Why would the patient be instructed to avoid tobacco and caffeine? Why did the physician recommend 6 weeks of medical management?
Follow the MRU Soap Note Rubric as a guide:
Use APA format and must include mia minimum of 2 Scholarly Citations.
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)
Turn it in' s Score must be less than 25% or will not be accepted for credit; it must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 25%. Copy-paste from websites or textbooks will not be accepted or tolerated and will receive a grade of 0 (zero) with no resubmissions allowed.
.
Must use the sample templates for your soap note. Keep this template for when you start clinicals.
The use of templates is ok with regards to Turn it in, but the Patient History, CC, HPI, Assessment, and Plan should be of your own work and individualized to your made-up patient.
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).
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 and Respiratory systems should be assessed on every patient regardless of the chief complaint.
Testing Results: Results of any diagnostic or lab testing ordered during that patient visit.
A: ASSESSMENT: (this is your diagnosis (es) with the appropriate ICD 10 code)
List and number the possible diagnoses (problems) you have identified. These diagnoses are the conclusions you have drawn from the subjective and objective data.
Remember: Your subjective and objective data should support your diagnoses and your therapeutic plan.
Do not write that a diagnosis is to be "ruled out" rather state the working definitions of each differential or primary diagnosis (es).
For each diagnoses provide a cited rationale for choosing this diagnosis. This rationale includes a one sentence cited definition of the diagnosis (es) the pathophysiology, the common signs and symptoms, the patients presenting signs and symptoms and the focused PE findings and tests results that support the dx. Include the interpretation of all lab data given in the case study and explain how those results support your chosen diagnosis.
P: PLAN (this is your treatment plan specific to this patient). Each step of your plan must include an EBP citation.
1. Medications write out the prescription including dispensing information and provide EBP to support ordering each medication. Be sure to include both prescription and OTC medications.
2. Additional diagnostic tests include EBP citations to support ordering additional tests
3. Education this is part of the chart and should be brief, this is not a patient education sheet and needs to have a reference.
4. Referrals include citations to support a referral
5. Follow up. Patient follow-up should be specified with time or circumstances of return. You must provide a reference for your decision on when to follow up.
,
1
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C
Soap Note # ____ Main Diagnosis: Z00.01-Annual Wellness Check up
PATIENT INFORMATION
Name S.N.
Age: 55 yrs
Gender at Birth: Male
Gender Identity: Male
Source: Patient
Allergies: Denies food, environmental, or drug allergy
Current Medications: Denies use of medications. Takes no herbal medicines or supplement
medications.
PMH: He has no history of hospitalizations. Denies chronic illnesses such as cancer, HTN,
psychiatric diseases, asthma, or diabetes.
Immunizations: COVID 19 vaccine on 10/12/2021. He received the influenza vaccine on
5/2021. Tdap booster was given in 2010. He received all childhood immunizations but was
unable to recall the exact dates.
Preventive Care: RBS done on 20/3/2021. B.P. measurements taken on 20/3/2021
Surgical History: No history of recent or previous surgeries.
2
Family History: Raised by biological parents. His mother is 78years and has HTN and diabetes.
Father is 85 years with no chronic illness. His maternal grandfather died at 80 years and had a
history of BPH and HTN.
Social History: He is a small-scale farmer. Married to one wife.Has three children. He neither
smokes nor drinks.
Sexual Orientation: He has one wife, and he is heterosexual
Nutrition History: He takes a balanced diet. He avoids fat-rich diets and processed foods. He
takes a fruit every day in the morning. He drinks seven glasses of water every day. He does not
drink sweetened drinks or coffee.
Subjective Data:
Chief Complaint: "I am feeling great, but I am here for my annual check-up."
Symptom analysis/HPI: The patient's last annual check-up was in May 2021. The patient
reports the absence of any abnormal laboratory or physical findings during that check-up. His
previous eye examination was on October 2021. His last dental review was in November 2021.
Colonoscopy and PSA test were done in January 2018. His previous B.P. screening, Blood Sugar
Screening were done in March 2021. Lip profile tests were done in January 2017. There were no
other current concerns or complaints by the patient.
Review of Systems (ROS
CONSTITUTIONAL: No fatigue, chills, general body weakness, night sweats, or fever
RESPIRATORY: No dyspnea, wheezing, chest pains, or cough
GASTROINTESTINAL: No nausea, abdominal pain, vomiting, or diarrhea
3
NEUROLOGIC: No numbness, loss of consciousness, tingling, or confusion
HEENT: H: no dizziness, headache, or confusion. Eyes: no itching, pain, diplopia, or blurry
vision Ears: no pain, hearing loss, tingling sensation, or discharges Nose: No bleeding, itching,
or discharge o Throat: no sore throat, edema, or voice changes
CARDIOVASCULAR: no chest pains, palpitations,dizzness or edema
GENITOURINARY: no dysuria, discharge, urinary urgency, or hematuria
MUSCULOSKELETAL: no muscle pains, joint swelling, joint pain, or muscle spasms
SKIN: no hives, skin rashes, or hyperpigmentation
Objective Data:
VITAL SIGNS: BP-110/90 mmHg, RR 19, Pulse rate 70b/min . SPo2 is 100%. Height-180cm,
Weight-63kg, computed BMI-22.5
GENERAL APPEARANCE: A white male, seated, alert and well-nourished, with no signs of
respiratory distress. There is no pallor, jaundice, cyanosis, dehydration, edema, or
lymphadenopathy.
NEUROLOGICAL: Normal speechA& O x3, typical gait, no tremors, normal speech, no
cerebellar S/S, or motor-sensory loss.
RESPIRATORY: Chest wall is symmetrical, rises following respiration, no visible masses or
scars, no tenderness, percussion note is tympanic, bilateral entry of air, breath sounds were
normal following auscultation.
4
CARDIOVASCULAR: Normoactive precordium, palpable apical pulse mid-clavicular line at
the 5th ICS, regular H.R., no thrills, no heaves, On auscultation, there were no murmurs, and S1
and S2 were heard.
GASTROINTESTINAL: Flat abdomen, umbilicus everted, moving with respiration, no
masses, no tenderness or organomegaly; warm. Normoactive bowel sounds were heard.
INTEGUMENTARY: Dark, warm, and dry. No rashes, abrasions, lesions, or hives
HEENT: H: Normocephalic, no scars, masses, or bruises. E: Pupils are equal, round, and
reactive to light, with no discharges. E: no ear discharges or impacted wax N: Symmetrical,
patent nasal nares, no discharge or bleeding.
Neck: No distended veins or lymphadenopathy and supple
MUSCULOSKELETAL: No abnormalities, normal gait, normal reflexes, no deformities, and
normal ROM.
ASSESSMENT:
55-year-old S.N. came to our clinical for his annual check-up. There are no current complaints.
His last yearly check-up showed no abnormal findings. His past check-ups were eye exam,
dental exam, Prostate screening, colonoscopy, lipid profile check-up, and B.P. and B.S.
screenings mother has hypertension and diabetes. His maternal grandfather had a history of
hypertension and BPH. On general and physical examination, there were no abnormal findings
noted.
Main Diagnosis
-1. ICD Z00.00- Annual checkup with no abnormal findings.
5
CDC recommends the performance of routine check-ups annually and lab testing to aid in
identifying any health disorders to facilitate early medications and management (CDC,2020).
The patient requires his annual check-up this year.
Preventative Service Task Recommended Screenings:
2. PSA screening-ICD 10 –CM Z12.5. This is essential for screening for malignant cancers of the
prostate.PSA screening is vital in all men above 50 years because of the risk of developing
prostate cancer (Catalona,2018). The patient is at risk of prostate cancer or BPH because of his
old age and a positive family history of BPH.
3. Update for immunization-ICD-10-CM-Z23-which is the encounter for immunization.CDC
recommends that every adult be given a single dose of Tdap and then Td or a booster for Tdap
after ten years (Hibberd,2020). Mr. SN has his immunization updated apart from Tdap.
4. Colonoscopy- ICD 10 -CM Z12.11, which is for encounter for screening for the malignant
cancers of the colon. Colonoscopy is a requirement for individuals above 50 years as it will help
in the early diagnosis of benign or malignant lesions in the rectum or the colon (Saito et
al.,2021).
5. Blood Pressure screening-ICD 10-CM Z01.30 is the encounter for assessing blood pressure
with no abnormal findings. B.P. should be regularly checked in adults above 50 years (Carey et
al.,2018). This patient is at risk of developing HTN because of the positive family of HTN.
6. Blood Sugar Screening- ICD 10-CM R73.09, the code for the HBa1c blood test. This will help
rule out diabetes mellitus and is a requirement for people above 45 years. The patient is at risk of
developing D.M. because of the positive family history.
6
7. Lipid profile Check-ICD 10-CM Z13.220 in assessing lipid metabolism errors, the cholesterol
and lipid-protein levels in the blood (Vijan & Elmore, 2020). CDC recommends that adults
above 20 years have cholesterol check-ups every five years (CDC,2020).
PLAN:
Investigations
-CBC- To investigate the white blood cell differentials, RBC, and platelet
-Urinalysis-To assess any abnormalities in the urine
-UECs-To assess the electrolytes
-Lipid tests-Helps in the assessment of the levels of LDL, cholesterol, T.G.s, and HDL
-ECG and ECHO- To assess the electrical activity of the heart and any heart disorders
-Renal function tests-To assess any kidney problems
-TSH-For assessment of any thyroid disorders.
Education
1. Continue monitoring any health changes, and for any threatening health conditions, call,911
2. Have a physical exercise plan at least exercise four times a week
3. Continue with his diet and maximize taking a balanced diet, more fruits and vegetables, and
drinking seven glasses of water daily.
Follow-ups
7
Advise the patient to return to the hospital after one week to assess his laboratory
findings. He can book an appointment or make a call in case of any health issues. His next
annual check-up is to be scheduled for January 2023.
8
References
Carey, R. M., Whelton, P. K., & 2017 ACC/AHA Hypertension Guideline Writing Committee*.
(2018). Prevention, detection, evaluation, and management of high blood pressure in
adults: synopsis of the 2017 American College of Cardiology/American Heart
Association Hypertension Guideline. Annals of internal medicine, 168(5), 351-358.
https://doi.org/10.7326/M17-3203
Catalona, W. J. (2018). Prostate cancer screening. Medical Clinics, 102(2), 199-214.
https://doi.org/10.1016/j.mcna.2017.11.001
Diphtheria, tetanus, and pertussis vaccine recommendations. (2020). Centers for Disease Control
and Prevention. Retrieved January 31, 2021, from
https://www.cdc.gov/vaccines/vpd/dtap-tdap-td/hcp/recommendations.html
Hibberd, P. L. (2020). Tetanus-diphtheria toxoid vaccination in adults. UpToDate. Retrieved
February 1, 2021, from https://www.uptodate.com/contents/tetanus-diphtheria-toxoid-
vaccination- in-adults
Saito, Y., Oka, S., Kawamura, T., Shimoda, R., Sekiguchi, M., Tamai, N., … & Inoue, H. (2021).
Colonoscopy screening and surveillance guidelines. Digestive Endoscopy, 33(4), 486-
519. https://doi.org/10.1111/den.13972
Vijan, S., & Elmore, J. G. (2020). Screening for lipid disorders in adults. UpToDate. Waltham,
MA: UpToDate. https://www.medilib.ir/uptodate/show/4553
,
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?
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