Jack Baldwin VE iHuman Episodic SOAP Note

Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples

In this guide, we focus on creating a comprehensive SOAP note for the Jack Baldwin VE iHuman episodic case. A SOAP note breaks down into Subjective, Objective, Assessment, and Plan sections, allowing for systematic clinical documentation.

Subjective (S)

Includes the patient’s chief complaint (CC), history of present illness (HPI), and relevant details like past medical history (PMH), medications, allergies, and review of systems (ROS).

Example for Jack Baldwin VE:
CC: “Sharp chest pain radiating to my left arm.”
HPI: The patient reports sharp pain that began 2 days ago and worsens with exertion.

Objective (O)

The objective section records measurable data, including vital signs, general appearance, physical exam findings, and lab results.

Example:

• Temp: 98.6°F, BP: 140/90, HR: 82 bpm, RR: 18
• Findings: Mild chest tenderness, no wheezing or crackles in lung auscultation.

Assessment (A)

This includes the differential diagnoses. Based on the subjective and objective data, create three possible diagnoses, ranked by likelihood, and justify them with evidence from literature.

Example Differential Diagnoses:

1. Myocardial Ischemia: Supported by exertional chest pain radiating to the arm, worsened by physical activity.
2. Gastroesophageal Reflux Disease (GERD): Considered due to the presence of burning chest discomfort.
3. Costochondritis: Localized chest pain upon palpation supports this musculoskeletal cause.

Plan (P)

This section outlines the treatment plan, including further diagnostic tests, medications, lifestyle modifications, and follow-up care.

Example Treatment Plan:

• Order an ECG and cardiac enzymes to rule out myocardial infarction.
• Prescribe antacids for symptomatic relief if GERD is suspected.
• Recommend NSAIDs for pain management in case of costochondritis.
• Follow up in 48 hours if symptoms persist or worsen.

Genitourinary/ Gynecological Examination

Bladder is non-distended with no CVA tenderness. Coarse pubic hair is observed in normal distribution. Skin color matches the general pigmentation, and no vulvar lesions are seen. The patient appears well estrogenized. During the speculum exam, the vaginal walls are pink and rugated, with no lesions present. The cervix is pink and nulliparous with scant, clear to cloudy drainage. A bimanual exam reveals a firm cervix with no cervical motion tenderness (CMT). The uterus is anteverted and lies behind a slightly distended bladder, with no masses, fullness, or tenderness. Ovaries are non-palpable.

Male Examination

Both testes are palpable with no masses, lesions, or hernia detected, and no urethral discharge is noted. Rectal examination reveals no evidence of hemorrhoids, fissures, bleeding, or masses. For males, the prostate is smooth, non-tender, and free of nodules, with normal size and firm sphincter tone.

Musculoskeletal Examination:
Full range of motion (ROM) is observed in all four extremities as the patient moves about the exam room.

Neurological Examination:
The patient demonstrates clear speech, good tone, an erect posture, stable balance, and a normal gait.

Psychiatric Examination:
The patient is alert and oriented, dressed appropriately in clean clothes. Eye contact is maintained, and the patient’s speech is soft but clear, with a normal rate and cadence. Responses to questions are appropriate.

Lab Tests:

• Urinalysis: Pending
• Urine culture: Pending
• Wet prep: Pending

Special Tests:
None performed.

Diagnosis:
Presumptive Diagnosis:

1. Herpes zoster without mention of complication (ICD-10 code: 053.9)

Differential Diagnosis:

1. Herpes zoster without mention of complication (053.9)
2. Rash and other nonspecific skin eruption (782.1)
3. Other malaise and fatigue (780.79)

Plan/Therapeutics:

• Diagnosis: Herpes zoster without complication (053.9)
• Further Testing: None required.
• Medication: Valtrex 1000 mg PO every 8 hours for 7 days.
• Education: The patient should continue using Tylenol 650 mg PO to manage pain, limiting it to less than 4 g per day. Cool compresses may help with discomfort. Inform the patient that vesicles may burst and crust over, with pain subsiding in 2-3 days, although healing may take up to six weeks. The patient should monitor for signs of infection (redness, fever, purulent drainage) and avoid contact with vulnerable groups (e.g., children, pregnant women, immunocompromised individuals) until blisters dry. A future shingles flare-up is possible, and managing stress and maintaining a healthy lifestyle may help reduce recurrence risk.
• Non-Medication Treatment: Maintain hydration by drinking 6-8 glasses of water daily and continue regular workouts.
• Return to Clinic: Follow-up in one week if pain persists or if infection symptoms develop. Otherwise, return as needed (PRN).

Evaluation of Patient Encounter

The SOAP note should include a complete review of symptoms (ROS) and a thorough history of present illness (HPI) with details about onset, severity, and symptoms. Descriptions of findings are preferred over using terms like “normal” in learning environments. Each encounter should reflect an ideal examination and documentation process, including the completion of a total ROS for every patient.

Section	Details
Objective	Weight: 180 lbs, BMI: 24.4, Temp: 99°F (oral), BP: 170/94 mmHg, Height: 6’0″, Pulse: 130 bpm (tachycardia), RR: 18 bpm, Oxygen Sat: 98% on RA
General Appearance	Healthy, acute distress, well-groomed, fit, cheerful, alert, and oriented x4.
Skin	Warm, diaphoretic, no delayed healing, rashes, bruising, bleeding, discoloration, or lesion/mole changes.
HEENT	Normocephalic, atraumatic, PERRLA, EOMs intact, no conjunctival/scleral injection, patent canals, pearly grey TMs, normal nasal mucosa, no septal deviation, full ROM, no lymphadenopathy, oral mucosa pink/moist, no pharyngeal erythema/exudate.
Carotids	No JVD, bruits.
Cardiovascular	Tachycardia, S1/S2 regular, no extra sounds, capillary refill 2 sec, pulses 3+, no edema.
Respiratory	Clear lungs bilaterally, regular and easy respirations, symmetric chest wall.
Gastrointestinal	Abdomen flat, hyperactive bowel sounds, soft, non-tender, no hepatosplenomegaly.
Genitourinary	Left groin swollen, tenderness in left inguinal canal, right normal, scrotum swollen (left), testicles normal.
Musculoskeletal	Full ROM in all extremities.
Neurological	Clear speech, stable gait, normal balance, erect posture.
Psychiatric	Alert to person only, well-dressed, soft but clear speech, unable to answer questions appropriately.
Lab Results	Elevated WBCs (19500 mm³), normal RBC (5.0 million/µl), Hgb (14.2 g/dl), Hct (45%), platelets (310 k/dL).
Urinalysis	Light amber, clear, pH 5.1, 1 mg/dL protein, specific gravity 1.013, no glucose, RBCs, WBCs, or bacteria.
Electrolytes	Na+ 141 mmol/L, K+ 4.0 mmol/L, Cl- 99 mmol/L, CO2 25 mmol/L.
Diagnosis	Inguinal hernia.
Differential Diagnoses	Testicular torsion, epididymitis, kidney stones.
Plan of Care	Cancer screening, smoking cessation, increased exercise, better nutrition, hernia truss use, surgery as needed.

References
Buttaro, T., Trybulski, J., Bailey, P., & Sandberg-Cook, J. (2013). Primary care: A collaborative practice (4th ed.). Mosby/Elsevier.
Cash, J. C. (2014). Family Practice Guidelines (3rd ed.). South University.
Fischbach, F. T., & Dunning, M. B. (2014). A manual of laboratory and diagnostic tests. Wolters Kluwer Health/Lippincott Williams & Wilkins.
Goolsby, M. J., & Grubbs, L. (2015). Advanced assessment: Interpreting findings and formulating differential diagnoses. F.A. Davis Company.