In addition to Journal Entries, SOAP Note submissions are a way to reflect on your Practicum experiences and connect these experiences to your classroom experience. SOAP Notes, such as the ones required in this course, are often used in clinical settings to document patient care. Please refer to this week’s Learning Resources for guidance on writing SOAP Notes.
Select a patient who you examined during the last 3 weeks. With this patient in mind, address the following in a SOAP Note:
- Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent, as well as possible reasons for these discrepancies.
- Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.
- Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
- Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
- Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?Subjective:
Chief complaint: headaches and blurriness of vision on the right side
History of present illness: the patient is 67 years old Caucasian female, she complains of having had headaches for 2 weeks now. The pain is located in the right temporal area. She describes the pain as 8-10/10, sharp, constant, interferes with her sleep, she states that nothing aggravates it, not even the bright lights or high sounds, but she gets a little relief by taking Ibuprofen 800 mg. She stated that she has been having some blurriness in the right eye, while her left eye is fine. She also complains of pain in her jaw and tongue while chewing food. Her appetite has been low, and lost about 5 pounds in the last 2 weeks. She noticed low grade fever as well. She also reported ringing sounds in the right ear. She denies any nausea or vomiting. She denied having similar headaches in the past. The patient denies complaining of nasal or postnasal drainage.
PMH: past medical history is significant for Hypertension, type II diabetes mellitus, asthma, and degenerative arthritis of the knees.
Medications: Lisinopril 10 mg PO QD
Metformin 500 mg PO BID.
Proair HFA 2 puffs PRN.
Ibuprofen 800 mg TID
By comparing the medications that the patient is taking with Beers criteria, they all looked appropriate to be used in elderly patients.
Father: HTN, diabetes, and stroke.
Mother: HTN, Diabetes, and breast cancer at the age of 72.
Social Hx: the patient never smoked tobacco products.
ETOH: social drinker
Illicit substances: denies ever using illicit drugs.
Review of systems:
Constitutional: the patient complains of fever, fatigue, anorexia, and weight loss.
Head: the patient denies complaining dizziness or lightheadedness.
Eyes: blurriness in the right eye.
Ears: the patient reports tinnitus- right ear, but denies complaining of ear pain or ear discharge
Nose: the patient denies any nasal bleeding, discharge or obstruction
Mouth: the patient reports painful chewing, she denies gingival bleeding, having mouth sores, or having dental difficulties
Throat: no sore throat
Cardiovascular: the patient denies complaining of Chest pain, palpitations, or swelling in the legs.
Respiratory: the patient denies any wheezing, shortness of breath or coughing.
Gastrointestinal: the patient denies any nausea, vomiting, GERD, epigastric pain, diarrhea, constipation, having black stools, or blood in stool.
Genitourinary: the patient denies any dysuria, polyuria, or visible hematuria
Musculoskeletal: bilateral knee pain.
Integumentary (Skin): the patient denies having any skin rash or skin discolorations.
Neurological: the patient denies complaining of tingling or numbness in any extremity; there is no history of seizures, stroke, syncope, or memory changes.
Psychiatric: the patient denies complaining of depression, or anxiety, denies complaining of hallucinations.
Endocrine: the patient denies any cold or heat intolerance, no polyuria
Hematologic/Lymphatic: the patient denies noticing swollen glands in the neck, armpits, or the groin area. She denies easy bruising.
Allergic/Immunologic: no environmental allergens.
Height: 63.00 in
Weight: 191.20 lbs
Blood Pressure: 121/81 mmHg
B/P Side: Left
B/P Position: Sitting
Temperature: 97.40 F
Pulse: 73 beats/min
Resp. Rate: 15
The neurological exam: tenderness in the right temporal area. The patient is alert and orientated to time/place/self-cranial nerves II-XII intact DTRs 2+/4 in the upper and lower extremities. The muscle strength is 5/5 in all 4 extremities.
Cardiovascular: Palpation of the head reveals prominent right temporal artery with weak pulsation, and bruit on auscultation. No JVD was noticed. The heart auscultation: normal S1, and S2, no murmurs, or rubs.
Constitutional: the patient is well groomed, alert and oriented x 3. pt responds appropriate to questions
Eyes ,ears, Nose, Mouth, and Throat: the funduscopic examination showed a swollen pale right disc, while the left one was normal. EOMI: the extraocular eye movements are intact, but the patient reported double visions when she looked to the right side upon doing the finger tracking, the visual acuity using Snellen chart is 20/50 for the right eye and 20/25 for the left eye. The oropharynx is well hydrated, there is no exudates or plaques, the mucous membranes are moist, not erythematous, there are no ulcerations, there are no tongue plaques, no cyanosis, there is no facial droop, the swallowing intact, CNs II-XII grossly intact PEERLA: pupil equal, round, reactive to light and accommodation.
Neck: no lymphadenopathy, no thyromegaly. The cervical spine: there are no tender points, FROM
Respiratory: the patient is not tachypneic, dyspneic, no clubbed fingers were noted, the Lung: no wheezing, crackles, or ralls.
Lymphatic: no palpable lymph nodes in the cervical, axillary or the inguinal areas.
Extremities: I noticed +2 pitting edema extending from the knees to the feet. The peripheral pulse is strong +2 and regular.
The functional assessment was performed too: when the patient was asked about eating, dressing, bathing, transferring between the bed and a chair, using the toilet, controlling bladder and bowel functions, doing housework, preparing meals, taking medications properly, managing finances, using a telephone; she stated that she can perform all these tasks without the needing help. During the examination, the patient was noticed to be able to unbutton and then button up her jacket, take off, and put on her shoes, and climbing up and down the examination table without the help.
Primary diagnosis: Temporal arteritis
Differential diagnosis: .
2. Migraine headaches
3. Acute paranasal sinusitis
4. Polymyalgia rheumatica
5. Brain tumor
6. Granulomatosis with Polyangiitis (Wegener Granulomatosis)
7. Iritis and Uveitis
8. Persistent Idiopathic Facial Pain
9. Retinal Artery Occlusion
10. Retinal Vein Occlusion
Care Plan: CBC, CMP, ESR, and C-reactive protein.
Biopsy of the Carotid artery
Evaluating the patient by an ophthalmologist for Tonometry and evaluation for glaucoma.
Treatment plan: Methylprednisolone 1 gram IV for 3 days, followed by 40-60 mg Prednisone orally, and then starts tapering.
The alternative therapy includes Methotrexate if the patient developed severe side effects to steroids.
And as a caregiver I explained to the patient how important it was to start her on high dosage of steroids, to prevent her from getting blind, and how important was it to get a carotid biopsy, especially after she showed concern about her getting a cut in a major neck vessel.
1. If there was no visual involvement I would put the patient on 40-66 mg oral prednisone.
2. I would order Head CT scan or MRI if the patient had focal neurological findings.
3. Head X ray if there was nasal or postnasal drainage.
For me I understood how serious headache could be. And it was clear to me how taking a thorough history, and physical exam helps in determining what diagnostic tests are needed. And with the collaboration of physicians in different fields of practice we can reach the final diagnosis and helping patient from getting severe irreversible complications.
Making a concise and accessible report will help other professionals to care for the patient effectively even if some of the symptoms are no longer present. It would be beneficial to facilitate clear channel relationships with the other professionals or teams that will be involved in caring for the patient and avoid the stereotypes that are commonly held about other health care professions involved. Furthermore, to improve interprofessional collaboration, as part of patient report update, I could utilize visual layouts to convey some of my findings and try to communicate in necessary ways to different groups within a team (Ross, King & Firth, 2005)
Ross, A., King, N., & Firth, J. (2005). Interprofessional relationships and collaborative working: encouraging reflective practice. Online Journal of issues in Nursing, 10(1).
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