SOAP note Template for Shadow Health

Identifying Information: Esther Park, 78 year old, Korean American Female. Information given by patient. Reports private insurance through Shadow Mutual. Here in the office transported by daughter with complaints of “pain in her belly” Patient appears to be a reliable historian. Subjective (S) Chief Complaint (CC): Ms. Park states, "I’m having pain in my belly” HPI: Esther is a pleasant 78-year-old Korean American woman who comes to the clinic today with complaints of belly pain and a “bought” of diarrhea 3 days ago. Mrs. Park reports she has not had a bowel movement since her loose stool and has had quite a bit of abdominal discomfort. Patient reports her pain is currently 6/10 and describes it as dully and crampy. Patient also reports feeling bloated. Patient states the pain is in her lower abdomen and has increased over the last 2-3 days. Mrs. Park denies any nausea, vomiting, blood or mucous in her stools. Patient also denies any fever, or pain in her rectum. Mrs. Parks state her appetite is decreased some as well as her water consumption. She has not taken any medications at home to help ease her pain, and reports movement and eating makes it worse, but rest helps some. Past Medical History: Hypertension diagnosed at age 54 Past Surgical History: C-Section at age 40. Cholecystectomy at age 42. Family History: Mother- deceased at age 88 due to CVA while hospitalized for pneumonia. Type II DM, HTN Father- deceased at age 82 in his sleep. HLD, HTN, Overweight Maternal Grandfather- deceased at unknown due to MI. Not sure of other health issues. Maternal Grandmother- deceased, not sure at what age or cause. CAD, Diabetes Paternal Grandfather- died in his 90’s Paternal Grandmother- deceased due to lung cancer at age 88. HTN Brother- living 80 y/o, HTN Brother- living 81 y/o, HTN, HLD, Prostate Cancer Son- living 48, no known medical issues Daughter living 46, no known medical issues Social History: Lives at home with her daughter. No pets in the home. Patient is a retired nurse and she is currently insured through Shadow Mutual. Patient denies salting her food, and eats a “light” diet with fruits and vegetables “every few days”. Tina reports she has increased her water consumption lately. Esther denies drink caffeinated beverages, but does report she drinks one glass of dry white wine every Sunday. Denies any illicit substance use, or any use of tobacco products or vaping throughout her entire life. Patient reports she feels safe at home and is able to access medical care without any limitations. Patient does not drive, but reports she is able to afford a ride or have her daughter bring her into the clinic Sexual/Reproductive History: Gravida/Para- 3/2 LMP- “twenty years or more ago” maybe at age 54 Patient is currently sexually active, reports last PAP smear was around 10 years ago Immunizations Tdap- age 54 Flu- not yet this year Hepatitis B- believes she received as a child, unsure of date MMR- believes she received as a child, unsure of date Varicella- had chicken pox as a child, didn’t receive vaccination Pneumococcal- unsure Zostavax- unknown/unsure