Episodic/Focused   SOAP Note Exemplar (pls use this template)
 

Focused   SOAP Note for a patient with chest pain

 S.
  CC: Chest pain
 

  HPI: The patient is a 65 year old AA male who developed sudden onset of   chest pain, which began early this morning.  The pain is described as   crushing and is rated nine out of 10 in terms of intensity. The pain is   located in the middle of the chest and is accompanied by shortness of breath.   The patient reports feeling nauseous. The patient tried an antacid with   minimal relief of his symptoms.
 

  PMH: Positive history of GERD and hypertension is controlled
 

  FH: Mother died at 78 of breast cancer; Father at 75 of CVA.  No   history of premature cardiovascular disease in first degree relatives.
 

  SH : Negative for tobacco abuse, currently or previously; consumes   moderate alcohol; married for 39 years
 

  ROS   
General–Negative for fevers,   chills, fatigue
Cardiovascular–Negative for   orthopnea, PND, positive for intermittent lower extremity edema
Gastrointestinal–Positive for   nausea without vomiting; negative for diarrhea, abdominal pain
Pulmonary–Positive for   intermittent dyspnea on exertion, negative for cough or   hemoptysis  

O.

VS:   BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70

General–Pt appears diaphoretic and anxious

Cardiovascular–PMI is in the 5th inter-costal   space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is   heard best at the

second   right inter-costal space which radiates to the neck.

A   third heard sound is heard at the apex. No fourth heart sound or rub are   heard. No cyanosis, clubbing, noted, positive for bilateral 2+ LE edema is   noted.

Gastrointestinal–The abdomen is symmetrical   without distention; bowel

sounds   are normal in quality and intensity in all areas; a

bruit   is heard in the right para-umbilical area. No masses or

splenomegaly   are noted. Positive for mid-epigastric tenderness with deep palpation.

Pulmonary— Lungs are clear to   auscultation and percussion bilaterally 

Diagnostic   results: EKG, CXR, CK-MB (support with evidenced and guidelines)

A.

Differential   Diagnosis:

1)   Myocardial Infarction (provide supportive documentation with evidence based   guidelines).

2)   Angina (provide supportive documentation with evidence based guidelines).

3)   Costochondritis (provide supportive documentation with evidence based   guidelines).

Primary   Diagnosis/Presumptive Diagnosis: Myocardial Infarction

P. This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

Assignment 1: Case Study Assignment: Assessing Neurological Symptoms

Case #2: 

CASE STUDY 2: Numbness and Pain A 47-year-old obese female complains of pain in her right wrist, with tingling and numbness in the thumb and index and middle fingers for the past 2 weeks. She has been frustrated because the pain causes her to drop her hair-styling tools

Imagine not being able to form new memories. This is the reality patients with anterograde amnesia face. Although this form of amnesia is rare, it can result from severe brain trauma. Anterograde amnesia demonstrates just how impactful brain disorders can be to a patient’s quality of living. Accurately assessing neurological symptoms is a complex process that involves the analysis of many factors.

In this Case Study Assignment, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.

To Prepare

 You will be assigned to a specific case study for this Case Study Assignment (Please see Above)

Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format( as in exampler above) rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.

With regard to the case study you were assigned:

Review this week’s Learning Resources, and consider the insights they provide about the case study.

Consider what history would be necessary to collect from the patient in the case study you were assigned.

Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?

Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

The Case Study Assignment

Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided ( ABOVE). Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each. 

Resource for references

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

• Chapter 7, Mental Status

       This chapter revolves around the mental status evaluation of an      individuals overall cognitive state. The chapter includes a list of      mental abnormalities and their symptoms.

• Chapter 23, Neurologic System

       The authors of this chapter explore the anatomy and physiology of the      neurologic system. The authors also describe neurological examinations and      potential findings.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

• Chapter 2, “The Comprehensive History      and Physical Exam” (“Cranial Nerves and Their Function” and      “Grading Reflexes”) (Previously read in Weeks 1, 2, 3, and 5)

This article reviews the use of electrocenographs (EEG) to assist in differential diagnoses. The authors provide differential diagnostic scenarios in which the EEG was useful.