writing assessment of soap note for healthy patients?

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CLR2303

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Hi guys,
Please direct me to previous threads if this has already been asked (I checked and couldn't find). I am having trouble figuring out what to write in my assessment of a healthy asymptomatic standardized patient who came in for concerns about STIs. I was taught that this is where you put your differential diagnoses, but this patient has no diagnoses or illnesses (including chronic health issues). I did a lot of counseling, but I have no idea what I would write in my assessment for that. Suggestions?

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S: CC - STI concerns, HPI (basically you'll explain concerns they mentioned, what they said/described), PMHx, SurgHx, Hosp, Meds, Allergies, FamHx, SocialHx
O: General appearance, Vitals, Systems that you checked in physical (if applicable, you'd have a lot of normal findings), MMSE/psych stuff, Lab results (if applicable)
A: DDx, not really sure what you would put here, but maybe you can just say differential isn't applicable, or simply say STI concerns again
P: Talk about the counseling you provided, refer to resources/social group for more info, advise to return/call with any additional questions
 
Thanks- it's really just the assessment part I'm struggling with. I was thinking of using 1) STI concerns, 2) Sexuality or something like that.
 
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Thanks- it's really just the assessment part I'm struggling with. I was thinking of using 1) STI concerns, 2) Sexuality or something like that.
At our school they tell us to include lifestyle issues such as poor diet or exercise, risky sexual behavior, tobacco use, illicit drug use, or alcohol abuse in our assessment, regardless of any other differentials. Depending on the patient's presentation, you may want to include a psych differential such as hypochondriasis. Eg. "Doc, I was having sex with my wife and I had a milky white discharge so I definitely have gonorrhea and I'm afraid that it will kill me and also I've been feeling fatigued and I once visited Africa a few years ago so I'm pretty sure I also have Ebola".
I have yet to see a real patient or second-year SP with a perfectly healthy lifestyle. If even these don't apply, I would put "Assessment: Healthy patient" or something along those lines.
Disclaimer: I'm a second-year student, so maybe they'll have different rules at hospitals.
 
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At our school they tell us to include lifestyle issues such as poor diet or exercise, risky sexual behavior, tobacco use, illicit drug use, or alcohol abuse in our assessment, regardless of any other differentials. Depending on the patient's presentation, you may want to include a psych differential such as hypochondriasis. Eg. "Doc, I was having sex with my wife and I had a milky white discharge so I definitely have gonorrhea and I'm afraid that it will kill me and also I've been feeling fatigued and I once visited Africa a few years ago so I'm pretty sure I also have Ebola".
I have yet to see a real patient or second-year SP with a perfectly healthy lifestyle. If even these don't apply, I would put "Assessment: Healthy patient" or something along those lines.
Disclaimer: I'm a second-year student, so maybe they'll have different rules at hospitals.

Good thoughts, but don't put hypochondriac on any standardized patient, especially when you take the PE. Not a good plan.

Someone who is presenting for STI concerns you can put that under your assessment....we aren't reinventing the wheel here don't over think yourself.

If I saw this patient in clinic (I have seen a few with this issue as a 4th year now) I would simply put.
A/P
47 year a old asymptomatic male presents to the office today with concerns of STI.
1. STI screening exam
Ordered GC/CC swab, HIV-etc, will F/U with results when received. BTO if become symptomatic. Educated patient on STI prevention and S/S of common infections.

2. Chronic tobacco use. (Everyone is a damn tobacco user)
Educated patient and provided resources for tobacco cessation.

3. Etc,

You don't HAVE to have a differential in your A/P, sometimes there isn't one. You can still assess why the patient is there and talk about the plan you came up with. Definitely don't put hypochondriac unless you want to fail (not joking).



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prevention is always indicated in a healthy individual:

vaccines, healthy diet, quit smoking, drink moderately, etc etc.
 
At our school they tell us to include lifestyle issues such as poor diet or exercise, risky sexual behavior, tobacco use, illicit drug use, or alcohol abuse in our assessment, regardless of any other differentials. Depending on the patient's presentation, you may want to include a psych differential such as hypochondriasis. Eg. "Doc, I was having sex with my wife and I had a milky white discharge so I definitely have gonorrhea and I'm afraid that it will kill me and also I've been feeling fatigued and I once visited Africa a few years ago so I'm pretty sure I also have Ebola".
I have yet to see a real patient or second-year SP with a perfectly healthy lifestyle. If even these don't apply, I would put "Assessment: Healthy patient" or something along those lines.
Disclaimer: I'm a second-year student, so maybe they'll have different rules at hospitals.

It really depends on the attending or whoever supervises you. And no, don't mention hypochondriasis. The diagnosis code for most cases is not 300.7, it's 569.42.
 
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It really depends on the attending or whoever supervises you. And no, don't mention hypochondriasis. The diagnosis code for most cases is not 300.7, it's 569.42.

Well...That's compassion for ya!...
 
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