10 Common Physician SOAP Note Examples

Written by SOAPNoteAI Editorial Team · Updated January 2026

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List of cases

1. Type 2 Diabetes with Hypertension — Quarterly Follow-Up
2. Chest Pain Workup — New Onset
3. Upper Respiratory Infection
4. COPD Exacerbation Management
5. Gastroesophageal Reflux Disease (GERD)
6. Dyslipidemia with Cardiovascular Risk Assessment
7. Hypothyroidism Follow-Up
8. Acute Low Back Pain
9. Generalized Anxiety with Depression
10. Annual Wellness Visit

1. Type 2 Diabetes with Hypertension — Quarterly Follow-Up

Description

Established patient presenting for quarterly follow-up of type 2 diabetes and hypertension, with recent lab review and medication adjustment.

SOAP Note

Patient Name: Robert Chen

Date of Visit: 01/08/2025

Subjective

Robert Chen, a 58-year-old male, presents for scheduled 3-month follow-up of type 2 diabetes mellitus and essential hypertension. Reports home fasting glucose readings of 150-180 mg/dL, elevated from prior visit range of 120-140 mg/dL. Attributes worsening to decreased dietary adherence, noting increased consumption of processed foods over the past 6 weeks. Reports taking metformin 1000 mg twice daily and lisinopril 10 mg daily as prescribed. Home blood pressure readings running 140-148/88-92 mmHg over the past month. Denies chest pain, shortness of breath, palpitations, lower extremity edema, polyuria, polydipsia, or vision changes. Exercises by walking 20 minutes, 2-3 times per week. Denies tobacco use; occasional alcohol use (2-3 drinks per week).

Objective

• Vital Signs:
  • BP: 144/88 mmHg (right arm, seated)
  • HR: 74 bpm, regular
  • RR: 16/min
  • Temp: 98.4°F
  • SpO2: 98% on room air
  • Weight: 214 lbs | BMI: 30.8 kg/m²
• Physical Examination:
  • General: Alert, well-appearing male in no acute distress
  • HEENT: PERRLA, no papilledema, no AV nicking on fundoscopic exam
  • Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops; no peripheral edema
  • Respiratory: Clear to auscultation bilaterally
  • Extremities: Dorsalis pedis and posterior tibial pulses 2+ bilaterally; intact monofilament sensation bilateral feet
• Recent Labs (5 days prior):
  • HbA1c: 8.1% (up from 7.4% three months ago)
  • Fasting glucose: 172 mg/dL
  • BMP: Within normal limits; sodium 138, potassium 4.2, creatinine 1.1
  • eGFR: 62 mL/min/1.73m²
  • Urine albumin/creatinine ratio: 38 mg/g (mildly elevated)
  • Lipid panel: Total cholesterol 198, LDL 112, HDL 44, TG 185

Assessment

1. Type 2 Diabetes Mellitus, uncontrolled (ICD-10: E11.65)
   • HbA1c worsened to 8.1%; above goal of less than 7%
   • Dietary nonadherence identified as primary contributing factor
   • Mild microalbuminuria present — early nephropathy surveillance warranted
2. Essential Hypertension, not at goal (ICD-10: I10)
   • Home and office readings persistently above 130/80 mmHg target
   • Currently on lisinopril 10 mg daily; uptitration appropriate
3. Overweight/Class I Obesity (ICD-10: E66.01)
   • BMI 30.8; contributing to both insulin resistance and hypertension
4. Dyslipidemia (ICD-10: E78.5)
   • LDL 112; statin therapy to be continued and optimized

Plan

1. Medications:

   • Add semaglutide (Ozempic) 0.25 mg subcutaneously once weekly; increase to 0.5 mg after 4 weeks if tolerated
   • Increase lisinopril from 10 mg to 20 mg daily; recheck BMP and renal function in 2 weeks
   • Continue metformin 1000 mg twice daily with meals

2. Monitoring:

   • Fasting glucose daily; post-prandial glucose 2x per week
   • Home blood pressure daily; log readings
   • Recheck HbA1c, BMP, and urine albumin/creatinine ratio in 3 months

3. Referrals and Orders:

   • Diabetes self-management education (DSME) referral placed
   • Ophthalmology referral for annual diabetic eye exam (overdue)
   • Nutritional counseling referral for medical nutrition therapy (MNT)

4. Patient Education:

   • Reviewed importance of consistent carbohydrate intake and portion control
   • Counseled on semaglutide administration technique and GI side effects (nausea, vomiting)
   • Reinforced blood pressure monitoring technique and foot care

5. Follow-Up:

   • Return in 3 months for HbA1c recheck
   • Lab callback in 2 weeks for BMP following lisinopril increase
   • Call immediately for symptoms of severe hypoglycemia, chest pain, dyspnea, or BP >180/110

CPT Code: 99214 (Level 4 Established Patient Visit — moderate complexity: multiple chronic conditions with suboptimal control, medication change with monitoring required)

2. Chest Pain Workup — New Onset

Description

A 54-year-old male with cardiovascular risk factors presenting with new-onset exertional chest pain requiring urgent evaluation and workup.

SOAP Note

Patient Name: David Williams

Date of Visit: 01/09/2025

Subjective

David Williams, a 54-year-old male with a history of hypertension, dyslipidemia, and former tobacco use, presents for evaluation of new-onset chest pain over the past 2 weeks. Describes the pain as a pressure-like sensation in the center of his chest, rated 4-5/10, occurring exclusively with moderate exertion (climbing two flights of stairs or brisk walking more than two blocks). Pain resolves within 2-3 minutes of resting. Denies radiation to the arm, jaw, or back. Denies dyspnea at rest. Reports one episode of associated mild shortness of breath during exertion. Denies palpitations, syncope, or near-syncope. No rest pain. No prior cardiac history; no prior cardiac workup. Last stress test: never performed. Family history significant for father who died of a myocardial infarction at age 62. Currently taking lisinopril 20 mg daily and atorvastatin 40 mg daily. Smoked 1 ppd x 20 years; quit 8 years ago.

Objective

• Vital Signs:
  • BP: 136/84 mmHg
  • HR: 78 bpm, regular
  • RR: 16/min
  • Temp: 98.6°F
  • SpO2: 99% on room air
  • BMI: 28.2 kg/m²
• Physical Examination:
  • General: Alert, well-appearing male in no acute distress
  • Cardiovascular: Regular rate and rhythm; no murmurs, rubs, or gallops; no S3/S4; peripheral pulses 2+ bilaterally; no JVD; no peripheral edema
  • Respiratory: Clear to auscultation bilaterally; no wheezing
  • Abdomen: Soft, non-tender; no pulsatile mass
• ECG (Obtained Today):
  • Normal sinus rhythm; rate 78; normal axis; no ST changes; no Q waves; no bundle branch block; no ectopy
• Labs (Drawn Today):
  • Troponin I: Pending (stat)
  • BMP: Ordered
  • CBC: Ordered
  • Lipid panel (non-fasting): Total cholesterol 228, LDL 140 (elevated above goal for moderate cardiovascular risk), HDL 42, TG 192

Assessment

1. New-onset exertional chest pain — stable angina pattern (ICD-10: I20.9)
   • Classic exertional pattern with reproducible relief on rest; low-risk features (no rest pain, hemodynamically stable, normal ECG at rest)
   • Pre-test probability: Moderate-to-high given age, sex, and risk factor burden; cardiac etiology must be excluded
2. Hypertension (ICD-10: I10) — not at goal on current therapy
3. Dyslipidemia (ICD-10: E78.5) — LDL 140; below-goal; atorvastatin dose may require uptitration
4. Cardiovascular Risk — elevated (ICD-10: Z82.49 — Family history of ischemic heart disease)
   • 10-year ASCVD risk: Clinician to calculate at current visit using Pooled Cohort Equations

Plan

1. Urgent Cardiac Workup:

   • Refer for stress testing: Exercise treadmill stress test (if able to exercise adequately) vs. pharmacological stress imaging if exercise capacity limited — order placed today
   • Cardiology referral placed — urgent (within 1 week) given clinical profile
   • Troponin result to be reviewed before patient leaves office; serial troponin at 3 hours if initial elevated or borderline

2. Medications:

   • Start sublingual nitroglycerin 0.4 mg PRN for acute chest pain episodes; counseled on proper use and when to call 911
   • Increase atorvastatin from 40 mg to 80 mg daily given LDL 140 with elevated cardiac risk
   • Consider low-dose aspirin 81 mg daily pending cardiology review (shared decision-making discussion held with patient)

3. Activity Guidance:

   • Advised to avoid high-intensity exertion until cardiac workup completed
   • Instructed to call 911 for chest pain lasting >5 minutes at rest, pain not relieved by nitroglycerin, associated diaphoresis, or syncope

4. Patient Education:

   • Reviewed cardiac risk factor modification: diet, activity, blood pressure control
   • Discussed significance of symptoms and urgency of workup

5. Follow-Up:

   • Return in 1 week or sooner pending stress test results
   • Cardiology appointment arranged for next available urgent slot
   • Patient given written after-visit summary with emergency instructions

CPT Code: 99215 (Level 5 Established Patient Visit — high complexity: new problem with workup, urgent referral, cardiovascular risk), 93000 (ECG with interpretation)

3. Upper Respiratory Infection

Description

An adult patient presenting with 5 days of typical upper respiratory infection symptoms including congestion, cough, and low-grade fever.

SOAP Note

Patient Name: Maria Hernandez

Date of Visit: 01/10/2025

Subjective

Maria Hernandez, a 38-year-old female, presents with 5 days of nasal congestion, productive cough with yellowish sputum, sore throat, and low-grade fever. Reports maximum temperature at home of 100.4°F. Symptoms started with sore throat, then progressed to nasal congestion and cough. Using over-the-counter guaifenesin and acetaminophen with partial relief. Denies shortness of breath, ear pain, facial pain, or chest tightness. No sick contacts identified. Up to date on flu and COVID vaccines. Asthma history but well-controlled; using albuterol inhaler less than once per month at baseline. Denies tobacco use.

Objective

• Vital Signs:
  • BP: 118/74 mmHg
  • HR: 84 bpm
  • RR: 16/min
  • Temp: 100.1°F
  • SpO2: 98% on room air
• Physical Examination:
  • General: Alert, mildly ill-appearing female
  • HEENT: Nasal mucosa erythematous with clear-to-cloudy discharge; oropharynx mildly erythematous without exudates; no peritonsillar fullness; tympanic membranes clear bilaterally; no sinus tenderness on palpation
  • Neck: No anterior cervical lymphadenopathy
  • Respiratory: Clear to auscultation bilaterally; no wheezing
  • Cardiovascular: Regular rate and rhythm
• Point-of-Care Testing:
  • Rapid Strep: Negative
  • COVID-19 Rapid Antigen: Negative
  • Influenza A/B: Negative

Assessment

1. Acute Upper Respiratory Infection, viral (ICD-10: J06.9)
   • Viral etiology most likely; negative rapid testing for strep, COVID, influenza
   • No indication for antibiotics at this time
2. Mild persistent asthma (ICD-10: J45.30) — monitoring
   • No current exacerbation; SpO2 normal; lung exam clear

Plan

1. Medications:

   • Acetaminophen 650 mg every 6 hours as needed for fever and discomfort
   • Guaifenesin 600 mg every 12 hours for productive cough
   • Saline nasal rinse or spray, 2-3x daily
   • Honey and warm liquids for sore throat (evidence-based supportive measure)

2. Supportive Care:

   • Rest and increased fluid intake (goal 2+ liters/day)
   • Humidifier use at home if available

3. Asthma Monitoring:

   • Continue current albuterol PRN; contact office if wheeze or shortness of breath develops

4. Return Precautions:

   • Return for: fever >102°F, worsening shortness of breath, severe headache, stiff neck, ear pain, or symptoms not improving after 10 days

5. Follow-Up:

   • As needed if symptoms persist beyond 10 days (consider bacterial superinfection at that point)

CPT Code: 99213 (Level 3 Established Patient Visit — low complexity: acute uncomplicated URI)

4. COPD Exacerbation Management

Description

A patient with moderate COPD presenting with worsening dyspnea and increased purulent sputum consistent with an acute exacerbation.

SOAP Note

Patient Name: James Patterson

Date of Visit: 01/11/2025

Subjective

James Patterson, a 67-year-old male with GOLD Stage 2 COPD, presents with 4 days of worsening shortness of breath and increased cough with yellow-green sputum production. Reports using his albuterol rescue inhaler every 2-3 hours with only partial relief. Baseline dyspnea is MMRC Grade 2 (walks slower on level ground due to breathlessness); current dyspnea is MMRC Grade 3 (must stop to catch breath after 100 yards on level ground). Denies fever or chills. No chest pain. Denies current tobacco use (quit 10 years ago; 35 pack-year history). Currently on tiotropium 18 mcg daily (Spiriva) and fluticasone/salmeterol 250/50 mcg BID (Advair). Has not received a pulmonary function test in 18 months. No hospitalizations for COPD in the past 3 years; one course of antibiotics/steroids in the past year.

Objective

• Vital Signs:
  • BP: 142/86 mmHg
  • HR: 96 bpm
  • RR: 22/min
  • Temp: 99.2°F
  • SpO2: 92% on room air (improved to 96% after albuterol nebulizer treatment in office)
• Physical Examination:
  • General: Mildly dyspneic at rest; able to speak in complete sentences; no cyanosis
  • Respiratory: Barrel chest; prolonged expiratory phase; diffuse expiratory wheezing bilaterally; decreased breath sounds at lung bases; no rales
  • Cardiovascular: Tachycardic but regular; no JVD; no peripheral edema
  • Extremities: No cyanosis; no clubbing
• Treatment in Office:
  • Albuterol nebulizer 2.5 mg/3 mL — administered x1; SpO2 improved to 96%
• Chest X-Ray (Portable, Obtained Today):
  • Hyperinflation consistent with known COPD; no focal consolidation; no pneumothorax; no pleural effusion

Assessment

1. Acute Exacerbation of COPD, moderate (ICD-10: J44.1)
   • Purulent sputum + worsening dyspnea beyond baseline = acute bacterial exacerbation; outpatient management appropriate given no severe hypoxemia, able to ambulate, no altered consciousness
   • Criteria for hospitalization not met at this time
2. COPD, moderate (GOLD Stage 2) (ICD-10: J44.1)
   • Baseline FEV1 50-80% predicted on last PFT 18 months ago

Plan

1. Immediate Treatment:

   • Albuterol nebulizer administered in office (completed); SpO2 improved to 96%
   • Prescribe albuterol 2.5 mg nebulizer solution — q4h at home for 5 days, then PRN

2. Medications:

   • Azithromycin 500 mg PO x 1 day, then 250 mg daily x 4 days (Z-pak) — antibiotic coverage for bacterial exacerbation (or amoxicillin-clavulanate if local resistance patterns warrant)
   • Prednisone 40 mg PO daily x 5 days — systemic corticosteroid for exacerbation
   • Continue tiotropium and fluticasone/salmeterol as prescribed

3. Return Precautions:

   • Return immediately for: SpO2 <90% at home (instruct on oximeter use), severe dyspnea unable to speak in full sentences, altered mental status, high fever, or worsening despite antibiotics/steroids

4. Monitoring and Follow-Up:

   • Recheck in 5-7 days for reassessment of exacerbation response
   • Prescribe pulse oximeter — home monitoring
   • Schedule pulmonary function testing (PFT) when clinically stable (overdue)
   • Review current COPD maintenance regimen; consider escalation if exacerbation frequency increasing

5. Prevention:

   • Pneumococcal vaccine status reviewed — PCV15 or PCV20 recommended if not received; ordered
   • Annual influenza vaccine current; COVID vaccine reviewed
   • Pulmonary rehabilitation referral to be considered at follow-up

CPT Code: 99214 (Level 4 Established Patient Visit — moderate complexity: acute exacerbation of chronic condition, medication management, in-office treatment)

5. Gastroesophageal Reflux Disease (GERD)

Description

A patient with previously diagnosed GERD presenting with breakthrough symptoms despite current therapy, with evaluation for escalation of treatment.

SOAP Note

Patient Name: Susan Miller

Date of Visit: 01/12/2025

Subjective

Susan Miller, a 49-year-old female, presents for follow-up of gastroesophageal reflux disease. Has been on omeprazole 20 mg daily for 4 months with partial symptom control. Reports 3-4 episodes of heartburn per week, typically occurring after dinner and when lying down. Rates heartburn as 4-5/10. Reports chronic, low-grade hoarseness in the morning, which she attributes to "post-nasal drip," but has not had prior laryngology evaluation. Denies dysphagia, odynophagia, unexplained weight loss, anemia, or hematemesis (no alarm symptoms). Identifies triggers: spicy foods, wine, and late evening meals. BMI 30.2. Reports sleeping with head of bed elevated on two pillows, eating dinner 2 hours before bedtime. No tobacco. 1-2 glasses of wine, 3-4 nights per week.

Objective

• Vital Signs:
  • BP: 126/78 mmHg | HR: 70 bpm | Temp: 98.6°F | BMI: 30.2 kg/m²
• Physical Examination:
  • General: Well-appearing female in no acute distress
  • HEENT: Oropharynx mildly erythematous posteriorly; no dental erosion noted; no tonsillar hypertrophy
  • Abdomen: Soft, non-tender; no epigastric tenderness; normal bowel sounds; no organomegaly

Assessment

1. Gastroesophageal Reflux Disease, chronic (ICD-10: K21.9)
   • Inadequately controlled on omeprazole 20 mg daily; 3-4 breakthrough episodes/week
   • Morning hoarseness may represent laryngopharyngeal reflux (LPR) component — evaluation warranted
   • No alarm symptoms at this time; endoscopy not urgently indicated but to be considered if symptoms persist on optimized therapy
2. Overweight (ICD-10: E66.09)
   • BMI 30.2; weight is contributing to increased intraabdominal pressure and reflux

Plan

1. Medications:

   • Increase omeprazole to 40 mg daily (take 30-60 minutes before breakfast)
   • Add famotidine 20 mg at bedtime for nocturnal acid control (adjunct)
   • Trial for 8 weeks on new regimen before reassessment

2. Lifestyle Modifications:

   • Elevate head of bed 6-8 inches with bed risers (pillows alone are insufficient)
   • Extend post-meal to bedtime interval to 3 hours minimum
   • Reduce alcohol to weekends only; avoid wine (high acid content) near mealtime
   • Trial elimination of specific trigger foods for 2 weeks to identify primary offenders
   • Weight loss: 5% body weight reduction target (approximately 8-10 lbs); referred to nutritionist

3. Referral:

   • ENT/Laryngology referral placed for hoarseness evaluation — rule out LPR, vocal cord changes, or other laryngeal pathology

4. Return Precautions:

   • Return sooner for new dysphagia, progressive hoarseness, significant weight loss, blood in stool/vomit — would trigger endoscopy referral

5. Follow-Up:

   • Return in 8 weeks to assess response to optimized therapy
   • If symptoms persist or worsen on optimized regimen, upper endoscopy referral to be placed

CPT Code: 99214 (Level 4 Established Patient Visit — moderate complexity: suboptimally controlled chronic condition, medication change, specialist referral)

6. Dyslipidemia with Cardiovascular Risk Assessment

Description

A middle-aged patient presenting for cardiovascular risk assessment and dyslipidemia management, including ASCVD risk calculation and statin initiation discussion.

SOAP Note

Patient Name: Thomas Anderson

Date of Visit: 01/13/2025

Subjective

Thomas Anderson, a 50-year-old male, presents for cardiovascular risk assessment and lipid management follow-up. He was informed at last visit that his cholesterol was elevated. No prior statin therapy. Denies chest pain, dyspnea, or palpitations. Reports moderate exercise — jogging 20-25 minutes, 2 times per week. Diet includes red meat 3-4 times per week; limited fruits and vegetables. Moderate alcohol use (1-2 drinks daily). Denies tobacco use (never smoker). No family history of premature cardiovascular disease. No personal history of hypertension, diabetes, or kidney disease. Fasting labs drawn 1 week ago per order from last visit.

Objective

• Vital Signs:
  • BP: 128/82 mmHg | HR: 68 bpm | BMI: 26.8 kg/m²
• Physical Examination:
  • General: Well-appearing male; no xanthelasma or tendon xanthomas noted
  • Cardiovascular: Regular rate and rhythm; no murmurs; normal peripheral pulses; no bruits
  • Abdomen: No hepatosplenomegaly
• Fasting Labs (1 week prior):
  • Total cholesterol: 246 mg/dL
  • LDL: 162 mg/dL
  • HDL: 48 mg/dL
  • Triglycerides: 178 mg/dL
  • Non-HDL cholesterol: 198 mg/dL
  • Fasting glucose: 98 mg/dL (borderline; no prediabetes diagnosis at this time)
  • BMP: Within normal limits; eGFR >60
  • TSH: 2.1 mIU/L (normal — secondary dyslipidemia from hypothyroidism excluded)
• ASCVD Risk Calculation (Pooled Cohort Equations, performed at visit):
  • 10-year ASCVD risk: 8.4% (Intermediate risk: 7.5-20%)

Assessment

1. Dyslipidemia — Elevated LDL and non-HDL (ICD-10: E78.5)
   • LDL 162 mg/dL; intermediate ASCVD risk (8.4%); statin therapy discussion indicated per ACC/AHA guidelines
   • No secondary causes identified (normal TSH, no diabetes, normal renal function)
2. Intermediate Cardiovascular Risk (ICD-10: Z13.6)
   • 10-year ASCVD risk 8.4%; shared decision-making regarding statin initiation performed
3. Borderline fasting glucose (ICD-10: R73.01)
   • Fasting glucose 98 mg/dL; prediabetes screening repeat in 12 months; lifestyle modification counseling provided

Plan

1. Shared Decision-Making — Statin Therapy:

   • Discussed benefits and risks of moderate-intensity statin therapy
   • Patient agreed to initiate statin therapy
   • Prescribe atorvastatin 20 mg daily (moderate-intensity statin; target LDL reduction 30-50%)
   • Goal LDL: Less than 100 mg/dL for intermediate ASCVD risk
   • Reviewed potential side effects: myalgias (3-5% of patients), rare hepatotoxicity, monitoring plan

2. Lifestyle Modifications:

   • Mediterranean-style diet counseling: reduce saturated fat, increase omega-3 fatty acids (salmon, walnuts), increase soluble fiber (oat bran, beans)
   • Increase exercise to 150 minutes per week of moderate-intensity aerobic activity
   • Alcohol reduction: limit to 1 drink/day to reduce TG contribution
   • Weight neutral; continue current habits that support healthy BMI

3. Monitoring:

   • Fasting lipid panel and ALT at 4-12 weeks post-statin initiation
   • HbA1c at next annual visit given borderline fasting glucose
   • BP monitoring: currently borderline; recheck at next visit; lifestyle modification first

4. Follow-Up:

   • Return in 3 months for lipid panel recheck and statin tolerability assessment
   • Annual visit in 12 months for comprehensive prevention assessment

CPT Code: 99214 (Level 4 Established Patient Visit — moderate complexity: new treatment decision with risk-benefit discussion, multiple conditions addressed, lab review)

7. Hypothyroidism Follow-Up

Description

An established patient with hypothyroidism presenting for routine follow-up with recent TSH results and evaluation of symptoms.

SOAP Note

Patient Name: Patricia Davis

Date of Visit: 01/14/2025

Subjective

Patricia Davis, a 44-year-old female, presents for routine 6-month follow-up of hypothyroidism. Currently taking levothyroxine 100 mcg daily. Reports she has been taking it correctly — on an empty stomach, 30-60 minutes before breakfast, not within 4 hours of calcium or iron supplements. Reports mild fatigue persisting despite therapy, though significantly better than before diagnosis. Denies weight gain, constipation, cold intolerance, or hair loss. No palpitations, tremor, heat intolerance, or insomnia (no hyperthyroid symptoms). Menstrual cycles regular. Reports new complaint of mild bilateral carpal tunnel symptoms — tingling in fingers bilaterally at night — present for 2 months; uncertain if related to thyroid condition. TSH drawn 10 days ago.

Objective

• Vital Signs:
  • BP: 114/70 mmHg | HR: 64 bpm | Temp: 98.0°F | BMI: 24.2 kg/m²
• Physical Examination:
  • Thyroid: No goiter; no palpable nodules; non-tender
  • Skin: No myxedema; no dry skin
  • Hair/Nails: No significant thinning or brittleness
  • Neurological: No hyporeflexia; Tinel's sign positive at bilateral wrists; Phalen's test positive bilaterally
  • Cardiovascular: Normal rate and rhythm; no bradycardia
• Lab Results:
  • TSH: 3.8 mIU/L (within normal range 0.5-4.5 mIU/L; above mid-normal range — acceptable given symptom profile)
  • Free T4: 1.1 ng/dL (normal)

Assessment

1. Hypothyroidism, controlled (ICD-10: E03.9)
   • TSH 3.8 within normal range; patient clinically euthyroid
   • Mild residual fatigue — not necessarily indicative of undertreated hypothyroidism; consider other etiologies if persists
2. Possible Bilateral Carpal Tunnel Syndrome (ICD-10: G56.00)
   • Positive Tinel's and Phalen's bilaterally; hypothyroidism is a recognized secondary cause of CTS
   • Nerve conduction study indicated for confirmation
3. Mild fatigue (ICD-10: R53.83)
   • Multifactorial; hypothyroidism may be contributing but TSH at high-normal — sleep quality, iron, B12 should be assessed

Plan

1. Levothyroxine:

   • Continue levothyroxine 100 mcg daily — no dose change at this time
   • If fatigue does not improve, consider uptitration to target TSH in the 1.0-2.5 mIU/L range (lower end of normal often preferred in symptomatic patients — shared decision making)

2. Carpal Tunnel Evaluation:

   • Order nerve conduction study/electromyography (NCS/EMG) to confirm CTS — if confirmed, orthopedic or neurology referral
   • In the interim: recommend neutral-position wrist splints at night
   • Treating underlying hypothyroidism (if undertreated) may improve CTS symptoms if hypothyroid-related

3. Fatigue Workup:

   • Order CBC (rule out anemia), ferritin, B12, folate, vitamin D — common causes of persistent fatigue
   • Reviewed sleep hygiene; inquired about sleep quality; patient reports adequate sleep

4. Monitoring:

   • Repeat TSH and free T4 in 6 months
   • NCS/EMG results to guide CTS management

5. Follow-Up:

   • Return in 6 months or sooner if symptoms change
   • NCS/EMG scheduling order provided to patient

CPT Code: 99213 (Level 3 Established Patient Visit — low complexity: stable chronic condition, one new concern, no urgent intervention required)

8. Acute Low Back Pain

Description

A working-age adult presenting with new-onset low back pain following a mechanical injury, without neurological symptoms.

SOAP Note

Patient Name: Michael Torres

Date of Visit: 01/15/2025

Subjective

Michael Torres, a 42-year-old male, presents with acute low back pain that began 3 days ago while moving furniture. Reports feeling a sudden sharp pain in the lower back when lifting a heavy couch. Pain has since become a dull, constant ache rated 6/10 at rest and 8/10 with movement. Located to the central and right paracentral lower lumbar area. No radiation to the leg. Denies numbness, tingling, or weakness in the lower extremities. Denies bowel or bladder dysfunction (no saddle anesthesia). Denies fever or chills. Tried ibuprofen 400 mg with minimal relief. Denies prior history of significant back problems. Works as an office manager; currently not working. No tobacco, no significant past medical history.

Objective

• Vital Signs:
  • BP: 124/78 mmHg | HR: 78 bpm | Temp: 98.6°F | BMI: 26.4 kg/m²
• Physical Examination:
  • General: Ambulating with mild antalgic gait; holds hand over lower back
  • Back: Paraspinal muscle spasm palpable in bilateral lumbar region, right greater than left; midline tenderness over L4-L5; no step-off deformity
  • Range of Motion: Lumbar flexion to 30° (limited by pain); extension limited; lateral flexion symmetric, moderately limited
  • Neurological: Strength 5/5 bilateral lower extremities; sensation intact bilateral L2-S1 distributions; deep tendon reflexes 2+ at bilateral patella and Achilles
  • Straight Leg Raise: Negative bilaterally
• No Imaging Ordered: Ottawa-equivalent criteria not met; acute mechanical low back pain without red flags does not require imaging per USPSTF/ACP guidelines

Assessment

1. Acute Lumbar Strain (ICD-10: S39.012A — Strain of muscle, fascia and tendon of lower back, initial encounter; or M54.50 — Low back pain, unspecified)
   • Classic acute mechanical pattern following heavy lifting; no neurological signs; no red flags
   • Imaging not indicated at this time (guidelines support watchful waiting in uncomplicated acute LBP)
   • Good prognosis: 80-90% of acute LBP resolves within 4-6 weeks with conservative management

Plan

1. Medications:

   • Naproxen sodium 500 mg twice daily with food for 7-10 days (anti-inflammatory analgesia)
   • Cyclobenzaprine 5 mg at bedtime for muscle spasm (short-term, caution re: sedation)
   • Avoid opioids at this time — not indicated for uncomplicated acute LBP

2. Non-Pharmacologic Therapy:

   • Heat to lower back 15-20 minutes, 2-3x daily for muscle relaxation
   • Remain as active as tolerable; bed rest is counterproductive — encouraged to resume gentle walking
   • Physical therapy referral placed if not significantly improved in 2-4 weeks

3. Activity Modification:

   • Avoid heavy lifting, bending, or prolonged static postures until resolved
   • Work restriction: Light duty only for 1 week; no lifting over 10 lbs

4. Patient Education:

   • Educated on favorable prognosis of acute LBP
   • Return sooner if new neurological symptoms develop: leg weakness, numbness, bowel/bladder dysfunction (cauda equina = emergency)
   • Reviewed proper lifting mechanics

5. Follow-Up:

   • Return in 2-4 weeks if not improving
   • If pain persists at 4-6 weeks, consider imaging and physical therapy initiation
   • If red flag symptoms develop, present to ED urgently

CPT Code: 99213 (Level 3 Established Patient Visit — low complexity: new problem without workup, no neurological signs, conservative management)

9. Generalized Anxiety with Depression

Description

An established patient presenting for follow-up of generalized anxiety disorder and comorbid depression, with medication management and coordination with therapist.

SOAP Note

Patient Name: Jennifer Kim

Date of Visit: 01/16/2025

Subjective

Jennifer Kim, a 36-year-old female, presents for 6-week follow-up of generalized anxiety disorder and major depressive disorder. Started escitalopram 10 mg daily 6 weeks ago. Reports moderate improvement: anxiety has decreased from a GAD-7 of 17 to 11; sleep is slightly better (falling asleep in 30-40 minutes vs. prior 1-2 hours). Mood remains low most days; PHQ-9 today: 13 (down from 18 at initiation). Reports daily fatigue and low motivation — these have not improved. Denies suicidal ideation, intent, or plan. Denies self-harm. Attending weekly cognitive-behavioral therapy (CBT) with outpatient therapist; reports finding sessions helpful. Denies medication side effects — no nausea, no sexual dysfunction, no activation syndrome. Reports compliance: taking escitalopram every morning. Reports significant work-related stress as a contributing factor; starting a new job in 3 weeks. Works as a middle school teacher.

Objective

• Vital Signs:
  • BP: 112/68 mmHg | HR: 72 bpm | Weight: 132 lbs (stable)
• Physical Examination:
  • General: Well-groomed, alert, mildly anxious appearance; appropriate eye contact
  • Affect: Somewhat restricted; congruent with stated mood; reactive when discussing positive topics
  • Speech: Normal rate and rhythm
  • Thought Process: Logical, goal-directed; no suicidal ideation
• Screening Tools:
  • PHQ-9: 13 (moderate depression; down from 18 at initiation)
  • GAD-7: 11 (moderate anxiety; down from 17 at initiation)

Assessment

1. Major Depressive Disorder, recurrent, moderate (ICD-10: F33.1)
   • Partial response to escitalopram 10 mg at 6 weeks; PHQ-9 improved but not at goal (less than 5 = remission)
   • Residual: low mood, fatigue, amotivation
2. Generalized Anxiety Disorder (ICD-10: F41.1)
   • Partial response; GAD-7 improved from 17 to 11; significant functional anxiety remains
3. Work-related psychosocial stressors (ICD-10: Z56.9)
   • Job transition anticipated in 3 weeks; may exacerbate anxiety in coming weeks

Plan

1. Medications:

   • Increase escitalopram from 10 mg to 20 mg daily (standard uptitration at 6 weeks given partial response and good tolerability)
   • Reviewed rationale and expected timeline for additional benefit (2-4 weeks)
   • Discussed side effects to watch for with dose increase: increased anxiety/activation in first 1-2 weeks (transient)

2. Safety:

   • Safety assessment: No SI/HI; no plan or intent; low acute risk
   • Crisis line information provided (988); confirmed patient has support persons

3. Therapy:

   • Encouraged continued weekly CBT — cognitive restructuring for anxiety and behavioral activation for depression are evidence-based
   • Coordination note sent to therapist regarding medication change

4. Monitoring:

   • Repeat PHQ-9 and GAD-7 at next visit
   • Contact office if new or worsening symptoms, activation, or any safety concerns

5. Lifestyle:

   • Sleep hygiene reviewed; advised consistent wake time regardless of sleep quality
   • Exercise: Even 20 minutes of brisk walking 3x/week has evidence-based antidepressant and anxiolytic benefit — encouraged

6. Follow-Up:

   • Return in 4-6 weeks for medication management review
   • Earlier if symptoms worsen or safety concerns arise

CPT Code: 99214 (Level 4 Established Patient Visit — moderate complexity: two psychiatric conditions requiring medication management, coordination with therapist, safety assessment)

10. Annual Wellness Visit

Description

A middle-aged patient presenting for annual wellness visit with focus on age-appropriate preventive screenings, immunizations, and cardiovascular risk assessment.

SOAP Note

Patient Name: Laura Johnson

Date of Visit: 01/17/2025

Subjective

Laura Johnson, a 52-year-old female, presents for annual wellness visit. No acute complaints. Reports generally good health; managing stress with yoga twice weekly and walking 30 minutes most days. Diet is primarily plant-based with occasional fish; denies red meat. No tobacco use. Alcohol: 1-2 glasses of wine on weekends. Family history: mother with breast cancer at 58 (paternal and maternal grandmothers both with breast cancer); father with hypertension and type 2 diabetes. Menstrual history: last menstrual period 8 months ago; experiencing hot flashes and mild sleep disruption; not on hormone therapy. Reports no new symptoms since last visit. Due for mammogram (last one 2 years ago). Last Pap smear 3 years ago — abnormal result (ASCUS); colposcopy was normal; routine surveillance recommended.

Objective

• Vital Signs:
  • BP: 118/72 mmHg
  • HR: 66 bpm
  • RR: 14/min
  • Temp: 98.4°F
  • Weight: 148 lbs | BMI: 24.6 kg/m²
• Physical Examination:
  • General: Well-appearing, fit female in no acute distress
  • HEENT: PERRLA; oropharynx clear; thyroid normal on palpation; no cervical lymphadenopathy
  • Cardiovascular: Regular rate and rhythm; no murmurs
  • Respiratory: Clear to auscultation bilaterally
  • Breasts: No masses, skin changes, nipple discharge, or axillary lymphadenopathy
  • Abdomen: Soft, non-tender; no organomegaly
  • Pelvic: Deferred to separate gynecologic exam (referred to OB/GYN)
  • Skin: No suspicious lesions; a few benign seborrheic keratoses on back, documented
  • Neurological: Grossly intact; no focal deficits
• Screening Tools Administered:
  • PHQ-2: 0 (negative for depression screening)
  • Alcohol screening (AUDIT-C): Score 2 (low-risk pattern)
  • Domestic violence screening: Negative
• Recent Labs (fasting, ordered at last visit):
  • Total cholesterol: 188; LDL 102; HDL 62; TG 118
  • Fasting glucose: 89 mg/dL
  • TSH: 1.8 mIU/L (normal)
  • Vitamin D (25-OH): 28 ng/mL (low-normal; target 30-60 ng/mL)

Assessment

1. Annual Health Maintenance — Female, age 52 (ICD-10: Z00.00)
   • Generally healthy; no acute or chronic active conditions requiring management at this visit
2. Perimenopause / Menopausal Transition (ICD-10: N95.1)
   • 8 months amenorrhea; vasomotor symptoms (hot flashes, sleep disruption) present
   • Hormone therapy discussion: patient inquired; counseled on risks/benefits; patient prefers to defer
3. Elevated Breast Cancer Risk (ICD-10: Z80.3 — Family history of malignant neoplasm)
   • First-degree relative (mother) and second-degree relatives with breast cancer; BRCA counseling indicated; formal risk assessment recommended
4. Vitamin D Insufficiency (ICD-10: E55.9)
   • 25-OH vitamin D 28 ng/mL; below optimal; supplementation initiated
5. Preventive Services Due — multiple items (see Plan)

Plan

1. Preventive Screenings Ordered/Scheduled:

   • Mammogram: Order placed (annual due to elevated family history; standard screening for all women 40+ per USPSTF guidelines)
   • Colon cancer screening: Colonoscopy recommended — due at age 45+ per current guidelines; patient has not had one; order placed
   • Cervical cancer surveillance: Pap smear with HPV co-test (due this year given ASCUS + colposcopy history); OB/GYN referral placed
   • DEXA scan (bone density): Order placed — recommended for women at menopause onset with risk factors (family history, low BMI — not present but monitoring appropriate given perimenopause)
   • Skin cancer screening: No action today; referred to dermatology for baseline screening given age

2. Breast Cancer Risk Assessment:

   • Formal hereditary breast/ovarian cancer risk assessment recommended — referral to genetic counseling placed (BRCA1/BRCA2 testing may be indicated given two first-and second-degree relatives with breast cancer)

3. Immunizations:

   • Influenza vaccine: Administered today
   • Tdap: Reviewed — patient received in 2019; not due
   • Shingrix (RZV): Recommended at age 50+; Patient has not received — order placed; schedule first dose today or at convenience
   • COVID-19 booster: Status reviewed; updated booster recommended

4. Menopausal Symptoms:

   • Hot flashes and sleep disruption: Counseled on non-hormonal options — CBT-I for sleep, low-dose venlafaxine or paroxetine (non-hormonal) for vasomotor symptoms if bothersome
   • Patient to follow up with OB/GYN for discussion of hormone therapy risks/benefits if symptoms worsen

5. Supplements:

   • Vitamin D3 2000 IU daily — initiated; recheck level in 6 months
   • Calcium from dietary sources preferred over supplementation (reviewed dietary calcium sources)

6. Lifestyle Reinforcement:

   • Excellent health behaviors noted; counseled to maintain current exercise and diet patterns
   • Stress management: yoga practice is evidence-supported; reinforce

7. Follow-Up:

   • Annual wellness visit in 12 months
   • Earlier return for any new symptoms; follow up on colonoscopy, mammogram, and DEXA results

CPT Code: 99396 (Preventive Medicine Visit, Established Patient, age 40-64) — Note: if additional chronic conditions are addressed in the same visit, separate E/M code (99213-99215) may be billed with modifier -25 if medically significant decision-making occurred for a separate problem