Comprehensive SOAP Template Patient Initials: _______ Age ✓ Solved

Comprehensive SOAP Template Patient Initials: _______ Age:

Comprehensive SOAP Template Patient Initials: _______ Age: _______ Gender: _______ Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.

O = onset of symptom (acute/gradual)

L= location

D= duration (recent/chronic)

C= character

A= associated symptoms/aggravating factors

R= relieving factors

T= treatments previously tried – response? Why discontinued?

S= severity

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.

History of Present Illness (HPI): 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. You need to start EVERY HPI with age, race, and gender (i.e. 34-year-old AA male).

You must include the 7 attributes of each principal symptom:

• Location
• Quality
• Quantity or severity
• Timing, including onset, duration, and frequency
• Setting in which it occurs
• Factors that have aggravated or relieved the symptom
• Associated manifestations

Medications: Include over the counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.

Allergies: Include specific reactions to medications, foods, insects, and environmental factors.

Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations, and risky sexual behaviors.

Past Surgical History (PSH): Include dates, indications, and types of operations.

Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, and sexual function.

Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADLs and IADLs if applicable, and exercise and eating habits.

Immunization History: Include last Tdp, Flu, pneumonia, etc.

Significant Family History: Include history of parents, Grandparents, siblings, and children.

Lifestyle: Include cultural factors, economic factors, safety, and support systems.

Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History. Remember that the information you include in this section is based on what the patient tells you. You do not need to do them all unless you are doing a total H&P.

General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.

HEENT: Neck: Breasts: Respiratory: Cardiovascular/Peripheral Vascular: Gastrointestinal: Genitourinary: Musculoskeletal: Psychiatric: Neurological: Skin: Include rashes, lumps, sores, itching, dryness, changes, etc. Hematologic: Endocrine: Allergic/Immunologic:

OBJECTIVE DATA: 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 unless you are doing a total H&P.

Do not use WNL or normal. You must describe what you see.

Physical Exam: Vital signs: Include vital signs, ht, wt, and BMI. General: Include general state of health, posture, motor activity, and gait.

This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of conscience, and affect and reactions to people and things.

ASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least 3 differential diagnoses, each of which must be supported with evidence and guidelines.

Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses.

For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled.

These should also be included in your treatment plan.

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

Reflection: Reflect on your clinical experience and consider what you learned from this experience and what you would do differently.

Paper For Above Instructions

This paper will discuss a comprehensive case analysis of a fictional 65-year-old female patient named Sara Jones, who presents with significant respiratory symptoms, particularly a productive cough accompanied by fever and associated symptoms. The following SOAP note format will be employed to ensure thorough documentation and facilitate high-quality patient care.

Subjective Data

Chief Complaint (CC): Sara Jones reports coughing up phlegm and experiencing fever.

History of Present Illness (HPI): Sara is a 65-year-old Caucasian female presenting with a productive cough lasting three weeks and fever for the last three days. She describes the cold as descending into her chest, and her cough is nagging and productive. Sara brings a few paper towels with expectorated yellow/brown phlegm. Symptoms include dyspnea on exertion and fever with a maximum temperature recorded at 102.4°F. Treatment with Ibuprofen 400mg every six hours reduces her fever temporarily, rating her discomfort at 4/10.

Medications: Sara takes several medications including Lisinopril 10mg daily, Combivent 2 puffs every 6 hours as needed, and over-the-counter Ibuprofen 200mg as needed.

Allergies: Sara has an allergy to sulfa drugs which results in a rash.

Past Medical History (PMH): Sara has a history of emphysema with a recent exacerbation, well-controlled hypertension, gastroesophageal reflux disease (GERD), osteopenia, and allergic rhinitis.

Past Surgical History (PSH): Surgical history includes a cholecystectomy and total abdominal hysterectomy in 1998.

Sexual/Reproductive History: Sara is heterosexual (G1P1A0) and non-menstruating due to TAH in 1998.

Personal/Social History: Sara has a 30-year smoking history (2 packs/day), denies alcohol or illicit drug use, and exhibits a healthy diet and is socially active participating in community groups.

Review of Systems

- General: Fatigue has accompanied the illness, with fever noted but no chills or significant weight changes.

- Respiratory: She reports cough and sputum production (as noted in HPI), dyspnea on exertion, and a history of COPD and previous pneumonia.

- Cardiovascular: No chest discomfort or documented arrhythmias, although patient history shows previous cardiovascular assessments.

Objective Data

Physical Exam: Upon examination, Sara was alert and oriented but appeared mildly uncomfortable. Vital signs include BP 110/72, P 70, T 98.3°F, RR 16.

Chest examination reveals clear lung sound but with signs of condition deterioration. The abdomen is benign with mild suprapubic tenderness noted.

Assessment

Diagnosis: The primary diagnosis is COPD exacerbation leading to acute bronchitis. Differential diagnoses include pulmonary embolism and lung cancer given risk factors such as extensive smoking history.

Laboratory Tests: CBC shows elevated WBCs at 15,000 with a positive left shift indicating infection or inflammation.

Plan

Treatment Recommendations: In preparation for future interventions (not required in this assignment), considerations would include pharmacological treatment such as bronchodilators and corticosteroids, lifestyle modifications, and possibly referrals to specialists as necessary based on overall evaluation.

Reflection

In reflecting upon this clinical case, there is a need for vigilance in monitoring respiratory conditions, particularly given the disturbances in Sara's health status and the multifactorial nature of her condition. A comprehensive understanding of her historical conditions provides crucial context for treatment decisions moving forward. In future encounters, closer tracking of symptom fluctuation and enhanced communication about medication efficacy could be beneficial.

References

• Centers for Disease Control and Prevention. (2021). Chronic Obstructive Pulmonary Disease. Retrieved from https://www.cdc.gov/copd/index.html
• Global Initiative for Chronic Obstructive Lung Disease. (2022). Global Strategy for the Diagnosis, Management, and Prevention of COPD. Retrieved from https://goldcopd.org/
• National Institutes of Health. (2020). COPD: Learn More. Retrieved from https://www.nhlbi.nih.gov/health-topics/copd
• Denny, N. C., & Ziegler, A. (2020). Legal implications of tobacco cessation in the context of chronic respiratory disease. American Journal of Respiratory Cell and Molecular Biology, 63(1), 1-2.
• Lee, A., & Doan, L. (2021). Evaluating the effectiveness of corticosteroid therapy in acute exacerbations of chronic obstructive pulmonary disease. Journal of Clinical Medicine, 10(2), 282.
• Murphy, D., & Bhorat, I. (2020). Evidence-based clinical assessment of COPD. Clinics in Chest Medicine, 41(3), 467-487.
• American Lung Association. (2022). Lung Health & COPD Research. Retrieved from https://www.lung.org/
• Singh, D., & Agusti, A. (2020). The evolving role of biomarkers in COPD. Chest, 157(4), 900-911.
• Wang, Y. et al. (2021). Prevalence of comorbid conditions in patients with COPD. Nutritional Review, 79(1), 89-92.
• Watz, H., & Zippert, M. (2021). Personalized medicine in chronic obstructive pulmonary disease. The American Journal of Respiratory and Critical Care Medicine, 203(9), 1075-1086.