Soap Note 2 ‘Acute Sinusitis’
Discussion Topic: Soap Note 2 "Acute Sinusitis"
Requirements
– The discussion must address the topic
– Rationale must be provided
– Use at least 600 words (no included 1st page or references in the 600 words)
– May use examples from your nursing practice
– Formatted and cited in current APA 7
– Use 3 academic sources, not older than 5 years. Not Websites are allowed.
– Plagiarism is NOT permitted
I have attached a SOAP note template, a sample, and the rubric.
Soap Note # ____ Main Diagnosis ______________
PATIENT INFORMATION
Name:
Age:
Gender at Birth:
Gender Identity:
Source:
Allergies:
Current Medications:
1.
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 7th Edition.
Differential diagnosis (minimum 4)
–
–
PLAN:
Labs and Diagnostic Test to be ordered (if applicable)
1. –
1. –
Pharmacological treatment:
–
Non-Pharmacologic treatment:
Education (provide the most relevant ones tailored to your patient)
Follow-ups/Referrals
References (in APA Style)
,
Student’s Name
Miami Regional University
Date of Encounter: Mo/day/year
Preceptor/Clinical Site: MSN5600L Class
Clinical Instructor: Patricio Bidart MSN, APRN-IP, FNP-C
Soap Note # _____ Main Diagnosis: Dx: Herpes Zoster
PATIENT INFORMATION
Name: Ms. GP
Age: 78
Gender at Birth: Female
Gender Identity: Female
Source: Patient
Allergies: Peanut. Iodine
Current Medications:
Insulin Lantus 100 u/ml 15 unit in the morning and at bedtime
Metformin 500 mg 1 tablet PO once a day
Atorvastatin 20 mg 1 tablet PO at bedtime
PMH:
Diabetes mellitus type II
Hyperlipidemia
Varicella (Chickenpox) at the age of 20 year-old
Immunizations: Flu vaccine in 2020, Covid -19 (Pfizer) in 2021
Preventive Care: Wellness exam on 03/2021
Surgical History: appendicectomy 20 years ago
Family History: daughter 48 years old / hyperlipidemia
Social History: Patient is widow, lives with her daughter. Catholic religion. No alcohol. No
smoker. No history of drug used, sedentary lifestyle. Does not work.
Sexual Orientation: Straight
Nutrition History: Regular diet, low in carbohydrates and fat.
Subjective Data:
Chief Complaint: I have been feeling itching and pain on my right lower back” started 3 day
ago.
Symptom analysis/HPI: The patient is Ms. GP is 78-year-old Hispanic woman, who is
complaining about itching, pain or tingling on her right lower back. Patient stated that 3 days ago
she started to feel an increase in burning sensation on the area taking all right lower back and
don’t relieve the pain with analgesic, she stated that wear any clothes that touch the area is very
uncomfortable. Denies any episodes of fever but she feels fatigue and chills and mild headache.
She stated that today in the morning she feel worse and noted some redness in the area and
decided to come to the clinic to PCP evaluation.
Review of Systems (ROS)
CONSTITUTIONAL: fatigue, chills, denies weakness, no thirsty, no loss of weight. No fever.
NEUROLOGIC: mild headache, no dizziness, no changes in LOC, no loss of strength or
weakness/paresis/paralysis on extremities, no Hx of tremors or seizures.
HEENT: denies any head injury, denies any pain
Eyes: patient denies blurred vision, no diplopia, no wear glasses for reading
Ears: patient denies tinnitus, ear pain, no ear drainage through ear canal.
Nose: no presence of nasal obstruction, no nasal discharge, denies nasal bleeding. (No
epistaxis)
Throat: no sore throat, no hoarse voice, no difficult to swallow
RESPIRATORY: patient denies shortness of breath, cough, expectoration, or hemoptysis.
CARDIOVASCULAR: patient denies chest pain, tachycardia. No orthopnea or paroxysmal
nocturnal dyspnea.
GASTROINTESTINAL: patient denies abdominal pain or discomfort. Denies flatulence,
nausea, vomiting or diarrhea. (BM pattern) every other day, last BM: today, no rectal bleeding
visible for her.
GENITOURINARY: patient denies polyuria, no dysuria, no burning urination, no hematuria, no
lumbar pain, no urinary incontinence.
MUSCULOSKELETAL: denies falls or pain. Denies hearing a clicking or snapping sound
SKIN: patient states itching, pain, or tingling sensation on her right lower back.
HEMO/LYMPH/ENDOCRINE: glands swelling on groin, denies bruising or abnormal
bleeding.
PSYCHIATRIST: patient denies anxiety, depression, denies hallucinations or delusions, no
mood changes
Objective Data:
VITAL SIGNS:
Temperature: 98.4 °F, Pulse: 82x ‘, BP: 122/71 mm hg, RR 19, PO2-97% on room air, Ht- 5’3”,
Wt 164 lb, BMI 30.2. Report pain 6/10.
GENERAL APPREARANCE: Adult, female. Alert and oriented x 3.
NEUROLOGIC: Alert, oriented to person, place, and time. Cranial nerves from I to XII intact.
Sensation intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5. Pupil
normal in size and equal. Deep tendon reflex presents.
HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no
tenderness.
Eyes: No conjunctival injection, no icterus, visual acuity, and extraocular eye movements
intact. No nystagmus noted. Wear glasses.
Ears: BL external canal pattern, permeable, no redness, no drainage, tympanic membrane
intact, pearly gray with sharp cone of light. No pain or edema noted.
Nose: Nasal mucosa normal. No irritations.
Mouth: oral mucosa pink, tongue central, papillaes normal distributed, no lesions
detected, present of upper and lower denture, fitting properly. Lips with no lesions.
Neck: No lymphadenopathy noted. No jugular vein distention. No thyroid swelling or
masses, no thrills on auscultation.
CARDIOVASCULAR: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary
refill < 2 sec. Peripheral pulses present and symmetric. No edema on BLE.
RESPIRATORY: Lungs sounds clear. Chest wall symmetric and no deformities, no intercostal
retractions, patient no noticed dyspnea, no orthopnea. No egophony, no pectoriloquy, no fremitus
or sign of condensation tissue on palpation. Resonance equal in both hemithorax. Lungs: breath
sounds present and clear on auscultation, no rales, no wheezing, no rhonchi.
GASTROINTESTINAL: Abdomen soft and non-tender. Continent to BB. Bowel sounds
present in all four quadrants; no bruits present over aortic or renal arteries. Last BM today.
GENITOURINARY: Costovertebral angles non-tenders, kidneys no palpable. External
genitalia present, no enlargement, no tumors palpable. Groins area noted with redness.
MUSKULOSKELETAL: No pain to palpation. Active and passive ROM within normal limits,
no stiffness.
INTEGUMENTARY: painful redness rash, with crops of vesicles on an erythematous base
with a few satellite lesions in linear distribution, do not cross midline, some of the blisters are
filled with purulent fluids and other are crusted. Area is swollen and redness.
ASSESSMENT:
Patient Ms. GP is 78-year-old Hispanic woman with Hx of DM Type II and Hyperlipidemia,
came into our clinic today complaining about itching, pain and tingling on her right lower back
starting 3 days ago. During the physical exam was noted painful redness rash, with crops of
vesicles on an erythematous base with a few satellite lesions in linear distribution, which do not
cross midline. Diagnosis is based on the clinical evaluation through history and physical
examination. According to patient presentation, signs and symptoms patient is diagnosed with
herpes zoster. Patients falls into the high risk group based on Buttaro (2017). Herpes zoster is
viral infection that occurs with reactivation of the varicella-zoster virus and the patient referred
has history of Chickenpox when she was 20 years old.
Main Diagnosis
Herpes Zoster (ICD10 B02.9): Herpes zoster is infection that results when varicella-zoster virus
reactivates from its latent state in a posterior dorsal root ganglion. Symptoms usually begin with
pain along the affected dermatome, followed within 2 to 3 days by a vesicular eruption that is
usually diagnostic. (Domino, Baldor, Golding, &Stephens,2017).
Other diagnosis:
Diabetes mellitus type II. (ICD-10 E11.9)
Hyperlipidemia. (ICD-10 E78.5)
Differential diagnosis
Irritant contact dermatitis (ICD10 L24)
Impetigo. (ICD10 L01.0)
Varicella. (ICD 10 B01)
Dermatitis herpetiformis. (ICD10 L13.0)
PLAN:
Labs and Diagnostic Test to be ordered (if applicable)
Viral culture, polymerase chain reaction for VZV
Pharmacological treatment:
Valtrex 1 gm TID x 7 days ideally during the prodrome, and is less likely to be effective if
given > 72 hours after skin lesions appear,
VZV vaccine
Pain-reliever NSAIDs
Management of post herpetic neuralgia (Treatments include gabapentin, pregabalin)
Continue with current medication for chronic condition:
Insulin Lantus 100 u/ml 15 unit in the morning and at bedtime
Metformin 500 mg 1 tablet PO once a day
Atorvastatin 20 mg 1 tablet PO at bedtime
Non-Pharmacologic treatment:
Do not scratch the area with dirty hands. Use lotion like calamine to refresh the area.
Keep the area clean and dry.
Education
Isolation precaution – Type Contact
Avoid contact with susceptible person like pregnancy woman, kids and
Immunocompromised patient.
Education about hand washing.
Avoid ABT cream.
Follow-ups/Referrals
Follow up appointment 2 weeks / No referral needed at this time
Call if the symptoms are worse or you noticed any adverse reaction.
References
Buttaro, T. M., Trybulski, J. A., Polgar-Bailey, P., & Sandberg-Cook, J. (2017). Primary care: a
collaborative practice. St. Louis, MO: Elsevier.
Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Clinical Consult 2017
(25th ed.). Print (The 5-Minute Consult Series).
McCance, K. L., & Huether, S. E. (2019). Pathophysiology: the biologic basis for disease in
adults and children. St. Louis, MO: Elsevier.
,
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 (5/5pts): 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 (30/30pts.): 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.(10/10pts).
b) Review of systems of associated systems, reporting all pertinent positives and negatives (10/10pts).
c) Any PMH, family hx, social hx, allergies, and medications related to the complaint/problem (10/10pts). If more than one chief complaint, each should be written u in this manner.
3)Objective Data(25/25pt.): 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.(10/10pts).
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. (5/5pts).
4)Assessment (10/10pts.): Diagnoses should be clearly listed and worded appropriately. REMEMBER NEED TO USE A ICD 10 CODE FOR ENCOUNTER
5)Plan (15/15pts.): 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 (10/10pts.): 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(5/5pts.): Is it literate, organized and complete? Remember to use APA when doing any type of writing or papers at the Nursing Graduate level.
Comments:
Total Score:
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