Description
SOAP Note
This assignment will demonstrate your ability to provide age-appropriate anticipatory guidance while recognizing the need to refer patients that are outside of the scope of practice of the family nurse practitioner. This will be demonstrated by completing a SOAP note based on the virtual reality patient you evaluated in Unit 4.
HERE IS ALL THE PATIENT INFORMATION NEEDED.
Ms. Cassie Fisher, 52 y/o female, has come in today with complaints of abdominal pain. Vital signs: T 98.8°F, BP 138/84, HR 92/min, RR 16/min, Weighs 150 lb. [University of Cincinnati]
Alleviating factors:
“I started taking Ibuprofen when the pain first started. It helped a little at first, but over the past couple of days, it hasn’t really helped. I keep taking them because I am not sure how bad the pain would get if I stop.”
Married and divorced twice, not currently in a relationship.
Does not drink alcohol has been sober for 12 years.
Smokes half to a pack a day.
Lives alone.
Occupation:
“I am a professional actor, my current play is on hiatus in London but I am expected back next week. I’m in the revival of Fame right now, playing the voice instructor.”
Medications she takes :
“I am taking Simvastatin, Glyburide, Metformin, Lithium, and Quetiapine. I’m also taking a couple of vitamins and Advil.”
Medical history :
“Once a year I see my general physician. I regularly see my psychiatrist and talk to an AA coundelor.”
Children:
Has 2 children.
Surgical History:
“I had an abdominal hysterectomy 5 years ago, no other surgeries.”
Physical Exam: You are only assessing
Cardiovascular
Respiratory
GI palpation
GI auscultation
Diagnostics:
Labs: CBC, CMP, Lipase, Imaging(CT scan)(X-Ray of abdomen)
Management:
Orders/Treatments – anti-emetrics
Orders/Treatments – alternative NSAID
Consult
Follow Up
Health Promotion
Lead differential: Pancretitis
Lead diagnosis: Biliary Colic
Write-ups
The SOAP note serves several purposes:
It is an important reference document that provides concise information about a patient’s history and exam findings at the time of patient visit.
It outlines a plan for addressing the issues which prompted the office visit. This information should be presented in a logical fashion that prominently features all of the data that’s immediately relevant to the patient’s condition.
It is a means of communicating information to all providers who are involved in the care of a particular patient.
It allows the NP student an opportunity to demonstrate their ability to accumulate historical and examination-based information, make use of their medical knowledge, and derive a logical plan of care.
Knowing what to include and what to leave out will be largely dependent on experience and your understanding of illness and pathophysiology. If, for example, you were unaware that chest pain is commonly associated with coronary artery disease, you would be unlikely to mention other coronary risk-factors when writing the history. As you gain experience, your write-ups will become increasingly focused. You can accelerate the process by actively seeking feedback about all the SOAP notes that you create, as well as by reading those written by more experienced practitioners.
The core aspects of the SOAP note are described in detail below.
For ease of learning, a SOAP Note Template ATTACHED FILE BELOW has been provided. For this assignment, proper citation and referencing is required because this is an academic paper.
S: Subjective information. Everything the patient tells you. This includes several areas including the chief complaint (CC), the history of present illness (HPI), medical history, surgical history, family history, social history, medications, allergies, and other information gathered from the patient. A commonly used mnemonic to explore the core elements of the history of present illness (HPI) is OLDCARTS, which includes: Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Treatments, and Severity.
O: Objective is what you see, hear, feel or smell. Your physical exam including vital signs.
A: Assessment/Your differentials
P: Plan of care including health promotion and disease prevention for the patient related to their age and gender.
ASSIGNMENT MUST BE APA FORMAT AND MUST HAVE AT LEAST 3 REFERENCES.
Unformatted Attachment Preview
Name:
Pt. Encounter Number:
Date:
Age:
SUBJECTIVE
CC:
Reason given by the patient for seeking medical care “in quotes”
Sex:
HPI:
Describe the course of the patient’s illness, including when it began, character of symptoms,
location where the symptoms began, aggravating or alleviating factors, pertinent positives and
negatives, other related diseases, past illnesses, and surgeries or past diagnostic testing related
to the present illness.
Medications: (List with reason for med )
Allergies: (List with reaction)
Medication Intolerances:
Past Medical History:
Chronic Illnesses/Major traumas
Hospitalizations/Surgeries
“Have you ever been told that you have diabetes, HTN, peptic ulcer disease, asthma, lung
disease, heart disease, cancer, TB, thyroid problems, kidney problems, or psychiatric diagnosis?”
Family History
Does your mother, father, or siblings have any medical or psychiatric illnesses? Is anyone
diagnosed with: lung disease, heart disease, HTN, cancer, TB, DM, or kidney disease?
Social History
Education level, occupational history, current living situation/partner/marital status, substance
use/abuse, ETOH, tobacco, and marijuana. Safety status
ROS Student to ask each of these questions to the patient: “Have you had any…..”
General
Cardiovascular
Weight change, fatigue, fever, chills, night
Chest pain, palpitations, PND, orthopnea, and
sweats, and energy level
edema
Skin
Delayed healing, rashes, bruising, bleeding or
skin discolorations, and any changes in lesions
or moles
Respiratory
Cough, wheezing, hemoptysis, dyspnea,
pneumonia hx, and TB
Eyes
Corrective lenses, blurring, and visual changes
of any kind
Gastrointestinal
Abdominal pain, N/V/D, constipation, hepatitis,
hemorrhoids, eating disorders, ulcers, and
black, tarry stools
Ears
Ear pain, hearing loss, ringing in ears, and
discharge
Genitourinary/Gynecological
Urgency, frequency burning, change in color of
urine.
Contraception, sexual activity, STDs
Female: last pap, breast, mammo, menstrual
complaints, vaginal discharge, pregnancy hx
Male: prostate, PSA, urinary complaints
Nose/Mouth/Throat
Sinus problems, dysphagia, nose bleeds or
discharge, dental disease, hoarseness, and
throat pain
Musculoskeletal
Back pain, joint swelling, stiffness or pain,
fracture hx, and osteoporosis
Breast
SBE, lumps, bumps, or changes
Neurological
Syncope, seizures, transient paralysis,
weakness, paresthesias, and black-out spells
Psychiatric
Depression, anxiety, sleeping difficulties,
suicidal ideation/attempts, and previous dx
Heme/Lymph/Endo
HIV status, bruising, blood transfusion hx, night
sweats, swollen glands, increase thirst,
increase hunger, and cold or heat intolerance
OBJECTIVE
Weight
BMI
Temp
BP
Height
Pulse
Resp
General Appearance
Healthy-appearing adult female in no acute distress. Alert and oriented; answers questions
appropriately. Slightly somber affect at first and then brighter later.
Skin
Skin is brown, warm, dry, clean, and intact. No rashes or lesions noted.
HEENT
Head is normocephalic, atraumatic, and without lesions; hair evenly distributed. Eyes: PERRLA.
EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly gray
with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal
turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no
occipital nodes. No thyromegaly or nodules. Oral mucosa, pink and moist. Pharynx is
nonerythematous and without exudate. Teeth are in good repair.
Cardiovascular
S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs. Capillary refills
two seconds. Pulses 3+ throughout. No edema.
Respiratory
Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.
Gastrointestinal
Abdomen obese; BS active in all the four quadrants. Abdomen soft, nontender. No
hepatosplenomegaly.
Breast
Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of
the skin.
Genitourinary
Bladder is nondistended; no CVA tenderness. External genitalia reveals coarse pubic hair in
normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted.
Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no
lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On
bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly
distended bladder; no fullness, masses, or tenderness. No adnexal masses or tenderness.
Ovaries are nonpalpable.
(Male: Both testes are palpable, no masses or lesions, no hernia, and no uretheral discharge.)
(Rectal as appropriate: No evidence of hemorrhoids, fissures, bleeding, or masses—Males:
Prostrate is smooth, nontender, and free from nodules, is of normal size, and sphincter tone is
firm).
Musculoskeletal
Full ROM seen in all four extremities as the patient moved about the exam room.
Neurological
Speech clear. Good tone. Posture erect. Balance stable; gait normal.
Psychiatric
Alert and oriented. Dressed in clean slacks, shirt, and coat. Maintains eye contact. Speech is soft,
though clear and of normal rate and cadence; answers questions appropriately.
Lab Tests
Urinalysis—point of care test done today in the office- results positive for nitrites and blood,
negative for leukocytes.
Urine culture collected in office—pending results, sent to lab
Wet prep collected in office—pending results, sent to lab
Assessment
o
Include at least three differential diagnoses
Provide rationale for each differential diagnosis
▪
o
Final diagnosis
Pathophysiology of primary and rationale for choosing as final
▪
Plan
o
o
o
o
o
o
o
o
Medications
Non-pharmacological recommendations
Diagnostic tests
Patient education
Culture considerations
Health promotion
Referrals
Follow up
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