Sara Jones is a 65-year-old woman who presents with a 3-week productive cough and 3 days of fever. She reports yellow/brown sputum and dyspnea on exertion. Her temperature has reached 102.4 degrees. She has a history of emphysema, hypertension, GERD, osteopenia, allergic rhinitis, and is a long-time smoker. On examination, she has fatigue but is otherwise normal. A review of systems is positive for respiratory symptoms and fever, but otherwise negative.
8. E= exacerbating/relieving factors
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 (e.g., 34-year-old AA
male). You must include the seven attributes ofeach principal
symptom in paragraph form not a list. If the CC was
“headache”, the LOCATES for the HPI might look like the
following example:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia,
phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes
it tolerable but not completely better
Severity: 7/10 pain scale
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. Identify if it is an allergy or
intolerance.
Past Medical History (PMH): Include illnesses (also childhood
illnesses), hospitalizations.
Past Surgical History (PSH): Include dates, indications, and
types of operations.
Sexual/Reproductive History: If applicable, include obstetric
history, menstrual history, methods of contraception, sexual
9. function, and risky sexual behaviors.
Personal/Social History: Include tobacco use, alcohol use, drug
use, patient’s interests, ADL’s and IADL’s if applicable, and
exercise and eating habits.
Immunization History: Includelast Tdap, Flu, pneumonia, etc.
Significant Family History: Include history of parents,
grandparents, siblings, and children.
Lifestyle: Include cultural factors, economic factors, safety, and
support systems and sexual preference.
Review of Systems: From head-to-toe, include each system that
covers the Chief Complaint, History of Present Illness, and
History (this includes the systems that address any previous
diagnoses).Remember that the information you include in this
section is based on what the patient tells you so ensure that you
include all essentials in your case (refer to Chapter 2 of the
Sullivan text).
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:
10. Genitourinary:
Musculoskeletal:
Psychiatric:
Neurological:
Skin:
Hematologic:
Endocrine:
Allergic/Immunologic:
OBJECTIVE DATA: From head-to-toe, includewhat 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- only in this course.
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
consciousness, and affect and reactions to people and things.
12. Page 1 of 3
Comprehensive SOAP Exemplar
Purpose: To demonstrate what each section of the SOAP Note
should include. Remember that nurse practitioners treat patients
in a holistic manner, and your SOAP Note should reflect that
premise.
Patient Initials: _______
Age: _______
Gender: _______
SUBJECTIVE DATA:
Chief Complaint (CC): Coughing up phlegm and fever
History of Present Illness (HPI): Sara Jones is a 65-year-old
Caucasian female who presents today with a productive cough x
3 weeks and fever for the last 3 days. She reported that the
“cold feels like it is descending into her chest.” The cough is
nagging and productive. She brought in a few paper towels with
expectorated phlegm – yellow/brown in color. She has
associated symptoms of dyspnea of exertion and fever. Her
Tmax was reported to be 102.4 last night. She has been taking
Ibuprofen 400mg about every 6 hours and the fever breaks, but
it returns after the medication wears off. She rated the severity
of her symptom discomfort at 4/10.
Medications:
1.) Lisinopril 10mg daily
13. 2.) Combivent 2 puffs every 6 hours as needed
3.) Serovent daily
4.) Salmeterol daily
5.) Over-the-counter Ibuprofen 200mg -2 PO as needed
6.) Over-the-counter Benefiber
7.) Flonase 1 spray each night as needed for allergic rhinitis
symptoms
Allergies:
Sulfa drugs - rash
Past Medical History (PMH):
1.) Emphysema with recent exacerbation 1 month ago – deferred
admission – RX’d with outpatient antibiotics and hand held
nebulizer treatments.
2.) Hypertension – well controlled
3.) Gastroesophageal reflux (GERD) – quiet, on no medication
4.) Osteopenia
5.) Allergic rhinitis
Past Surgical History (PSH):
1.) Cholecystectomy 1994
2.) Total abdominal hysterectomy (TAH) 1998
Sexual/Reproductive History:
Heterosexual
G1P1A0
14. Non-menstruating – TAH 1998
Personal/Social History:
She has smoked 2 packs of cigarettes daily x 30 years; denied
ETOH or illicit drug use.
Immunization History:
Her immunizations are up to date. She received the influenza
vaccine last November and the Pneumococcal vaccine at the
same time.
Significant Family History:
Two brothers – one with diabetes, dx at age 65, and the other
with prostate CA, dx at age 62. She has one daughter in her 30s,
healthy, living in nearby neighborhood.
Lifestyle:
She is retired, has been widowed x 8 years, and lives in the city
in a moderate crime area with good public transportation. She is
a college graduate, owns her home, and receives a pension of
$50,000 annually – financially stable.
She has a primary care nurse practitioner provider and goes for
annual and routine care twice annually and as needed for
episodic care. She has medical insurance but often asks for drug
samples for cost savings. She has a healthy diet and eating
pattern. There are resources and community groups in her area
at the senior center that she attends regularly. She enjoys bingo.
She has a good support system composed of family and friends.
Review of Systems:
General: + fatigue since the illness started; + fever, no chills or
night sweats; no recent weight gains of losses of significance
HEENT: No changes in vision or hearing; she does wear
glasses, and her last eye exam was 1 ½ years ago. She reported
15. no history of glaucoma, diplopia, floaters, excessive tearing, or
photophobia. She does have bilateral small cataracts that are
being followed by her ophthalmologist. She has had no recent
ear infections, tinnitus, or discharge from the ears. She reported
her sense of smell is intact. She has not had any episodes of
epistaxis. She does not have a history of nasal polyps or recent
sinus infection. She has a history of allergic rhinitis that is
seasonal. Her last dental exam was 3/2014. She denied
ulceration, lesions, gingivitis, gum bleeding, and has no dental
appliances. She has had no difficulty chewing or swallowing.
Neck: No pain, injury, or history of disc disease or
compression. Her last Bone Mineral density (BMD) test was
2013 and showed mild osteopenia, she said.
Breasts: No reports of breast changes. No history of lesions,
masses, or rashes. No history of abnormal mammograms.
Respiratory: + cough and sputum production (see HPI); denied
hemoptysis, no difficulty breathing at rest; + dyspnea on
exertion; she has history of COPD and community acquired
pneumonia 2012. Last PPD was 2013. Last CXR – 1 month ago.
CV: No chest discomfort, palpitations, history of murmur; no
history of arrhythmias, orthopnea, paroxysmal nocturnal
dyspnea, edema, or claudication. Date of last ECG/cardiac work
up is unknown by patient.
GI: No nausea or vomiting, reflux controlled. No abd pain, no
changes in bowel/bladder pattern. She uses fiber as a daily
laxative to prevent constipation.
GU: No change in her urinary pattern, dysuria, or incontinence.
She is heterosexual. She has had a total abd hysterectomy. No
history of STDs or HPV. She has not been sexually active since
the death of her husband.
MS: She has no arthralgia/myalgia, no arthritis, gout or
limitation in her range of motion by report. No history of
trauma or fractures.
Psych: No history of anxiety or depression. No sleep
16. disturbance, delusions, or mental health history. She denied
suicidal/homicidal history.
Neuro: No syncopal episodes or dizziness, no paresthesia,
headaches. No change in memory or thinking patterns; no
twitches or abnormal movements; no history of gait disturbance
or problems with coordination. No falls or seizure history.
Integument/Heme/Lymph: No rashes, itching, or bruising. She
uses lotion to prevent dry skin. She has no history of skin
cancer or lesion removal. She has no bleeding disorders,
clotting difficulties, or history of transfusions.
Endocrine: No endocrine symptoms or hormone therapies.
Allergic/Immunologic: Has hx of allergic rhinitis, but no known
immune deficiencies. Her last HIV test was 10 years ago.
OBJECTIVE DATA
Physical Exam:
Vital signs: B/P 110/72, left arm, sitting, regular cuff; P 70 and
regular; T 98.3 orally; RR 16; non-labored; Wt: 115 lbs; Ht:
5’2; BMI 21
General: A&O x3, NAD, appears mildly uncomfortable
HEENT: PERRLA, EOMI, oronasopharynx is clear
Neck: Carotids no bruit, jvd or tmegally
Chest/Lungs: CTA AP&L
Heart/Peripheral Vascular: RRR without murmur, rub, or gallop;
pulses+2 bilat pedal and +2 radial
ABD: benign, nabs x 4, no organomegaly; mild suprapubic
tenderness – diffuse – no rebound
17. Genital/Rectal: external genitalia intact, no cervical motion
tenderness, no adnexal masses.
Musculoskeletal: symmetric muscle development - some age-
related atrophy; muscle strengths 5/5 all groups
Neuro: CN II – XII grossly intact, DTR’s intact
Skin/Lymph Nodes: No edema, clubbing, or cyanosis; no
palpable nodes
ASSESSMENT:
Lab Tests and Results:
CBC – WBC 15,000 with + left shift
SAO2 – 98%
Diagnostics:
Lab:
Radiology:
CXR – cardiomegaly with air trapping and increased AP
diameter
ECG
Normal sinus rhythm
Differential Diagnosis (DDx):
1.) Acute Bronchitis
2.) Pulmonary Embolis
3.) Lung Cancer
19. observations, and use the techniques of differential diagnosis to
determine the most likely condition.
To prepare:
· Review the Skin Conditions document provided in this week’s
Learning Resources, and select one condition to closely
examine for this Assignment. – For this assignment, the topic of
choice is Melanoma. Please see this link for details on
melanoma -
https://www.visualdx.com/visualdx/diagnosis/melanoma?modul
eId=101&diagnosisId=51936
· Consider the abnormal physical characteristics you observe in
the graphic you selected. How would you describe the
characteristics using clinical terminologies?
· Explore different conditions that could be the cause of the skin
abnormalities in the graphics you selected.
· Consider which of the conditions is most likely to be the
correct diagnosis, and why.
· Download the SOAP Template found in this week’s Learning
Resources.
To complete:
· Choose one skin condition graphic (identify by number in your
Chief Complaint) to document your assignment in the SOAP
(Subjective, Objective, Assessment, and Plan) note format,
rather than the traditional narrative style. Refer to Chapter 2 of
the Sullivan text and the Comprehensive SOAP Template in this
week's Learning Resources for guidance. Remember that not all
comprehensive SOAP data are included in every patient case.
· Use clinical terminologies to explain the physical
characteristics featured in the graphic. Formulate a differential
diagnosis of three to five possible conditions for the skin
graphic that you chose. Determine which is most likely to be the
correct diagnosis and explain your reasoning using at least 3
different references from current evidence based literature.
21. Major Variables
Studied
List and define
dependent and
independent variables
Measurement
Identify primary
statistics used to
answer clinical
questions
Data Analysis
Statistical or
qualitative
findings
Findings and
Recommendations
General findings and
recommendations of
the research
Appraisal
Describe the general
worth of this research
to practice. What are
the strengths and
limitations of study?
What are the risks
associated with
implementation of the
suggested practices
