Focused SOAP Note Discussion Paper

Focused SOAP Note Discussion Paper

Patient Information:

Mrs. L, 68 y.o., Caucasian, Female

S

CC (chief complaint): tiredness, weakness and “I can’t catch my breath sometimes.”

HPI: Mrs. L., a 68-year-old Caucasian female, came to the facility with a report of persistent exhaustion, as well as unusual feelings of weakness and difficulty breathing. She claims that she has to catch her breath from time to time. She claims to be generally healthy, with the exception of having high cholesterol, which she presently manages with Lipitor. She relates her symptoms to the untimely death of her spouse, which occurred nine months ago, but believes that they are becoming worse as time goes by Focused SOAP Note Discussion Paper.

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Current Medications: Lipitor

Allergies: None.

PMHx: Last Tetanus booster 2017. All other age-appropriate vaccinations are current.

Soc and Substance Hx: Mrs. L., is a widow of 9 months. She is a retired a retired teacher.  She lives alone but has two daughters who live nearby. Denies tobacco, alcohol, and illicit drug use.

Fam Hx: Mother- 87 years old- diabetes type 2. Father- passed away at 72, medical history of hypertension and hyperlipidemia.

Surgical Hx: Appendectomy in childhood; hysterectomy for uterine myoma 10 years ago.

Mental Hx: No Hx. of mental health. No past or current SI/HI. No Hx. depression or anxiety.

Violence Hx: Denies any current or past physical, sexual, or emotional abuse. Feels safe at home.

Reproductive Hx: LMP 14 years ago. Currently not sexually active Focused SOAP Note Discussion Paper.

 

ROS:

GENERAL: Positive for weight loss of 10 pounds in 9 months. Reports feeling fatigued. Denies fever, chills, and night sweats.

HEENT:

• Eyes: No visual loss, blurred vision, double vision or yellow sclerae.
• Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

CARDIOVASCULAR: CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY: Denies shortness of breath, cough or sputum.

GASTROINTESTINAL: Denies anorexia, nausea, vomiting or diarrhea. Denies abdominal pain or blood.

GENITOURINARY: Denies recent changes in urinary habits. Denies urinary frequency, urgency or dysuria. Denies nocturia, urinary incontinence, and hematuria.

ALLERGIES: No history of asthma, hives, eczema or rhinitis Focused SOAP Note Discussion Paper.

O

 

Physical exam:

General: Slender, quiet-spoken older woman looking fatigued. Afebrile, BP 106/70, HR 98 and regular, RR 18. BMI 22.

HEENT:

Head- Normocephalic, atraumatic, and symmetrical. No lesions or masses. Normal hair distribution.

Eyes- Visual fields equal bilaterally. Pale and moist conjunctiva pale. PERRLA. No swelling, redness, or discharge.

Ears: Intact and symmetrical bilaterally. Intact tympanic membranes bilaterally. Tympanic membranes pearly, no fluid or swelling noted.

Nose- Atraumatic. Intact and symmetrical. Bilateral nares patent. No rhinorrhea. Moist and pink nasal        turbinate bilaterally.

Throat: Intact, moist, and pale mucous membranes. Tongue pale and smooth. No post-nasal discharge. No purulent exudate. No  tonsillar or cervical lymph node swelling.

Skin: Intact, cool, and pale. No masses, rashes, or lesions noted. Pale nail beds. Brittle nails.

Cardiovascular: Heart tachyarrhythmia. Regular S1, S2. Soft mid-systolic murmur. No rub or gallop. No carotid bruit or thrill.

Respiratory: Positive dyspnea with exertion. Chest expansion symmetrical. Lungs clear to auscultation  bilaterally. No wheezing, rales, or rhonchi. No crackles, pleural rub, or adventitious sounds. Normal tactile fremitus.

Gastrointestinal: Flat and soft abdomen. No tenderness. Bowel sounds normoactive x4. No organomegaly or splenomegaly. No hematemesis Focused SOAP Note Discussion Paper.

Diagnostic results:

Colonoscopy- Neoplasm of colon

Urine dispstick- Negative

A:

Differential diagnoses:

• Iron Deficiency Anemia- When iron deficiency anemia occurs, the main clinical manifestations include exhaustion and shortness of breath (Miller, 2013).
• Anemia of Chronic Disease- As the most prevalent hematological presentation of cancer, this condition might emerge as a primary outcome of a neoplasm (Madeddu al. 2018).
• Takotsubo Cardiomyopathy- Shortness of breath is a symptom that may accompany this illness, with emotional stress serving as a significant triggering component (Amin et al., 2020).

P:

For Mrs. L, the goal is for her to get optimum nutrition while maintaining her electrolyte and fluid and electrolyte equilibrium. Assigning her a counselor, encouraging her to joining support networks, or meditation may all help her cope with her anxiety. Following the findings of her coloscopy, we will refer her for a metastatic workup, which will include chest x-rays as well as abdominal computed tomography scan (Burz et al., 2019). Some of Mrs. L’s differential diagnoses might need surgical intervention, thus I would plan on referring her to a gastroenterologist for additional evaluation and therapy. In one month, after visiting the gastroenterologist and performing the suggested tests I scheduled, I would advise her to return to clinic.

Reflection

Following the analysis of this given scenario, I have learnt that a variety of variables influence individuals’ hematologic state, and that symptoms of such illnesses may present themselves in a variety of bodily functions. Aside from that, I gained an understanding of the relevance of several laboratory tests in the evaluation of anemia. Because numerous variables including nutrition, recent blood donation, transfusion, or loss may all play a part in this condition, it is critical to gather a thorough history and physical from such individuals Focused SOAP Note Discussion Paper.

References

Amin, H. Z., Amin, L. Z., & Pradipta, A. (2020). Takotsubo Cardiomyopathy: A Brief Review.

Journal of medicine and life, 13(1), 3–7. https://doi.org/10.25122/jml-2018-0067

Burz, C., Cismaru, A., Pop, V., & Bojan, A. (2019). Iron-deficiency anemia. Iron Deficiency Anemia. https://doi.org/10.5772/intechopen.80940

Madeddu, C., Gramignano, G., Astara, G., Demontis, R., Sanna, E., Atzeni, V., & Macciò, A. (2018). Pathogenesis and Treatment Options of Cancer Related Anemia: Perspective for a Targeted Mechanism-Based Approach. Frontiers in physiology, 9, 1294. https://doi.org/10.3389/fphys.2018.01294

Miller J. L. (2013). Iron deficiency anemia: a common and curable disease. Cold Spring Harbor perspectives in medicine, 3(7), a011866. https://doi.org/10.1101/cshperspect.a011866

Focused SOAP Note Template

 

Patient Information:

Initials, Age, Sex, Race

S (subjective)

CC (chief complaint): a BRIEF statement identifying why the patient is here, stated in the patient’s own words (for instance “headache,” NOT “bad headache for 3 days”).

HPI (history of present illness): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example: Focused SOAP Note Discussion Paper

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• Location: Head
• Onset: 3 days ago
• Character: Pounding, pressure around the eyes and temples
• Associated signs and symptoms: Nausea, vomiting, photophobia, phonophobia
• Timing: After being on the computer all day at work
• Exacerbating/relieving factors: Light bothers eyes; Aleve makes it tolerable but not completely better
• Severity: 7/10 pain scale

Current Medications: Include dosage, frequency, length of time used, and reason for use; also include over the counter (OTC) or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately, including a description of what the allergy is (i.e., angioedema, anaphylaxis, etc.). This will help determine a true reaction versus intolerance.

PMHx: Include immunization status (note date of last tetanus for all adults), past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed.

Soc and Substance Hx: Include occupation and major hobbies, family status, tobacco and alcohol use (previous and current use), and any other pertinent data. Always add some health promo question here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx: Illnesses with possible genetic predisposition, contagious, or chronic illnesses. Reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

Surgical Hx: Prior surgical procedures.

Mental Hx: Diagnosis and treatment. Current concerns (anxiety and/or depression). History of self-harm practices and/or suicidal or homicidal ideation.

Violence Hx: Concern or issues about safety (personal, home, community, sexual (current and historical).

Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse (oral, anal, vaginal, other, any sexual concerns).

ROS (review of symptoms): Cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: Focused SOAP Note Discussion Paper

• General:
• Head:
• EENT (eyes, ears, nose, and throat):
• :

Note: You should list these in bullet format, and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT:

• Eyes: No visual loss, blurred vision, double vision or yellow sclerae.
• Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination. Last menstrual period (LMP), MM/DD/YYYY.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.

HEMATOLOGIC: No anemia, bleeding or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

REPRODUCTIVE: Not pregnant and no recent pregnancy. No reports of vaginal or penile discharge. Not sexually active.

ALLERGIES: No history of asthma, hives, eczema or rhinitis.

O (objective)

Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format (i.e., General: Head: EENT: etc.).

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)Focused SOAP Note Discussion Paper.

A (assessment)

Differential diagnoses: List a minimum of three differential diagnoses. Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.

P (plan)

Includes documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, and any planned follow up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.

Also included in this section is the reflection. Reflect on this case, and discuss what you learned, including any “aha” moments or connections you made.

Also include in your reflection, a discussion related to health promotion and disease prevention taking into consideration patient factors (such as, age, ethnic group, etc.), PMH, and other risk factors (e.g., socio-economic, cultural background, etc.).

References

You are required to include at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting Focused SOAP Note Discussion Paper