noted erythema in the ear canal…, this, and that etc.)

Main Diagnosis

(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 6th or 7th Edition.

Differential diagnosis (minimum 3) along with the rationale behind them. (why you decide to include these differential diagnosis for this patient? What part of your assessment supports them?)

–

–

–

PLAN

Labs and Diagnostic Test to be ordered (if applicable)

· –

· –

Pharmacological treatment:

–

Non-Pharmacologic treatment:

Education (provide the most relevant ones – tailored to this specific patient – not in general)

Follow-ups/Referrals

Visit Complexity / CPT Code: _______

References (in APA Style)

Examples

Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).

ISBN 978-0-8261-3424-0

Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010

(25th ed.). Print (The 5-Minute Consult Series).

,

· Age: 45 years

· Biological Sex: Female

· Race: Hispanic

· Insurance: PPO

· Referral: No referral

⚕️ Clinical Information

· Time with Patient: 35 minutes

· Consult with Preceptor: 10 minutes

· Type of Decision-Making: Moderate complexity

· Reason for Visit: New consult

· Chief Complaint: “Severe headache for the last 2 days with light sensitivity and nausea.”

· Type of H&P: Problem-focused

🧠 History & Findings

Subjective: Patient reports a throbbing headache over the right temple for two days, rated 8/10, associated with photophobia, nausea, and mild vomiting. Denies fever, neck stiffness, visual loss, or weakness. History of recurrent migraines, usually triggered by stress or lack of sleep. No recent trauma.

Objective:

· Vitals: BP 128/82, HR 84, RR 18, Temp 98.3°F

· Neuro exam: Alert, oriented ×3, cranial nerves II–XII intact, normal strength and reflexes, no focal deficits.

· No meningeal signs or visual disturbances.

Assessment: Acute migraine without aura (G43.009)

🧾 ICD-10 Diagnosis Codes

1. G43.009 – Migraine without aura, not intractable

2. R11.0 – Nausea

3. R51.9 – Headache, unspecified

💊 CPT® Billing Codes

1. 99203 – Office or other outpatient visit for a new patient, moderate complexity

2. J1885 – Injection, ketorolac tromethamine, per 15 mg (if given)

3. 96372 – Therapeutic injection, subcutaneous or intramuscular

💉 Medications

· OTC Drugs Taken Regularly: Ibuprofen PRN

· Rx Currently Prescribed:

· Sumatriptan 50 mg PO PRN migraine (may repeat once after 2 hours)

· Ketorolac 30 mg IM once in clinic

· New/Refilled Rx This Visit: Yes – Sumatriptan

🧩 Social Problems Addressed

· Stress management

· Nutrition/Exercise (sleep hygiene and hydration counseling)

🗒️ Clinical Notes

Patient is a 45-year-old Hispanic female presenting with acute migraine crisis. Symptoms consistent with previous migraine episodes. No red flag signs. Administered ketorolac 30 mg IM with partial relief after 30 minutes. Advised to rest in dark room, maintain hydration, avoid known triggers, and follow-up if symptoms persist or worsen. Prescribed sumatriptan 50 mg for acute management. Educated on stress management, sleep hygiene, and avoidance of caffeine excess. Patient verbalized understanding.

🧠 Procedure/Skills (Observed/Assisted/Performed)

· Physical Assessment

· General Skills

· Neurology Assessment Skills