Nursing

Address the following in your SOAP note: (Fill in these blanks from patients you may have seen in the past)

What additional subjective data are you seeking?
What additional objective data will you be assessing for?
What medical history would you obtain from the patient? List at least three.
What tests will you order? Describe at least four lab tests.
What are the differential diagnoses that you are considering? Describe two.
What is your plan of care? List at least two diagnostic tests you will order to evaluate the cause of her condition.

USED FOCUSED SOAP NOTE TEMPLATE NOT NARRATIVE

ANSWER

Focused SOAP Note Template

Patient Information:

Initials, Age, Sex, Race

S (subjective)

CC (Chief Complaint): Mrs. L., a 68-year-old woman, presents to the office with a complaint of feeling tired all the time and now, more recently, feeling like they can’t breathe and weak.

HPI (History of Present Illness): Mrs. L has been healthy except for high cholesterol that she manages using Lipitor. Her husband died 9 months ago and she has attributed her fatigue to the struggle of dealing with the death but realizes that she is feeling no better as time passes.

• Location: Body
• Onset: Unknown
• Character: Feeling tired
• Associated signs and symptoms: Shortness of breath
• Timing: Throughout the day
• Exacerbating/relieving factors: Takes only Lipitor.
• Severity: 7/10 pain scale

Current medications: Only Takes lipitor

Allergies: No Known drug allergies.

PHMx: Appendectomy in childhood; hysterectomy for uterine myoma 10 years ago. However, no significant medical history

Soc and Substance Hx: No significant social and substance use history.

Fam Hx: Has two daughters living nearby.

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

Mental Hx: No significant mental health history.

Violence Hx: No significant violence history.

Reproductive Hx: No significant reproductive history.

ROS (review of symptoms):

ROS

GENERAL: Mr. L., complains of feeling tired, weak and shortness of breath. No vomiting, no nausea, no fevers, no weight loss, fatigue, appetite, temperature or weakness.

HEENT:

Head: Denies any headache

Eyes: Denies blurred vision, visual loss, eye pain or double vision.

Ears, Nose, Throat: Denies hearing loss, ear pain, nasal obstruction, nosebleeds, tinnitus, harness or sore throat.

SKIN: Denies any itching, bruising, lacerations, open wounds or skin rashes.

CARDIOVASCULAR: No palpitations, no chest pains, chest discomfort.

RESPIRATORY: No cough, denies SOB, and no sputum production shortness of breath.

GASTROINTESTINAL: Denies abdominal pains, vomiting, nausea or diarrhea.

GENITOURINARY: No burning on urination.

NEUROLOGICAL: No headache, numbness, dizziness, paralysis, ataxia, syncope.

MUSCULOSKELETAL: Denies back and join pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding or bruising.

LYMPHATICS: No history of splenectomy. No enlarged nodes.

PSYCHIATRIC: Denies anxiety and depression

ENDOCRINOLOGIC: Denies reports of cold or sweating. No polydipsia or.

ALLERGIES: Denies history of hives, asthma or rhinitis.

O (objective)

Physical Exam: Conjuntiva pale, mucus membrane moist. No lymphadenopathy of neck or femoral area. Herat tachyarrhythmia with regular rate, soft midsystolic murmur. Chest (CTA), good air movement. Abdomen soft, bowel sounds *4.

Lab Tests

Complete Blood Count test (CBC) – CBC is done to count the blood cells in the blood (Avalos-Fernandez, Touchais and Henriquez-Henriquez, 2020). The doctor will be interested in the red blood cells levels contained in the blood to determine whether the patient has anaemia.

Mean Corpuscular Volume (MCV) – A blood test used to examine the size of the red blood cells to monitor and diagnose different blood disorders.

Faecal occult blood test (FOBT) – The test for occult blood in the stool are used to screen colon polyps which indicate iron deficiency.

Urinalysis– this is a urine test that is used to discover the cause of anaemia. A urine sample can easily detect blood in the urine and other issues such as bladder diseases and urinary tract infection that can result in anaemia. Ideally, blood in the stool or urine can appear faintly to precede iron deficiency symptoms.

Diagnostic results:

A (assessment)

Differential diagnosis

Iron Deficiency Anemia –  The disease occurs when the body lacks enough anaemia. Ideally, without enough iron, the body cannot generate enough red blood cells which support haemoglobin. Blood loss during monthly periods and childbirth can result in anaemia. Lack of iron supplementation, Iron deficiency anemia is prevalent mostly in women. This is a result of bleeding to due menstrual bleeding, regular use of over-the-counter pain relievers and ulcers. The patient has shown some signs and symptoms such as extreme fatigue, weakness and loss of breath sometimes.

Anaemia of Inflammation- This is also known as anaemia of chronic disease, which affects people who have conditions that lead to inflammation such as autoimmune disease, chronic kidney disease and cancer link. Chronic diseases can lead to changes in the red blood cells and slow production. The patient depicts symptoms that are similar to the disease, such as feeling weak or tired and having shortness of breath.

Colon Cancer- Colon cancer can typically impact older adults. This begins with a non-cancerous clump of cells inside the colon, which eventually leads to colon cancer. The patient has an abnormal mass of tissue that has formed on the colon. Many patients with colon cancer tend to show signs and symptoms of anaemia since cancer may bleed. Some of the symptoms include shortness of breath, fatigue and feeling tired.

P (plan)

A proper treatment plan will include a comprehensive assessment of the expressed concerns of the patient, a clear set of goals, and active participation. Therefore, the treatment plan will start with examining the likely causes of fatigue, tiredness and shortness of breath. This will include assessing the patient’s medical history taking into account the social history, family history, medication, and allergic reactions. The clinician will then conduct a physical examination, review various symptoms, carry out diagnostic testing and lab tests to determine the main causes for tiredness, fatigue and shortness of breath. The diagnostic results will then be used for intervention coordination. The clinician will educate the patient concerning the health complication to ensure that they are part of the intervention process. Since the patient shows signs of color cancer, the clinician will combine radiation therapy, surgery and chemotherapy, which can be utilized in slowing the spread of the disease. Palliative care will also be essential in helping the patient to relieve the side effects and symptoms.

Reflection: Social history can involve aspects such as the patient’s family, developmental and life events, occupation and social class (Gossman, Lew and Ghassemzadeh, 2020). The family history entails information such as disorders that have direct blood relative of the patient have suffered (Gossman, Lew and Ghassemzadeh, 2020). The review of systems entails questions that are used to uncovering symptoms that are not mentioned by the patient (Podder, Lew, and Ghassemzade, 2020). Medical history offers the basis on which treatment and diagnosis are developed (Podder, Lew, and Ghassemzade, 2020). The past significant diseases include all the illnesses and diseases currently being traced and those that have a residual impact on the health of the patient. The family history is an essential aspect of medical history since it indicates the potential genetic predisposition to the disease. Past medications are essential in preventing consequent risks to patients as well as prescription errors. Accurate medication histories also allow the proper identification of drug-related changes or pathology in clinical signs that may be the outcome of the drug therapy. Diagnostic testing and lab tests are essential parameters in monitoring, diagnosis and screening. Ideally, the clinicians have to first on the lab results in the most appropriate context and utmost significance to understand what is behind the results.

References

Avalos-Fernandez, M., Touchais, H., & Henriquez-Henriquez, M. (2020). A decision-making tool to fine-tune abnormal levels in the complete blood count tests. arXiv preprint arXiv:2011.05900.

Camaschella, C. (2015). Iron-deficiency anaemia. New England journal of medicine, 372(19), 1832-1843.

Gossman, W., Lew, V., & Ghassemzadeh, S. (2020). SOAP Notes. In StatPearls [Internet]. StatPearls Publishing.

Podder, V., Lew, V., & Ghassemzadeh, S. (2020). SOAP Notes. StatPearls [Internet].

Roy, C. N. (2010). Anaemia of inflammation. Haematology 2010, the American Society of Hematology Education Program Book, 2010(1), 276-280.