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-Pick any “ADULT” Acute or Chronic Disease. Must use the sample template for your soap note .
-Templates used from another classes will not be accepted. Student must use the template provided in this class which must clearly contain the progress note (in the Assessment section) of the encounter with the patient ( this section is clearly mark in bold, highlighted and underlined).
– Follow the MRU Soap Note Rubric as a guide.
– Use APA format and must include minimum of 2 Scholarly Citations.
– Turn it in Score must be less than 20% or will not be accepted for credit, must be your own work and in your own words. The use of tempates is ok with regards to Turn it in, but the Patient History, CC, HPI, The Assessment and Plan should be of your own work and individualized to your made up patient.
Below I attach the Template, which must be completed in my Soap Note # 1 work and I also attach an example of a Soap Note (herpes Zoster), so that you can be guided by it and see how it is done. In addition, I am attaching 4 Cases, so that you can select one of those cases for my Soap Note # 1 work. I am also attaching the Soap Note Rubric as a guide.
Copyright © 2018 by Elsevier Inc. All rights reserved.
Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests, 6th Edition
Iron-Deficiency Anemia
Case Study
A 72-year-old man developed chest pain whenever he was physically active. The pain ceased on
stopping his activity. He has no history of heart or lung disease. His physical examination was
normal except for notable pallor.
Studies Result
Electrocardiogram (EKG), p. 485 Ischemia noted in anterior leads
Chest x-ray study, p. 956 No active disease
Complete blood count (CBC), p.
156
Red blood cell (RBC) count, p.
396
2.1 million/mm (normal: 4.7–6.1 million/mm)
RBC indices, p. 399
Mean corpuscular volume
(MCV)
72 mm 3 (normal: 80–95 mm
3 )
Mean corpuscular hemoglobin
(MCH)
22 pg (normal: 27–31 pg)
Mean corpuscular hemoglobin
concentration (MCHC)
21 pg (normal: 27–31 pg)
Red blood cell distribution width
(RDW)
9% (normal: 11%–14.5%)
Hemoglobin (Hgb), p. 251 5.4 g/dL (normal: 14–18 g/dL)
Hematocrit (Hct), p. 248 18% (normal: 42%–52%)
White blood cell (WBC) count, p.
466
7800/mm 3 (normal: 4,500–10,000/mcL)
WBC differential count, p. 466 Normal differential
Platelet count (thrombocyte
count), p. 362
Within normal limits (WNL) (normal: 150,000–
400,000/mm 3 )
Half-life of RBC 26–30 days (normal)
Liver/spleen ratio, p. 750 1:1 (normal)
Spleen/pericardium ratio <2:1 (normal)
Reticulocyte count, p. 407 3.0% (normal: 0.5%–2.0%)
Haptoglobin, p. 245 122 mg/dL (normal: 100–150 mg/dL)
Blood typing, p. 114 O+
Iron level studies, p. 287
Iron 42 (normal: 65–175 mcg/dL)
Total iron-binding capacity
(TIBC)
500 (normal: 250–420 mcg/dL)
Transferrin (siderophilin) 200 mg/dL (normal: 215–365 mg/dL)
Transferrin saturation 15% (normal: 20%–50%)
Case Studies
Copyright © 2018 by Elsevier Inc. All rights reserved.
2
Ferritin, p. 211 8 ng/mL (normal: 12–300 ng/mL)
Vitamin B12, p. 460 140 pg/mL (normal: 100–700 pg/mL)
Folic acid, p. 218 12 mg/mL (normal: 5–20 mg/mL or 14–34 mmol/L)
Diagnostic Analysis
The patient was found to be significantly anemic. His angina was related to his anemia. His
normal RBC survival studies and normal haptoglobin eliminated the possibility of hemolysis..
His RBCs were small and hypochromic. His iron studies were compatible with iron deficiency.
His marrow was inadequate for the degree of anemia because his iron level was reduced.
On transfusion of O-positive blood, his angina disappeared. While receiving his third unit of
packed RBCs, he developed an elevated temperature to 38.5°C, muscle aches, and back pain.
The transfusion was stopped, and the following studies were performed:
Studies Results
Hgb, p. 251 7.6 g/dL
Hct, p. 248 24%
Direct Coombs test, p. 157 Positive; agglutination (normal: negative)
Platelet count, p. 362 85,000/mm 3
Platelet antibody, p. 360 Positive (normal: negative)
Haptoglobin, p. 245 78 mg/dL
Diagnostic Analysis
The patient was experiencing a blood transfusion incompatibility reaction. His direct Coombs
test and haptoglobin studies indicated some hemolysis because of the reaction. His platelet count
dropped because of antiplatelet antibodies, probably the same ABO antibodies that caused the
RBC reaction.
He was given iron orally over the next 3 weeks, and his Hgb level improved. A rectal
examination indicated that his stool was positive for occult blood. Colonoscopy indicated a right-
side colon cancer, which was removed 4 weeks after his initial presentation. He tolerated the
surgery well.
Critical Thinking Questions
1. What was the cause of this patient’s iron-deficiency anemia?
2. Explain the relationship between anemia and angina.
3. Would your recommend B12 and Folic Acid to this patient? Explain your rationale for
the answer
4. What other questions would you ask to this patient and what would be your rationale for
them?
,
Copyright © 2018 by Elsevier Inc. All rights reserved.
Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests, 6th Edition
AIDS (Acquired Immunodeficiency Syndrome)
Case Studies
The patient, a 30-year-old homosexual man, complained of unexplained weight loss, chronic
diarrhea, and respiratory congestion during the past 6 months. Physical examination revealed
right-sided pneumonitis. The following studies were performed:
Studies Results
Complete blood cell count (CBC), p. 156
Hemoglobin (Hgb), p. 251 12 g/dL (normal: 14–18 g/dL)
Hematocrit (Hct), p. 248 36% (normal: 42%–52%)
Chest x-ray, p. 956 Right-sided consolidation affecting the posterior
lower lung
Bronchoscopy, p. 526 No tumor seen
Lung biopsy, p. 688 Pneumocystis jiroveci pneumonia (PCP)
Stool culture, p. 797 Cryptosporidium muris
Acquired immunodeficiency syndrome
(AIDS) serology, p. 265
p24 antigen Positive
Enzyme-linked immunosorbent assay
(ELISA)
Positive
Western blot Positive
Lymphocyte immunophenotyping, p. 274
Total CD4 280 (normal: 600–1500 cells/L)
CD4% 18% (normal: 60%–75%)
CD4/CD8 ratio 0.58 (normal: >1.0)
Human immune deficiency virus (HIV)
viral load, p. 265
75,000 copies/mL
Diagnostic Analysis
The detection of Pneumocystis jiroveci pneumonia (PCP) supports the diagnosis of AIDS. PCP is
an opportunistic infection occurring only in immunocompromised patients and is the most
common infection in persons with AIDS. The patient’s diarrhea was caused by Cryptosporidium
muris, an enteric pathogen, which occurs frequently with AIDS and can be identified on a stool
culture. The AIDS serology tests made the diagnoses. His viral load is significant, and his
prognosis is poor.
The patient was hospitalized for a short time for treatment of PCP. Several months after he was
discharged, he developed Kaposi sarcoma. He developed psychoneurologic problems eventually
and died 18 months after the AIDS diagnosis.
Case Studies
Copyright © 2018 by Elsevier Inc. All rights reserved.
2
Critical Thinking Questions
1. What is the relationship between levels of CD4 lymphocytes and the likelihood of
clinical complications from AIDS?
2. Why does the United States Public Health Service recommend monitoring CD4
counts every 3–6 months in patients infected with HIV?
3. This is patient seems to be unaware of his diagnosis of HIV/AIDS. How would you
approach to your patient to inform about his diagnosis?
4. Is this a reportable disease in Florida? If yes. What is your responsibility as a
provider?
.
,
Copyright © 2018 by Elsevier Inc. All rights reserved.
Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests, 6th Edition
Adolescent With Diabetes Mellitus (DM)
Case Studies
The patient, a 16-year-old high-school football player, was brought to the emergency room in a
coma. His mother said that during the past month he had lost 12 pounds and experienced
excessive thirst associated with voluminous urination that often required voiding several times
during the night. There was a strong family history of diabetes mellitus (DM). The results of
physical examination were essentially negative except for sinus tachycardia and Kussmaul
respirations.
Studies Results
Serum glucose test (on admission), p. 227 1100 mg/dL (normal: 60–120 mg/dL)
Arterial blood gases (ABGs) test (on admission),
p. 98
pH 7.23 (normal: 7.35–7.45)
PCO2 30 mm Hg (normal: 35–45 mm Hg)
HCO2 12 mEq/L (normal: 22–26 mEq/L)
Serum osmolality test, p. 339 440 mOsm/kg (normal: 275–300
mOsm/kg)
Serum glucose test, p. 227 250 mg/dL (normal: 70–115 mg/dL)
2-hour postprandial glucose test (2-hour PPG), p.
230
500 mg/dL (normal: <140 mg/dL)
Glucose tolerance test (GTT), p. 234
Fasting blood glucose 150 mg/dL (normal: 70–115 mg/dL)
30 minutes 300 mg/dL (normal: <200 mg/dL)
1 hour 325 mg/dL (normal: <200 mg/dL)
2 hours 390 mg/dL (normal: <140 mg/dL)
3 hours 300 mg/dL (normal: 70–115 mg/dL)
4 hours 260 mg/dL (normal: 70–115 mg/dL)
Glycosylated hemoglobin, p. 238 9% (normal: <7%)
Diabetes mellitus autoantibody panel, p. 186
insulin autoantibody Positive titer >1/80
islet cell antibody Positive titer >1/120
glutamic acid decarboxylase antibody Positive titer >1/60
Microalbumin, p. 872 <20 mg/L
Diagnostic Analysis
The patient’s symptoms and diagnostic studies were classic for hyperglycemic ketoacidosis
associated with DM. The glycosylated hemoglobin showed that he had been hyperglycemic over
the last several months. The results of his arterial blood gases (ABGs) test on admission
indicated metabolic acidosis with some respiratory compensation. He was treated in the
Case Studies
Copyright © 2018 by Elsevier Inc. All rights reserved.
2
emergency room with IV regular insulin and IV fluids; however, before he received any insulin
levels, insulin antibodies were obtained and were positive, indicating a degree of insulin
resistance. His microalbumin was normal, indicating no evidence of diabetic renal disease, often
a late complication of diabetes.
During the first 72 hours of hospitalization, the patient was monitored with frequent serum
glucose determinations. Insulin was administered according to the results of these studies. His
condition was eventually stabilized on 40 units of Humulin N insulin daily. He was converted to
an insulin pump and did very well with that. Comprehensive patient instruction regarding self-
blood glucose monitoring, insulin administration, diet, exercise, foot care, and recognition of the
signs and symptoms of hyperglycemia and hypoglycemia was given.
Critical Thinking Questions
1. Why was this patient in metabolic acidosis?
2. Do you think the patient will eventually be switched to an oral hypoglycemic agent?
3. How would you anticipate this life changing diagnosis is going to affect your patient
according to his age and sex?
4. The parents of your patient seem to be confused and not knowing what to do with this
diagnoses. What would you recommend to them?
,
Copyright © 2018 by Elsevier Inc. All rights reserved.
Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests, 6th Edition
Esophageal Reflux
Case Studies
A 45-year-old woman complained of heartburn and frequent regurgitation of “sour” material into
her mouth. Often while sleeping, she would be awakened by a severe cough. The results of her
physical examination were negative.
Studies Results
Routine laboratory studies Negative
Barium swallow (BS), p. 941 Hiatal hernia
Esophageal function studies (EFS), p. 624
Lower esophageal sphincter (LES)
pressure
4 mm Hg (normal: 10–20 mm Hg)
Acid reflux Positive in all positions (normal: negative)
Acid clearing Cleared to pH 5 after 20 swallows (normal:
<10 swallows)
Swallowing waves Normal amplitude and normal progression
Bernstein test Positive for pain (normal: negative)
Esophagogastroduodenoscopy (EGD), p. 547 Reddened, hyperemic, esophageal mucosa
Gastric scan, p. 743 Reflux of gastric contents to the lungs
Swallowing function, p. 1014 No aspiration during swallowing
Diagnostic Analysis
The barium swallow indicated a hiatal hernia. Although many patients with a hiatal hernia have
no reflux, this patient’s symptoms of reflux necessitated esophageal function studies. She was
found to have a hypotensive LES pressure along with severe acid reflux into her esophagus. The
abnormal acid clearing and the positive Bernstein test result indicated esophagitis caused by
severe reflux. The esophagitis was directly visualized during esophagoscopy. Her coughing and
shortness of breath at night were caused by aspiration of gastric contents while sleeping. This
was demonstrated by the gastric nuclear scan. When awake, she did not aspirate, as evident
during the swallowing function study. The patient was prescribed esomeprazole (Nexium). She
was told to avoid the use of tobacco and caffeine. Her diet was limited to small, frequent, bland
feedings. She was instructed to sleep with the head of her bed elevated at night. Because she had
only minimal relief of her symptoms after 6 weeks of medical management, she underwent a
laparoscopic surgical antireflux procedure. She had no further symptoms.
Critical Thinking Questions
1. Why would the patient be instructed to avoid tobacco and caffeine?
2. Why did the physician recommend 6 weeks of medical management?
Case Studies
Copyright © 2018 by Elsevier Inc. All rights reserved.
2
3. How do antacid medication work in patients with gastroesophageal reflux?
4. What would you approach the situation, if your patient decided not to take the medication
and asked you for an alternative medicine approach?
,
(Student Name)
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C
Soap Note # ____ Main Diagnosis ______________
PATIENT INFORMATION
Name:
Age:
Gender at Birth:
Gender Identity:
Source:
Allergies:
Current Medications:
·
PMH:
Immunizations:
Preventive Care:
Surgical History:
Family History:
Social History:
Sexual Orientation:
Nutrition History:
Subjective Data:
Chief Complaint:
Symptom analysis/HPI:
The patient is …
Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )
CONSTITUTIONAL:
NEUROLOGIC:
HEENT:
RESPIRATORY:
CARDIOVASCULAR:
GASTROINTESTINAL:
GENITOURINARY:
MUSCULOSKELETAL:
SKIN:
Objective Data:
VITAL SIGNS:
GENERAL APPREARANCE:
NEUROLOGIC:
HEENT:
CARDIOVASCULAR:
RESPIRATORY:
GASTROINTESTINAL:
MUSKULOSKELETAL:
INTEGUMENTARY:
ASSESSMENT:
(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data)
Example : “Pt came in to our clinic c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and that etc.)
Main Diagnosis
(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 6th or 7th Edition.
Differential diagnosis (minimum 3)
–
–
–
PLAN:
Labs and Diagnostic Test to be ordered (if applicable)
· –
· –
Pharmacological treatment:
–
Non-Pharmacologic treatment:
Education (provide the most relevant ones tailored to your patient)
Follow-ups/Referrals
References (in APA Style)
Examples
Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).
ISBN 978-0-8261-3424-0
Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010
(25th ed.). Print (The 5-Minute Consult Series).
image1.png
,
Grading Rubric
Student______________________________________
This sheet is to help you understand what we are looking for, and what our margin remarks might be about on your write ups of patients. Since at all of the white-ups that you hand in are uniform, this represents what MUST be included in every write-up.
1) Identifying Data (___5pts): The opening list of the note. It contains age, sex, race, marital status, etc. The patient complaint should be given in quotes. If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number.
2) Subjective Data (___30pts.): This is the historical part of the note. It contains the following:
a) Symptom analysis/HPI(Location, quality , quantity or severity, timing, setting, factors that make it better or worse, and associate manifestations.(10pts).
b) Review of systems of associated systems, reporting all pertinent positives and negatives (10pts).
c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem (10pts). If more than one chief complaint, each should be written u in this manner.
3) Objective Data(__25pt.): Vital signs need to be present. Height and Weight should be included where appropriate.
a) Appropriate systems are examined, listed in the note and consistent with those identified in 2b.(10pts).
b) Pertinent positives and negatives must be documented for each relevant system.
c) Any abnormalities must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe things. (5pts).
4) Assessment (___10pts.): Encounter paragraph and diagnoses should be clearly listed and worded appropriately including ICD10 codes.
5) Plan (___15pts.): Be sure to include any teaching, health maintenance and counseling along with the pharmacological and non-pharmacological measures. If you have more than one diagnosis, it is helpful to have this section divided into separate numbered sections.
6) Subjective/ Objective, Assessment and Management and Consistent (___10pts.): Does the note support the appropriate differential diagnosis process? Is there evidence that you know what systems and what symptoms go with which complaints? The assessment/diagnoses should be consistent with the subjective section and then the assessment and plan. The management should be consistent with the assessment/ diagnoses identified.
7) Clarity of the Write-up(___5pts.): Is it literate, organized and complete?
Comments:
Total Score: ____________ Instructor: __________________________________
Guidelines for Focused SOAP Notes
· Label each section of the SOAP note (each body part and system).
· Do not use unnecessary words or complete sentences.
· Use Standard Abbreviations
S: SUBJECTIVE DATA (information the patient/caregiver tells you).
Chief Complaint (CC): a statement describing the patient’s symptoms, problems, condition, diagnosis, physician-recommended return(s) for this patient visit. The patient’s own words should be in quotes.
History of present illness (HPI): a chronological description of the development of the patient’s chief complaint from the first symptom or from the previous encounter to the present. Include the eight variables (Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Treatment, Severity-OLDCARTS), or an update on health status since the last patient encounter.
Past Medical History (PMH): Update current medications, allergies, prior illnesses and injuries, operations and hospitalizations allergies, age-appropriate immunization status.
Family History (FH): Update significant medical information about the patient’s family (parents, siblings, and children). Include specific diseases related to problems identified in CC, HPI or ROS.
Social History(SH): An age-appropriate review of significant activities that may include information such as marital status, living arrangements, occupation, history of use of drugs, alcohol or tobacco, extent of education and sexual history.
Review of Systems (ROS). There are 14 systems for review. List positive findings and pertinent negatives in systems directly related to the systems identified in the CC and symptoms which have occurred since last visit; (1) constitutional symptoms (e.g., fever, weight loss), (2) eyes, (3) ears, nose, mouth and throat, (4) cardiovascular, (5) respiratory, (6) gastrointestinal, (7) genitourinary, (8) musculoskeletal, (9-}.integument (skin and/or breast), (10) neurological, (11) psychiatric, (12) endocrine, (13) hematological/lymphatic, {14) allergic/immunologic. The ROS should mirror the PE findings section.
0: OBJECTIVE DATA (information you observe, assessment findings, lab results).
Sufficient physical exam should be performed to evaluate areas suggested by the history and patient’s progress since last visit. Document specific abnormal and relevant negative findings. Abnormal or unexpected findings should be described. You should include only the information which was provided in the case study, do not include additional data.
Record observations for the following systems if applicable to this patient encounter (there are 12 possible systems for examination): Constitutional (e.g. vita! signs, general appearance), Eyes, ENT/mouth, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin, Neurological, Psychiatric, Hematological/lymphatic/immunologic/lab testing. The focused PE should only include systems for which you have been given data.
NOTE: Cardiovascular an
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