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Episodic/Focused SOAP Note Template

Episodic/Focused SOAP Note Template

Assignment 1: Lab Assignment: Assessing the Abdomen

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A male went to the emergency room for severe midepigastric abdominal pain. He was diagnosed with AAA; however, as a precaution, the doctor ordered a CTA scan.  Episodic/Focused SOAP Note Template

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Because of a high potential for misdiagnosis, determining the precise cause of abdominal pain can be time consuming and challenging. By analyzing case studies of abnormal abdominal findings, nurses can prepare themselves to better diagnose conditions in the abdomen.

In this Lab Assignment, you will analyze an Episodic note case study that describes abnormal findings in patients seen in a clinical setting. You will consider what history should be collected from the patients as well as which physical assessments and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions.

To Prepare

Review the Episodic note case study your instructor provides you for this week’s Assignment.

  • About      the Episodic note case study provided:
    • 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.
    • Consider       what physical assessment 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.

Case study Episodic/Focused SOAP Note Template

ABDOMINAL ASSESSMENT

Subjective:

CC: “My stomach has been hurting for the past two days.”

HPI: LZ, 65 y/o AA male, presents to the emergency department with a two days history of intermittent epigastric abdominal pain that radiates into his back. He went to the local Urgent Care where was given PPI’s with no relief. At this time, the patient reports that the pain has been increasing in severity over the past few hours; he vomited after lunch, which led his to go to the ED at this time. He has not experienced fever, diarrhea, or other symptoms associated with his abdominal pain.

PMH: HTN

Medications: Metoprolol 50mg

Allergies: NKDA

FH: HTN, Gerd,  Hyperlipidemia

Social Hx: ETOH, smoking for 20 years but quit both 2 years ago, divorced for 5 years, 3 children, 2 males, 1 female

Objective:

  • VS: Temp 98.2; BP 91/60; RR 16; P 76; HT 6’10”; WT 262lbs
  • Heart: RRR, no murmurs
  • Lungs: CTA, chest wall symmetrical
  • Skin: Intact without lesions, no urticaria
  • Abd: abdomen is tender in the epigastric area with      guarding but without mass or rebound.
  • Diagnostics: US and CTA

Assessment:

  1. Abdominal Aortic Aneurysm (AAA)
  2. Perforated Ulcer
  3. Pancreatitis

PLAN: 

The Assignment

  1. Analyze      the subjective portion of the note. List additional information that      should be included in the documentation.
  2. Analyze      the objective portion of the note. List additional information that should      be included in the documentation.
  3. Is      the assessment supported by the subjective and objective information? Why      or why not?
  4. What      diagnostic tests would be appropriate for this case, and how would the      results be used to make a diagnosis?
  5. Would      you reject/accept the current diagnosis? Why or why not? Identify three      possible conditions that may be considered as a differential diagnosis for      this patient. Explain your reasoning using at least three different      references from current evidence-based literature.Episodic/Focused SOAP Note Template

     

    Patient Information:

    Initials, Age, Sex, Race

    S.

    CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.

    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. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each 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

    Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

    Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).

    PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

    Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

    Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

    ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

    Example of Complete ROS:

    GENERAL:  Denies weight loss, fever, chills, weakness or fatigue.

    HEENT:  Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  Denies hearing loss, sneezing, congestion, runny nose or sore throat.

    SKIN:  Denies rash or itching.

    CARDIOVASCULAR:  Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.

    RESPIRATORY:  Denies shortness of breath, cough or sputum.

    GASTROINTESTINAL:  Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

    GENITOURINARY:  Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

    NEUROLOGICAL:  Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

    MUSCULOSKELETAL:  Denies muscle, back pain, joint pain or stiffness.

    HEMATOLOGIC:  Denies anemia, bleeding or bruising.

    LYMPHATICS:  Denies enlarged nodes. No history of splenectomy.

    PSYCHIATRIC:  Denies history of depression or anxiety.

    ENDOCRINOLOGIC:  Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

    ALLERGIES:  Denies history of asthma, hives, eczema or rhinitis.

    O.

    Physical exam: 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. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.

    Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)

    A.

    Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.

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

    References

    You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

     

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