Soap Note 1 Acute Conditions (15 Points)
asthma
Pick any Acute Disease from Weeks 1-5 (see syllabus)
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)
Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement.
Late Assignment Policy
Assignments turned in late will have 1 point taken off for every day assignment is late, after 7 days assignment will get grade of 0. No exceptions
Follow the MRU Soap Note Rubric as a guide:
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).
4) Assessment (___10pts.): Diagnoses should be clearly listed and worded appropriately.
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: __________________________________
Soap Note 1 Acute Conditions
Follow the MRU Soap Note Rubric as a guide:
Use APA format and must include minimum of 2 Scholarly Citations.
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)
Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement.
Please use the sample templates for you soap note, keep these templates for when you start clinicals.
The use of templates is ok with regards of Turn it in, but the Patient History, CC, HPI, The Assessment and Plan should be of your own work and individualized to your made up patient.
EXAMPLE
Acute Heart Failure
Patient Initials: N.M Age: 65 Gender: male
SUBJECTIVE DATA:
Chief Complaint (CC): “I have been experiencing some shortness while breathing for the previous three days”.
History of Present Illness (HPI): the patient is a 65-year-old white male who presents at the clinic with shortness of breath for the previous three days. The patient also claims that he has had his legs and abdomen swollen. He also says that over the past two weeks he has gained 5 pounds. He confirms that there is no specific time for the symptoms to arise. He then rates the pain associated with shortness of breath as 6 in a scale of 1 to 10.
Medications: the patient confirms that she has not used any medication as a result of the current symptom.
Allergies: none
Past Medical History (PMH): confirms that he was diagnosed with hypertension ten years ago. He also confirms that he has been taking medications on a daily basis to make sure that it is well controlled. He was also diagnosed with diabetes five years ago. He also uses medication to control diabetes.
Current medication: since he was diagnosed with hypertension, he has been taking enalapril on a daily basis. He also confirms that he has been taking metformin so as he can control his blood sugar levels
Past Surgical History (PSH): he confirms that he has not had any surgery.
Family History: he confirms that his father had a history of hypertension while his mother had history diabetes. He currently has an elder brother who has a history of hypertension.
Personal/Social History: denies taking alcohol smoking. He also denies taking other drugs.
Immunization: up to date.
Lifestyle: confirms that since he was diagnosed with hypertension, he has been taking healthy meals that are free from fats and cholesterol. He also says that he exercises but not often.
Review of Systems:
General: patient denies fever and chills. He also denies weakness and fatigue but confirms an increase in weight for the past few weeks.
HEENT: denies trauma or any other problem with the head but confirms having a headache. He then confirms that he has been wearing glasses for the past 20 years as he is short-sighted, he then deniers any other problem with his eyes. Denies having ringing ears or any other problem with the eyes. On the nose, he denies sinus problems, nosebleeds or any other problem. Denies having any problems while swallowing.
Neck: denies neck pain, swollen glands or asses.
Breasts: denies masses or any discharge
Respiratory: confirms that he has had a shortness of breath. Denies coughing, wheezing, lung issues or night sweats.
Cardiovascular/Peripheral Vascular: confirms that he been having some irregular heartbeats with some chest pains. Also confirms that he has had some swelling on the feet as well.
Gastrointestinal: denies appetite changes or diarrhea. He also states that he has not had abdominal problems nausea, vomiting, gas problems, constipation, blood in stool, jaundice or any other problem with the gastrointestinal system. Confirms that his abdomen is somehow swollen.
Genitourinary: denies burning sensation while passing urine, urgency, blood in urine, sexually transmitted disease or any other problem.
Musculoskeletal: confirms that his legs seem to be somehow swollen, with no other muscle pain. He also confirms that he has not had any pain with the joints.
Psychiatric: denies mood changes, anxiety, and depression.
Neurological: denies dizziness, faints, frequent headaches, ataxia, balance problems, problem sleeping, vertigo, and tremors.
Skin: denies having rashes discolored skin or any other problem.
Hematologic: denies bleeding, bruising or blood transfusion.
Endocrine: denies any endocrine disorders.
OBJECTIVE DATA:
Physical Exam:
Vital signs: Temperature: 98.1 F; BP: 147/99 mmHg; HR: 86 bpm; RR: 20/min; Oxygen Saturation: 99%; Pain: 5 (0-10 scale), Weight 160lb; Height 5’7”; BMI 23
General: patient appears to be of his age. He is confident while explaining his problems. He answers the questions as expected. He is ell dressed and has no speech problems.
HEENT: no head deformities noted and the hair distribution seems to be normal. on the eyes, pupils seem to be round and equal, with normal conjunctiva. Ears seem to be normal with no discharge and also no deformities noted. Normal nasal mucosa. Then, the tonsils and pillars are pink.
Neck: looks to be supple with no masses. Also, there is no abnormal ROM or tenderness.
Chest
Lungs: symmetric chest wall motion with no accessory muscle use. Also, there is no wheezing or crackles heard.
Heart: irregular rate and abnormal rhythm with no murmurs or gallop. Also, there is no clubbing or edema.
Peripheral Vascular: Abdomen: there are no masses or abnormalities noted. Seems top be soft and non-tender to palpation. Also, there are no masses or organomegaly.
Genital/Rectal: deferred
Musculoskeletal: both joints and muscles seem to be symmetric. Upon checking leg muscles, they seem to be somehow swollen together with toes. There are no major problems noted apart from the swelling.
Neurological: looks to be awake, alert, and oriented. Cranial nerves are intact. Then, he has normal coordination.
Skin: looks to be warm and moist. He does not have rashes or any changes with skin color
ASSESSMENT:
Differential Diagnosis
1. heart failure. It is sometimes known as congestive heart failure and it occurs when there is a problem with heart muscles where they cannot pump blood as expected. There are some conditions such as hypertension or coronary artery disease that are contributing factors to heart failure. Some of the common symptoms are shortness of breath, weakness, irregular heartbeat, sudden weight gain, and chest pains (Ponikowski, et al, 2016). It is clear that the patient was presenting some of these symptoms and it is the reason as to why it is in the list of differentials.
2. Heart arrhythmia: it is a condition that affects the heart’s rhythm. At times, it can also result in heart failure. Some of the common symptoms are racing heartbeat, shortness of breath, slow heart rate, sweating, and chest pain (Zarins, & Gifford III, 2015). Due to the symptoms that the patient presented, it means that the condition is in the differentials list.
3. Myocardial ischemia: occurs when a person’s blood flow to the heart is reduced. This means that most of the blood is not oxygenated. The main symptoms are shortness of breath, fatigue, sweating, fast heart rate, and neck pain (Ibáñez, Heusch, Ovize, & Van de Werf, 2015).
From both the subjective and objective data, it is clear that the main diagnosis is acute heart failure.
PLAN:
Treatment Plan:
The patient should continue taking hypertension and diabetes medication that he is already taking. He should also take metoprolol (Lopressor) once a day for 14 days so as to control the situation.
Non-pharmacological approaches
The patient should focus on exercising so as his weight problems can be completely controlled. Also, the patient should check his feet on a daily basis and make sure f more swelling is noted the problem is reported to the nearest health facility. At all times, the patient should focus on taking a healthy diet that is free from fats and cholesterol. With a healthy diet, it will assist him in controlling his weight problems. It is also good for the patient to reduce stress completely. Lastly, he should sleep easy with the head popped up using a pillow due to the shortness of breath.
For the follow-up, the patient should get back to the hospital after one week.
References
Ibáñez, B., Heusch, G., Ovize, M., & Van de Werf, F. (2015). Evolving therapies for myocardial ischemia/reperfusion injury. Journal of the American College of Cardiology, 65(14), 1454-1471.
Ponikowski, P., Voors, A. A., Anker, S. D., Bueno, H., Cleland, J. G., Coats, A. J., … & Jessup, M. (2016). 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. European journal of heart failure, 18(8), 891-975.
Zarins, D., & Gifford III, H. (2015). U.S. Patent No. 8,948,865. Washington, DC: U.S. Patent and Trademark Office.
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