10 Common Physician Assistant SOAP Note Examples

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List of cases

1. Upper Respiratory Infection
2. Low Back Pain
3. Type 2 Diabetes Follow-up
4. Hypertension Management
5. Annual Physical Exam
6. Acute Ankle Injury
7. Anxiety and Depression
8. Pediatric Well Visit
9. Skin Infection
10. Asthma Exacerbation

1. Upper Respiratory Infection

Description

The patient presents with symptoms of acute upper respiratory infection seeking evaluation and treatment.

SOAP Note

Patient Name: Emily Parker

Date of Visit: 09/01/2024

Subjective

Emily Parker, a 28-year-old female, presents with 4-day history of nasal congestion, sore throat, and cough. Reports low-grade fever, maximum 100.4°F. Cough is productive with clear sputum. Denies shortness of breath or chest pain. No sick contacts. No history of asthma or chronic respiratory conditions. Taking OTC Tylenol with minimal relief.

Objective

• Vital Signs:
  • BP: 118/76 mmHg
  • HR: 82 bpm
  • RR: 16/min
  • Temp: 99.8°F
  • SpO2: 98% on room air
• Physical Exam:
  • HEENT:
    • Nasal mucosa erythematous with clear discharge
    • Throat mildly erythematous, no exudates
    • TMs clear bilaterally
    • Mild cervical lymphadenopathy
  • Respiratory:
    • Clear breath sounds bilaterally
    • No wheezing or rales
    • Normal respiratory effort
  • Cardiovascular:
    • Regular rate and rhythm
    • No murmurs or gallops
• Point of Care Testing:
  • Rapid Strep: Negative
  • COVID-19 Antigen: Negative

Assessment

1. Acute Upper Respiratory Infection (Viral)
   • Typical presentation
   • No bacterial signs
   • No complications

Plan

1. Treatment:

   • Symptomatic management
   • OTC decongestants/antihistamines
   • Continue Tylenol prn
   • Rest and hydration
   • CPT Code: 99213

2. Medications:

   • Guaifenesin 600mg BID prn
   • Saline nasal spray prn
   • No antibiotics indicated

3. Patient Education:

   • Expected course 7-10 days
   • Hand hygiene
   • Rest and hydration
   • Return precautions

4. Follow-up:

   • PRN if symptoms worsen
   • Return if fever >101°F
   • Return if SOB develops

2. Low Back Pain

Description

The patient presents with acute low back pain following heavy lifting at work.

SOAP Note

Patient Name: Michael Thompson

Date of Visit: 09/02/2024

Subjective

Michael Thompson, a 45-year-old male construction worker, presents with acute low back pain after lifting heavy materials 2 days ago. Pain rated 7/10, worse with movement. No radiation to legs. Denies numbness, tingling, or weakness. No bowel/bladder changes. No previous back injuries. Using OTC ibuprofen with moderate relief.

Objective

• Vital Signs:
  • BP: 128/82 mmHg
  • HR: 76 bpm
  • RR: 16/min
  • Temp: 98.6°F
• Musculoskeletal Exam:
  • Inspection:
    • Normal spinal alignment
    • No visible bruising
    • Mild paraspinal muscle spasm
  • Range of Motion:
    • Forward flexion limited to 45°
    • Extension limited to 10°
    • Lateral bending limited bilaterally
  • Neurological:
    • Strength 5/5 all extremities
    • DTRs 2+ and symmetric
    • Straight leg raise negative
    • Normal sensation
• Special Tests:
  • No point tenderness over spine
  • Negative FABER test
  • Negative slump test

Assessment

1. Acute Low Back Strain
   • Work-related mechanism
   • No red flags
   • No radicular symptoms

Plan

1. Treatment:

   • Conservative management
   • Activity modification
   • Heat/ice therapy
   • CPT Code: 99213

2. Medications:

   • Naproxen 500mg BID with food
   • Cyclobenzaprine 10mg qhs prn
   • Continue current regimen

3. Patient Education:

   • Proper lifting techniques
   • Back exercises provided
   • Activity modifications
   • Ergonomic advice

4. Follow-up:

   • 1 week if not improving
   • Return sooner if worsening
   • Work restrictions discussed

3. Type 2 Diabetes Follow-up

Description

The patient presents for routine follow-up of type 2 diabetes mellitus and medication management.

SOAP Note

Patient Name: Robert Wilson

Date of Visit: 09/03/2024

Subjective

Robert Wilson, a 58-year-old male with 10-year history of type 2 diabetes, presents for 3-month follow-up. Reports good medication compliance. Checking blood sugar 2-3 times daily. Fasting readings 120-150 mg/dL. Following diabetic diet with occasional lapses. Exercises 30 minutes, 3 times weekly. Denies hypoglycemic episodes. No vision changes, numbness, or tingling.

Objective

• Vital Signs:
  • BP: 132/78 mmHg
  • HR: 74 bpm
  • RR: 16/min
  • Temp: 98.6°F
  • Weight: 88 kg (stable)
  • BMI: 29.4 kg/m²
• Physical Exam:
  • General: Well-appearing, no acute distress
  • HEENT: PERRLA, EOMI
  • Cardiovascular:
    • Regular rate and rhythm
    • No edema
    • Pulses 2+ all extremities
  • Neurological:
    • Monofilament testing intact
    • Vibratory sensation intact
    • DTRs symmetric
• Laboratory Data:
  • HbA1C: 7.4% (down from 8.1%)
  • Fasting Glucose: 132 mg/dL
  • Cr: 1.1 mg/dL
  • eGFR: >60 mL/min
  • LDL: 88 mg/dL
  • Microalbumin/Cr ratio: 22 mg/g

Assessment

1. Type 2 Diabetes Mellitus
   • Improved glycemic control
   • No complications
   • Good medication adherence
2. Hypertension
   • Well-controlled
   • On appropriate therapy

Plan

1. Treatment:

   • Continue current medications
   • Lifestyle modifications
   • Risk factor management
   • CPT Code: 99214

2. Medications:

   • Metformin 1000mg BID
   • Empagliflozin 10mg daily
   • Lisinopril 20mg daily
   • Atorvastatin 40mg daily

3. Patient Education:

   • Diet reinforcement
   • Exercise importance
   • Blood sugar monitoring
   • Foot care review

4. Follow-up:

   • Schedule 3-month follow-up
   • HbA1C check
   • Annual eye exam due

4. Hypertension Management

Description

The patient presents for follow-up of essential hypertension and medication adjustment.

SOAP Note

Patient Name: Sarah Martinez

Date of Visit: 09/04/2024

Subjective

Sarah Martinez, a 52-year-old female with hypertension, presents for blood pressure check. Reports home readings consistently elevated (150s/90s) despite medication compliance. Denies headaches, dizziness, or visual changes. Following low-sodium diet. Exercises regularly. No chest pain or shortness of breath.

Objective

• Vital Signs:
  • BP: 156/94 mmHg (repeat 152/92)
  • HR: 76 bpm
  • RR: 16/min
  • Temp: 98.6°F
  • Weight: 70 kg
  • BMI: 26.5 kg/m²
• Physical Exam:
  • General: Alert, well-appearing
  • HEENT:
    • No retinopathy
    • No JVD
  • Cardiovascular:
    • Regular rate and rhythm
    • No murmurs or gallops
    • No edema
  • Respiratory:
    • Clear to auscultation
    • Normal effort
• Laboratory Data:
  • Basic Metabolic Panel:
    • Na: 138 mEq/L
    • K: 4.0 mEq/L
    • Cr: 0.9 mg/dL
    • eGFR: >60 mL/min
  • Lipid Panel:
    • Total Cholesterol: 185 mg/dL
    • LDL: 102 mg/dL
    • HDL: 48 mg/dL

Assessment

1. Essential Hypertension
   • Suboptimal control
   • No end-organ damage
   • Medication adjustment needed
2. Cardiovascular Risk
   • Multiple risk factors
   • Primary prevention

Plan

1. Treatment:

   • Medication adjustment
   • Continue lifestyle changes
   • Monitor response
   • CPT Code: 99213

2. Medications:

   • Increase lisinopril to 40mg daily
   • Add HCTZ 12.5mg daily
   • Continue aspirin 81mg daily
   • Monitor potassium

3. Patient Education:

   • Sodium restriction
   • DASH diet review
   • Home BP monitoring
   • Medication compliance

4. Follow-up:

   • 2 weeks for BP check
   • BMP in 2 weeks
   • Continue home monitoring

5. Annual Physical Exam

Description

The patient presents for annual preventive health examination and health maintenance.

SOAP Note

Patient Name: David Anderson

Date of Visit: 09/05/2024

Subjective

David Anderson, a 45-year-old male, presents for annual physical examination. No acute complaints. Reports good overall health. Non-smoker, social alcohol use. Exercises 3-4 times weekly. Family history significant for hypertension and diabetes. Last physical exam 1 year ago. All immunizations up to date except for Tdap.

Objective

• Vital Signs:
  • BP: 122/76 mmHg
  • HR: 68 bpm
  • RR: 16/min
  • Temp: 98.6°F
  • Weight: 78 kg
  • Height: 175 cm
  • BMI: 25.5 kg/m²
• Physical Exam:
  • General: Well-developed, well-nourished
  • HEENT:
    • PERRLA, EOMI
    • TMs clear
    • Oropharynx clear
    • Dentition good
  • Neck:
    • Supple
    • No thyromegaly
    • No lymphadenopathy
  • Cardiovascular:
    • RRR, no murmurs
    • No edema
    • Pulses symmetric
  • Respiratory:
    • Clear to auscultation
    • Normal effort
  • Abdomen:
    • Soft, non-tender
    • No organomegaly
    • Normal bowel sounds
  • Musculoskeletal:
    • Full ROM all joints
    • Normal strength/tone
  • Skin:
    • No concerning lesions
    • Good turgor
  • Neurological:
    • Alert and oriented
    • CN II-XII intact
    • DTRs symmetric

Assessment

1. Routine Health Maintenance
   • Age-appropriate screening
   • Immunizations needed
   • Risk factor assessment
2. Preventive Care
   • Cardiovascular risk low
   • Cancer screening current
   • Healthy lifestyle

Plan

1. Preventive Services:

   • Age-appropriate screening
   • Immunization update
   • Risk assessment
   • CPT Code: 99395

2. Interventions:

   • Tdap vaccine administered
   • CBC, CMP ordered
   • Lipid panel ordered
   • PSA discussed, declined

3. Patient Education:

   • Diet/exercise review
   • Cancer screening schedule
   • Stress management
   • Sleep hygiene

4. Follow-up:

   • Annual exam in 1 year
   • Review labs when complete
   • PRN for acute issues

6. Acute Ankle Injury

Description

The patient presents with acute right ankle injury following sports activity.

SOAP Note

Patient Name: Jennifer Brooks

Date of Visit: 09/06/2024

Subjective

Jennifer Brooks, a 22-year-old female, presents with right ankle pain after inverting ankle during basketball game 2 hours ago. Pain rated 8/10, worse with weight bearing. Immediate swelling noted. Able to walk with significant limp. No prior ankle injuries. No numbness or tingling. Ice applied at site of injury.

Objective

• Vital Signs:
  • BP: 118/72 mmHg
  • HR: 74 bpm
  • RR: 16/min
  • Temp: 98.6°F
• Musculoskeletal Exam:
  • Inspection:
    • Moderate swelling lateral ankle
    • No gross deformity
    • No ecchymosis
  • Palpation:
    • Tender over ATFL
    • Pain lateral malleolus
    • No medial tenderness
  • Range of Motion:
    • Plantarflexion limited by pain
    • Inversion painful
    • Eversion intact
  • Special Tests:
    • Positive anterior drawer
    • Negative squeeze test
    • Negative Ottawa criteria
• Neurovascular:
  • Sensation intact
  • Pulses 2+ DP/PT
  • Cap refill less than 2 seconds

Assessment

1. Acute Right Ankle Sprain
   • Grade 2 lateral ankle sprain
   • ATFL involvement
   • No fracture suspected

Plan

1. Treatment:

   • RICE protocol
   • Early mobilization
   • Supportive care
   • CPT Code: 99213

2. Medications:

   • Ibuprofen 600mg TID with food
   • Acetaminophen 1000mg q6h prn
   • Ice 20 minutes q2h

3. Equipment/Therapy:

   • Ankle brace provided
   • Crutches for comfort
   • Home exercise program
   • PT referral given

4. Follow-up:

   • 1 week follow-up
   • Sooner if worsening
   • PT to evaluate next week

7. Anxiety and Depression

Description

The patient presents for follow-up of anxiety and depression with medication management.

SOAP Note

Patient Name: Rachel Cooper

Date of Visit: 09/07/2024

Subjective

Rachel Cooper, a 32-year-old female with GAD and MDD, presents for 1-month follow-up. Reports improved mood but persistent anxiety symptoms. Sleep improved to 6-7 hours nightly. Attending weekly counseling. Reports good medication adherence. Denies suicidal ideation. Using meditation app daily. Work stress remains significant stressor.

Objective

• Vital Signs:
  • BP: 118/72 mmHg
  • HR: 76 bpm
  • RR: 16/min
  • Temp: 98.6°F
  • Weight: 65 kg (stable)
• Mental Status Exam:
  • Appearance:
    • Well-groomed
    • Appropriate dress
    • Good eye contact
  • Behavior:
    • Cooperative
    • No psychomotor changes
    • Normal speech
  • Mood/Affect:
    • "Better than before"
    • Full range
    • Appropriate
  • Thought Process:
    • Linear
    • Goal-directed
    • No delusions
  • Cognition:
    • Alert and oriented x3
    • Good insight/judgment
    • Memory intact
• Assessment Tools:
  • PHQ-9: 8 (was 15)
  • GAD-7: 12 (was 18)
  • Columbia Suicide Scale: Negative

Assessment

1. Major Depressive Disorder
   • Moderate improvement
   • Medication responsive
   • Continued symptoms
2. Generalized Anxiety Disorder
   • Partial improvement
   • Ongoing stressors
   • Treatment engaged

Plan

1. Treatment:

   • Continue current therapy
   • Medication adjustment
   • Monitor response
   • CPT Code: 99214

2. Medications:

   • Increase sertraline to 100mg daily
   • Continue buspirone 15mg BID
   • Continue prazosin 2mg qhs

3. Patient Education:

   • Sleep hygiene review
   • Stress management
   • Coping strategies
   • Exercise importance

4. Follow-up:

   • 4 weeks follow-up
   • Continue counseling
   • Crisis resources reviewed

8. Pediatric Well Visit

Description

The patient presents for 4-year well-child check and immunizations.

SOAP Note

Patient Name: Lucas Chen

Date of Visit: 09/08/2024

Subjective

Lucas Chen, a 4-year-old male, presents for well-child check. Parents report normal growth and development. Attending preschool. No behavioral concerns. Eating and sleeping well. No acute illnesses since last visit. Up to date on immunizations except for scheduled 4-year vaccines.

Objective

• Vital Signs:
  • BP: 98/60 mmHg
  • HR: 88 bpm
  • RR: 20/min
  • Temp: 98.6°F
  • Weight: 16.8 kg (50th percentile)
  • Height: 103 cm (55th percentile)
  • BMI: 15.8 (45th percentile)
• Physical Exam:
  • General:
    • Active, playful
    • Well-developed
    • No acute distress
  • HEENT:
    • Normocephalic
    • TMs clear
    • Oropharynx normal
    • Red reflex present
  • Neck:
    • Supple
    • No masses
  • Cardiovascular:
    • Regular rhythm
    • No murmurs
    • Strong pulses
  • Respiratory:
    • Clear breath sounds
    • Good air entry
  • Abdomen:
    • Soft, non-tender
    • No organomegaly
  • Musculoskeletal:
    • Normal gait
    • Full ROM
  • Neurological:
    • Age-appropriate
    • Normal tone
• Development:
  • Language: Speaks in sentences
  • Motor: Hops, climbs stairs
  • Social: Plays cooperatively
  • Cognitive: Names colors

Assessment

1. Well Child Check
   • Age-appropriate growth
   • Normal development
   • Due for immunizations
2. Preventive Care
   • Healthy diet
   • Good sleep habits
   • Regular activity

Plan

1. Preventive Care:

   • Age-appropriate screening
   • Anticipatory guidance
   • Development review
   • CPT Code: 99383

2. Immunizations:

   • DTaP administered
   • IPV administered
   • MMR administered
   • Varicella administered

3. Patient/Parent Education:

   • Safety guidelines
   • Nutrition advice
   • Screen time limits
   • Dental hygiene

4. Follow-up:

   • Next well visit at 5 years
   • Development monitoring
   • PRN for acute issues

9. Skin Infection

Description

The patient presents with cellulitis of the right lower extremity requiring evaluation and treatment.

SOAP Note

Patient Name: William Foster

Date of Visit: 09/09/2024

Subjective

William Foster, a 58-year-old male with type 2 diabetes, presents with 3-day history of right lower leg redness and swelling. Reports scratching leg on garden bush. Area progressively expanding with increasing pain. Denies fever or chills. No previous history of cellulitis. Blood sugars well-controlled. No recent trauma or insect bites.

Objective

• Vital Signs:
  • BP: 128/78 mmHg
  • HR: 82 bpm
  • RR: 16/min
  • Temp: 99.2°F
  • SpO2: 98% on room air
• Physical Exam:
  • General:
    • Alert, well-appearing
    • No acute distress
  • Skin:
    • 12x8 cm area of erythema
    • Warmth and tenderness
    • Clear demarcation
    • No fluctuance
    • No crepitus
    • No purulent drainage
  • Extremity:
    • Mild edema
    • Pulses intact
    • Full ROM
    • No lymphangitis
• Laboratory:
  • WBC: 11.2 K/μL
  • Blood glucose: 142 mg/dL

Assessment

1. Cellulitis Right Lower Extremity
   • Early presentation
   • No systemic symptoms
   • No abscess
2. Type 2 Diabetes
   • Well-controlled
   • Risk factor for infection

Plan

1. Treatment:

   • Oral antibiotics
   • Wound care
   • Monitor progression
   • CPT Code: 99213

2. Medications:

   • Cephalexin 500mg QID x 7 days
   • Continue diabetes medications
   • Acetaminophen prn fever

3. Patient Education:

   • Elevation instructions
   • Wound care review
   • Warning signs discussed
   • Diabetes foot care

4. Follow-up:

   • 48-hour recheck
   • Sooner if worsening
   • Monitor blood sugars

10. Asthma Exacerbation

Description

The patient presents with acute asthma exacerbation requiring urgent evaluation and treatment.

SOAP Note

Patient Name: Maria Gonzalez

Date of Visit: 09/10/2024

Subjective

Maria Gonzalez, a 19-year-old female with moderate persistent asthma, presents with 2-day history of worsening shortness of breath, chest tightness, and cough. Using albuterol q2-3 hours with minimal relief. Symptoms worse at night and with exertion. Recent URI symptoms. No fever. Reports medication compliance.

Objective

• Vital Signs:
  • BP: 132/84 mmHg
  • HR: 102 bpm
  • RR: 24/min
  • Temp: 98.8°F
  • SpO2: 94% on room air
• Physical Exam:
  • General:
    • Mild respiratory distress
    • Speaking in phrases
    • Using accessory muscles
  • Respiratory:
    • Diffuse wheezing
    • Prolonged expiration
    • Decreased air entry
    • No crackles
  • Cardiovascular:
    • Tachycardic
    • Regular rhythm
    • No murmurs
  • Peak Flow:
    • 180 L/min (45% of personal best)
• Current Medications:
  • Fluticasone/Salmeterol 250/50 BID
  • Montelukast 10mg daily
  • Albuterol HFA prn

Assessment

1. Acute Asthma Exacerbation
   • Moderate severity
   • Triggered by URI
   • Suboptimal response to rescue inhaler
2. Moderate Persistent Asthma
   • Inadequate control
   • Compliant with medications
   • Needs step-up therapy

Plan

1. Treatment:

   • Nebulizer treatment
   • Oral steroids
   • Monitor response
   • CPT Code: 99214

2. Medications:

   • Albuterol/Ipratropium nebulizer x3
   • Prednisone 40mg daily x5 days
   • Continue maintenance inhalers
   • Increase rescue inhaler use

3. Patient Education:

   • Action plan review
   • Trigger avoidance
   • Proper inhaler technique
   • Peak flow monitoring

4. Follow-up:

   • 2-day follow-up
   • Continue peak flows
   • Sick plan reviewed