60 year old Arabic speaking female presents to establish primary care at your clinic. She expresses her concern feeling isolated after having arrived recently as a refugee from Iraq.

Her current meds:

Lisinopril 10mg one tab po daily for hypertension

Metformin 500 mg one tab po daily for diabetes

Rosuvastatin 10 mg one tab po at bed time for cholesterol

1. What are your initial differentials based on the presenting information in this case?

2.Write a hypothetical SOAP note based on the data above. You can be creative with objective and subjective data.

3. Write a substantive response to a minimum of two different students.

Is objective and subjective data included in the right format? Please be specific to information related to the SOAP note format.

  1. Would you agree with your peers differentials listed? Are there any diffs you would add/remove, if so explain your rationale.
  2. Does HPI have relevant information related to CC?
  3. Medication listed with right timing, dosing, and number of tablets specified? Any red flags with medication list?
  4. PMH, FH, and SH has all the appropriate information?
  5. Does information in ROS correlate to CC?
  6. Is there any information lacking in physical exam documentation of CC (Students often get confused between ROS and objective findings)?
  7. Includes assessment, plan, follow up information, and patient education?

See attached sample SOAP Note:

Sample_ SOAP_ Note