A 77 y/o Caucasian male with complaints of fever and feeling lethargic

Review the Comprehensive SOAP Note Template.

· Select a patient who you saw at your practicum site during the last 5 weeks. With this patient in mind, consider the following: 

· Subjective: What details did the patient provide regarding the personal and medical history?

· Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities and psychosocial issues.

· Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their CPT and ICD-10 codes for the diagnosis. What was your primary diagnosis and why?

· Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.

· Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?

Patient Information

A 77 y/o Caucasian male with complaints of fever and feeling lethargic. He reports decreased urinary output and swelling in legs and ankles. PMH: Hypertension, osteoarthritis Current medications: Hydrochlorothiazide and lisinopril to manage his blood pressure. Celecoxib medications. Plan: Normal saline IV, refer the patient to a nephrologist

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