course materials

1. Epilepsy Splenomegaly & Hepatitis B Discussion
Epilepsy Splenomegaly & Hepatitis B DiscussionEpilepsy Splenomegaly & Hepatitis B
DiscussionSince 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) b) c) Appropriate systems are examined, listed in the note
and consistent with those identified in 2b.(10pts). Pertinent positives and negatives must
be documented for each relevant system. 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 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) Epilepsy
Splenomegaly & Hepatitis B DiscussionORDER NOW FOR CUSTOMIZED, PLAGIARISM-FREE
PAPERSClarity of the Write-up(___5pts.): Is it literate, organized and complete? Comments:
Total Score: ____________ Instructor: __________________________________ Guidelines for Focused
SOAP Notes · Label each section of the SOAP note (each body part and system). · Do not use
unnecessary words or complete sentences. · Use Standard Abbreviations S: SUBJECTIVE
DATA (information the patient/caregiver tells you). Chief Complaint (CC): a statement

2. describing the patient’s symptoms, problems, condition, diagnosis, physician-recommended
return(s) for this patient visit. The patient’s own words should be in quotes. History of
present illness (HPI): a chronological description of the development of the patient’s chief
complaint from the first symptom or from the previous encounter to the present. Include
the eight variables (Onset, Location, Duration, Characteristics, Aggravating Factors,
Relieving Factors, Treatment, Severity-OLDCARTS), or an update on health status since the
last patient encounter. Past Medical History (PMH): Update current medications, allergies,
prior illnesses and injuries, operations and hospitalizations allergies, age-appropriate
immunization status. Family History (FH): Update significant medical information about the
patient’s family (parents, siblings, and children). Include specific diseases related to
problems identified in CC, HPI or ROS. Social History(SH): An age-appropriate review of
significant activities that may include information such as marital status, living
arrangements, occupation, history of use of drugs, alcohol or tobacco, extent of education
and sexual history. Review of Systems (ROS). There are 14 systems for review. List positive
findings and pertinent negatives in systems directly related to the systems identified in the
CC and symptoms which have occurred since last visit; (1) constitutional symptoms (e.g.,
fever, weight loss), (2) eyes, (3) ears, nose, mouth and throat, (4) cardiovascular, (5)
respiratory, (6) gastrointestinal, (7) genitourinary, (8) musculoskeletal, (9}.integument
(skin and/or breast), (10) neurological, (11) psychiatric, (12) endocrine, (13)
hematological/lymphatic, {14) allergic/immunologic.Epilepsy Splenomegaly & Hepatitis B
DiscussionThe ROS should mirror the PE findings section. 0: OBJECTIVE DATA (information
you observe, assessment findings, lab results). Sufficient physical exam should be
performed to evaluate areas suggested by the history and patient’s progress since last visit.
Document specific abnormal and relevant negative findings. Abnormal or unexpected
findings should be described. You should include only the information which was provided
in the case study, do not include additional data. Record observations for the following
systems if applicable to this patient encounter (there are 12 possible systems for
examination): Constitutional (e.g. vita! signs, general appearance), Eyes, ENT/mouth,
Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin, Neurological, Psychiatric,
Hematological/lymphatic/immunologic/lab testing. The focused PE should only include
systems for which you have been given data. NOTE: Cardiovascular and Respiratory
systems should be assessed on every patient regardless of the chief complaint. Testing
Results: Results of any diagnostic or lab testing ordered during that patient visit. A:
ASSESSMENT: (this is your diagnosis (es) with the appropriate ICD 10 code) List and
number the possible diagnoses (problems) you have identified. These diagnoses are the
conclusions you have drawn from the subjective and objective data. Remember: Your
subjective and objective data should your diagnoses and your therapeutic plan. Do not
write that a diagnosis is to be “ruled out” rather state the working definitions of each
differential or primary diagnosis (es). For each diagnoses provide a cited rationale for
choosing this diagnosis. This rationale includes a one sentence cited definition of the
diagnosis (es) the pathophysiology, the common signs and symptoms, the patients
presenting signs and symptoms and the focused PE findings and tests results that the dx.
Include the interpretation of all lab data given in the case study and explain how those

3. results your chosen diagnosis. P: PLAN (this is your treatment plan specific to this
patient).Epilepsy Splenomegaly & Hepatitis B DiscussionEach step of your plan must
include an EBP citation. 1. Medications write out the prescription including dispensing
information and provide EBP to ordering each medication. Be sure to include both
prescription and OTC medications. 2. Additional diagnostic tests include EBP citations to
ordering additional tests 3. Education this is part of the chart and should be brief, this is not
a patient education sheet and needs to have a reference. 4. Referrals include citations to a
referral 5. Follow up. Patient follow-up should be specified with time or circumstances of
return. You must provide a reference for your decision on when to follow up. (Student
Name) Miami Regional University Date of Encounter: Preceptor/Clinical Site: Clinical
Instructor: Dr. David Trabanco DNP, APRN, AGNP-C, FNP-C Soap Note # Main Diagnosis (
Exp: Soap Note #3 DX: Hypertension) PATIENT INFORMATION Name: Mr. DT Age: 68-year-
old Gender at Birth: Male Gender Identity: Male Source: Patient Allergies: PCN, Iodine
Current Medications: • Atorvastatin tab 20 mg, 1-tab PO at bedtime • ASA 81mg po daily •
Multi-Vitamin Centrum Silver PMH: Hypercholesterolemia Immunizations: Influenza last
2018-year, tetanus, and hepatitis A and B 4 years ago. Preventive Care: Coloscopy 5 years
ago (Negative) Surgical History: Appendectomy 47 years ago. Family History: Father- died
81 does not report information Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy Social History: No smoking history or illicit drug use,
occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives
alone. Sexual Orientation: Straight Nutrition History: Diets off and on, Does not each seafood
Subjective Data: Chief Complaint: “headaches” that started two weeks ago Symptom
analysis/HPI: The patient is 65 years old male who complaining of episodes of headaches
and on 3 different occasions blood pressure was measured, which was high (159/100,
158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and
sometimes it is accompanied by dizziness. He states that he has been under stress in his
workplace for the last month. Patient denies chest pain, palpitation, shortness of breath,
nausea or vomiting. Review of Systems (ROS) CONSTITUTIONAL: Denies fever or chills.
Denies weakness or weight loss. NEUROLOGIC: Headache and dizziness as describe above.
Denies changes in LOC. Denies history of tremors or seizures. HEENT: HEAD: Denies any
head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred
vision.Epilepsy Splenomegaly & Hepatitis B DiscussionEar: Denies pain in the ears. Denies
loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat
or neck pain, hoarseness, difficulty swallowing. RESPIRATORY: Patient denies shortness of
breath, cough or hemoptysis. CARDIOVASCULAR: No chest pain, tachycardia. No orthopnea
or paroxysmal nocturnal dyspnea. GASTROINTESTINAL: Denies abdominal pain or
discomfort. Denies flatulence, nausea, vomiting or diarrhea. GENITOURINARY: Denies
hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping
stream of urine or incontinence. MUSCULOSKELETAL: Denies falls or pain. Denies hearing a
clicking or snapping sound. SKIN: No change of coloration such as cyanosis or jaundice, no
rashes or pruritus. Objective Data: VITAL SIGNS: Temperature: 98.5 °F, Pulse: 87, BP:
159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 2/10.
GENERAL APPREARANCE: The patient is alert and oriented x 3. No acute distress noted.

4. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation
intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5. HEENT: Head:
Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes:
No conjunctival injection, no icterus, visual acuity and extraocular eye movements intact. No
nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate.
Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary sinuses
no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without lesions,.
Lids non-remarkable and appropriate for race. Neck: supple without cervical
lymphadenopathy, no jugular vein distention, no thyroid swelling or masses.
CARDIOVASCULAR: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary
refill < 2 sec. RESPIRATORY: Epilepsy Splenomegaly & Hepatitis B DiscussionNo dyspnea or
use of accessory muscles observed. No egophony, whispered pectoriloquy or tactile
fremitus on palpation. Breath sounds presents and clear bilaterally on auscultation.
GASTROINTESTINAL: No mass or hernia observed. Upon auscultation, bowel sounds
present in all four quadrants, no bruits over renal and aorta arteries. Abdomen soft non-
tender, no guarding, no rebound no distention or organomegaly noted on palpation
MUSKULOSKELETAL: No pain to palpation. Active and passive ROM within normal limits, no
stiffness. INTEGUMENTARY: intact, no lesions or rashes, no cyanosis or jaundice.
ASSESSMENT: Main Diagnosis Essential (Primary) Hypertension (ICD10 I10): Given the
symptoms and high blood pressure (156/92 mmhg), classified as stage 2. Once the organic
cause of hypertension has been ruled out, such as renal, adrenal or thyroid, this diagnosis is
confirmed (Codina Leik, 2015). Diagnosis is based on the clinical evaluation through history,
physical examination, and routine laboratory tests to assess risk factors, reveal identifiable
causes and detect target-organ damage, including evidence of cardiovascular disease
(Domino et al,. 2017). Differential diagnosis: ? Renal artery stenosis (ICD10 I70.1) ? Chronic
kidney disease (ICD10 I12.9) ? Hyperthyroidism (ICD10 E05.90) PLAN: Labs and Diagnostic
Test to be ordered: • CMP • Complete blood count (CBC) • Lipid profile • Thyroid-
stimulating hormone (TSH) • Urinalysis with Micro • Electrocardiogram (EKG 12 lead)
Pharmacological treatment: • Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally
once daily. • Lisinopril 10mg PO Daily Non-Pharmacologic treatment: • Weight loss •
Healthy diet (DASH dietary pattern): Diet rich in fruits, vegetables, whole grains, and low-fat
dairy products with reduced content of saturated and trans l fat • Reduced intake of dietary
sodium: Epilepsy Splenomegaly & Hepatitis B Discussion