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-styli.

1. 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

2. 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.

3. 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.

4. 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

5. 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

6. 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 individual’s 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.

7. Chapter 4, “Affective Changes”
This chapter outlines how to identify the potential cause of
affective changes in a patient. The authors provide a suggested
approach to the evaluation of this type of change, and they
include specific tools that can be used as part of the diagnosis.
Chapter 9, “Confusion in Older Adults”
This chapter focuses on causes of confusion in older adults,
with an emphasis on dementia. The authors include suggested
questions for taking a focused history as well as what to look
for in a physical examination.
Chapter 13, “Dizziness”
Dizziness can be a symptom of many underlying conditions.
This chapter outlines the questions to ask a patient in taking a
focused history and different tests to use in a physical
examination.
Chapter 19, “Headache”
The focus of this chapter is the identification of the causes of
headaches. The first step is to ensure that the headache is not a
life-threatening condition. The authors give suggestions for
taking a thorough history and performing a physical exam.
Chapter 31, “Sleep Problems”
In this chapter, the authors highlight the main causes of sleep
problems. They also provide possible questions to use in taking
the patient’s history, things to look for when performing a
physical exam, and possible laboratory and diagnostic studies
that might be useful in making the diagnosis.

8. 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)
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon,
B. S., & Stewart, R. W. (2011). Physical examination objective
data checklist. In
Mosby’s guide to physical examination
(7th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Mosby’s Guide to Physical Examination, 7th
Edition by Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A.,
Solomon, B. S., & Stewart, R. W. Copyright 2011 by Elsevier.
Reprinted by permission of Elsevier via the Copyright
Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. (2019). Neurologic system: Student checklist. In
Seidel's guide to physical examination: An interprofessional
approach
(9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel's Guide to Physical Examination, 9th
Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B.
S., & Stewart, R. W. Copyright 2019 by Elsevier Health
Sciences. Reprinted by permission of Elsevier Health Sciences
via the Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &

9. Stewart, R. W. (2019). Neurologic system: Key points. In
Seidel's guide to physical examination: An interprofessional
approach
(9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel's Guide to Physical Examination, 9th
Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B.
S., & Stewart, R. W. Copyright 2019 by Elsevier Health
Sciences. Reprinted by permission of Elsevier Health Sciences
via the Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. (2019). Mental status: Student checklist. In
Seidel's guide to physical examination: An interprofessional
approach
(9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel's Guide to Physical Examination, 9th
Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B.
S., & Stewart, R. W. Copyright 2019 by Elsevier Health
Sciences. Reprinted by permission of Elsevier Health Sciences
via the Copyright Clearance Center.
Bearden , S. T., & Nay, L. B. (2011). Utility of EEG in
differential diagnosis of adults with unexplained acute
alteration of mental status.
American Journal of Electroneurodiagnostic Technology, 51
(2), 92–104.
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.
Athilingam, P ., Visovsky, C., & Elliott, A. F. (2015). Cognitive
screening in persons with chronic diseases in primary care:
Challenges and recommendations for practice.

10. American Journal of Alzheimer’s Disease & Other Dementias,
30
(6), 547–558. doi:10.1177/1533317515577127
Sinclair , A. J., Gadsby, R., Hillson, R., Forbes, A., & Bayer, A.
J. (2013). Brief report: Use of the Mini-Cog as a screening tool
for cognitive impairment in diabetes in primary care.
Diabetes Research and Clinical Practice, 100
(1), e23–e25. doi:10.1016/j.diabres.2013.01.001
Roalf, D. R., Moberg, P. J., Xei, S. X., Wolk, D. A., Moelter, S.
T., & Arnold, S. E. (2013). Comparative accuracies of two
common screening instruments for classification of Alzheimer’s
disease, mild cognitive impairment, and healthy aging.
Alzheimer’s & Dementia, 9
(5), 529–537. doi:10.1016/j.jalz.2012.10.001. Retrieved from
http://www.alzheimersanddementia.com/article/S1552-
5260(12)02463-6/abstract