SOAP Note: Acute Problem-Based Assessment Essay
Primary Language: English, Interpreter ID: N/A
Date of Visit: 10/20/2020
Visit Method: Face-to-Face or Telehealth: Telehealth
Site of visit: Out-patient Primary Care (internal medicine or family practice), Urgent care, Skilled Nursing Facility, Other (specify) Shadow Health Clinic. SOAP Note: Acute Problem-Based Assessment Essay.
Chief complaint: Abdominal pain and lack of bowel movements. Patient reports “I have pain in my belly and I’m having some difficulty with going to the bathroom”.
History of present illness:
Esther Park states that she has been feeling discomfort for the last five days. Ms. Park reports pain with a steady onset that worsened in the past two to three days. When asked about the pain location, she identifies it as being in the lower abdomen and not being localized.
Ms. Park rates the pain as 6 out of 10 and defines the character as dull and cramping. She emphasizes that the pain is intermittent with aggravating factors such as eating and physical activity. When asked about treatment and relieving factors, the client reports that resting helps and taking small water sips is ineffective in bring relief. She has not taken pain medication for the stomach.
Initially, she rated her pain as a 2 out of 10 but it has now increased in intensity to a 6 out of 10. However; she describes the pain as fluctuating in severity and as primarily a generalized discomfort in the abdomen. Ms. Park reports recent difficulty in engaging in usual activities and states that she has low energy levels. She reports constipation in most of the past five days and has not tried to treat constipation. Ms. Park experienced diarrhea about six months ago, which had an unexpected onset lasting one day. She has no blood or mucus in stool and notes a minimal decrease in the regularity of urination. Recently she has had darker urine, but denies presence of blood. In the past few days Ms. Park she has had decreased thirst and fluid intake. SOAP Note: Acute Problem-Based Assessment Essay. She perceives her symptoms as not severe enough to warrant a trip to the hospital; noting that her daughter insisted she visit the clinic. In a review of systems, she denies recent fever, chills, sweats, bladder problems, or sore throats. She feels ‘bloated’ and has lost her appetite.
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PSH Cesarean-section, 1982
; she had a C-section at the age of 40 and
cholecystectomy at age 42.
The client reports no accidents or injuries during her shadow health visit.
Hospitalizations: Following the Cesarean-section, 1982
Following the Cholecystectomy, 1984
Ms. Park’s mother, deceased at age of 88, had a history of hypertension and Type II diabetes mellitus. Her father, deceased at age 82, had a history of hypercholesterolemia and hypertension. Maternal grandparents (deceased) had a history of diabetes mellitus Type II and coronary heart disease. Paternal grandparents (deceased) had a history of CVA, obesity and hypertension. Ms. Park has two brothers who are alive, the oldest is 81; he has a history of hypertension. The youngest is 80, with a history of prostate cancer, hypertension, and hypercholesterolemia. Ms. Park has two children, age 48 and 46 years old; both are healthy. SOAP Note: Acute Problem-Based Assessment Essay.
Ms. Park is living with her daughter and describes her familial support system as strong. she had toast for breakfast; her most recent meal. She normally eats three meals a day and denies regularly eating snacks. Her typical breakfast is toast, soup for lunch and chicken or fish and rice for dinner. She does not take any fiber supplements or other activities to include fiber in her diet. She consumes vegetables every? one to three days and fruits after every three to four days. Oral hydration?
When asked about her physical activity level, Ms. Park reports an increased level of mobility and independence. She notes that her activity level is moderate. She does not use any illicit drugs or smoke. She reports low alcohol consumption of at least one night a week; white wine is her typical drink.
latex allergy reaction? No known medication or food allergies
Accupril for hypertension , 10mg, taken orally, taken daily at 8 am (last taken?). Denies use of over the counter medications.
Ms. Park states that her immunizations are up to date, she get her influenza vaccine this season? , annual health check-ups and her most recent pap smear was ten years ago. Her colonoscopy was also ten years ago.
Overall, the client feels that her level of health and activity is suitable for her age.
Sexual preference and practices:
LMP: the client reports that her commencement of menopause was at age 54. Ms. Park reports she is heterosexual and is currently sexually active (how many partners? Do they use any methods of STI prevention?)
Ms. Park was asked about her constitutional health, to which she denies any fresh weight changes, chills, fever or night sweats. However, she reports short-term feelings of fatigue and exhaustion. SOAP Note: Acute Problem-Based Assessment Essay. She says she has been experiencing bloating and increased gas and loss of appetite, but denies nausea and vomiting. She has no history of bladder problems, painful urination, urinary incontinence, or UTIs and no respiratory issues.
Vitals: blood pressure 110/70, O² sat 99%, pulse 92, respirations 16, temperature 37.0 C.
General: Ms. Park was an edgy and flushed, appearing older woman. She appeared a bit distressed and was smirking at times.
HEENT: Cardiovascular: S1, S2, no murmurs, gallops, or rubs. No S3 and S4.
Skin: Moist, mucous membranes, normal skin turgor, no tenting. No lower extremity edema.
Respiratory: breathing was quiet and unlabored. She could construct full sentences and lung sounds were clear to auscultation where? Throughout?
Abdominal: 6 cm scar in RUQ and 10 cm scar at the midline in the suprapubic region. no skin discoloration and bowel sounds were normoactive in all four quadrants; no bruits; no friction sounds over spleen or liver; tympany presides with scattered dullness over LLQ; abdomen soft in all quadrants. Any tenderness with palpation? An oblong mass is noted in the LLQ with mild guarding, distension; no organomegaly; no CVA tenderness; liver span 7 cm at MCL and no hernias.
Rectal: no hemorrhoids, fissures or ulceration; strong sphincter tone, fecal mass in the rectal vault.
Pelvic: no inflammation or irritation of the vulva, abnormal discharge, bleeding, masses or growth or tenderness upon palpation.
The patient’s bowel sounds were normoactive in all quadrants, with no friction sounds or bruits. During percussion, scattered dullness was spotted in the LLQ, which is indicative of feces in the colon. The client’s abdomen was soft to palpation and mild guarding together with the oblong mass; indicating feces were founded in the LLQ. The patient had no CVA tenderness; liver span 7 cm at MCL and no splenic dullness. A digital rectal exam showed a fecal mass in the rectal vault. No aberrations were noted during the pelvic assessment, eliminating the likelihood of pelvic inflammatory disease. SOAP Note: Acute Problem-Based Assessment Essay. Ms. Park’s urinalysis was normal, ruling out the possibility of urinary tract infection. There were no signs of cardiovascular abnormalities or dehydration. The client’s health and symptoms indicate that she has constipation. Ms. Park’s differential diagnoses, in order of priority are internal obstruction, diverticulitis, and constipation.
Internal obstruction ICD-10CM diagnosis K56.69: The mechanical impairment or total arrest of the movement of the contents of the intestines resulting from a pathology that blocks the bowels (Puja Hari, 2016). Common symptoms are cramping pain and inability to pass stool. SOAP Note: Acute Problem-Based Assessment Essay.
Diverticulitis ICD-10CM diagnosis K57.92: according to Kamal, Baiomi, & Balar (2019). Diverticulitis is an infection or inflammation of one or more pouches of the digestive tract. The disease is more prevalent in persons over the age of 40. Symptoms encompass abdominal pain, fever, change in bowel habits and fever.
Constipation ICD-10CM diagnosis K59.0: occurs when a person’s bowel movements are uncommon, causing difficulty in passing stool. Typical causes are diet changes, physical inactivity and insufficient fiber intake (Forootan et al., 2018). Being a woman, older age, and taking certain medications are significant risk factors for constipation. Symptoms include bloating, abdominal cramps, and the inability to pass stool.
Health Promotion/ Disease Prevention: primary, secondary, and/or tertiary
for Ms. Park comprises the following;
Forootan, M., Bagheri, N., & Darvishi, M. (2018). Chronic constipation. Medicine, 97(20), e10631. https://doi.org/10.1097/md.0000000000010631
Kamal, M. U., Baiomi, A., & Balar, B. (2019). Acute Diverticulitis: A Rare Cause of Abdominal Pain. Gastroenterology Research, 12(4), 203.
Munch, L., Tvistholm, N., Trosborg, I., & Konradsen, H. (2016). Living with constipation—older people’s experiences and strategies with constipation before and during hospitalization. International Journal of Qualitative Studies on Health and Well-Being, 11(1), 30732. https://doi.org/10.3402/qhw.v11.30732
Pujahari, A. K. (2016). Decision making in bowel obstruction: A review. Journal of Clinical and Diagnostic Research. https://doi.org/10.7860/jcdr/2016/22170.8923
SOAP Note Grading Rubric – modified for NUR580Fa20
|Exceptional 96 -100||Above Average 88 – 95||Average 80% – 87||Below Average <80%|
|Documentation is clear, professionally written and well organized. (10 points)
|Documentation is clear and well organized. Appropriate medical terminology is used. Redundant (repetitious words, phrases, and other distracting information are omitted). Format follows the standard template provided w/o alteration. Narratives such as the HPI and Exam have a logical flow. (10 – 9.6 points) SOAP Note: Acute Problem-Based Assessment Essay.||Documentation meets criteria for “exceptional” but there is occasional redundant of distracting information. Documentation meets criteria for clarity but needs to be better organized. Documentation with little alteration from standard format for SOAP documentation. (9.5 – 8.8 points)||Documentation meets criteria for clarity but needs to be better organized. Documentation occasionally strays from standard format for SOAP documentation. Narratives such as the HPI and Exam occasionally stray from logical sequence, but the reader can determine findings with minimal difficulty. (8.7 – 8.0 points)||Documentation does not meet expectations for the graduate level as evidenced by either of the following: lay terminology, illogical sequencing, missing essential elements, altered format of template and/or more than 2 spelling or grammatical errors. (< 8.0 – 0 points)|
|Subjective assessment is fully developed. (20 points)
|Subjective assessment of health status is fully developed. CC and HPI are targeted toward the reason for presentation without the inclusion of extraneous information. CC is succinct. HPI is fully developed and includes location, duration, timing, character, severity, provocative/palliative factors and/or other features appropriate for the reason for presentation. Elements of the PMH, FH, and ROS that expand on the CC and HPI are included. (20 – 19.2 points)||Subjective assessment is missing 1 element needed for adequate evaluation of the patient’s problem. (19 – 17.6 points)
Review of systems is inadequate, also missing other various important details under other sections, hospitalizations, oral hydration, sexual history.
|Subjective assessment is missing 2 elements needed for adequate evaluation of the patient’s problem. Includes irrelevant information. (17.4 – 16 points)||Subjective assessment is missing more than 2 critical elements needed for adequate evaluation of the patient’s problem. Irrelevant information predominates subjective assessment. (< 16 – 0 points)|
|Objective assessment is fully developed. (20 points)
|Objective assessment of health status is fully developed. Physical exam includes vital signs, height and weight as appropriate, and any relevant developmental data related to assessment of CC. Appropriate diagnostic tests are performed/ordered. (20 – 19.2 points)||Objective assessment is missing 1 element needed for adequate evaluation of the patient’s problem. Includes irrelevant information. Selection of diagnostic tests is too broad or expensive for evaluating the presentation problem OR Selection of diagnostic tests is inadequate to address the presenting problem. (19 – 17.6 points)||2 or more elements needed for adequate evaluation of a patient’s problem is missing from the objective assessment. Selection of diagnostic tests is inappropriate for CC or is missing when needed. (17.4 – 16 points)||Objective assessment is not developed and/or the assessment is inappropriate for the patient’s age, gender, and/or inappropriate for the presenting problem. (< 16 points)|
|Differential diagnoses are adequate, coherent, and appropriate. EB research applied for each differential (30 points)
|Three or more appropriately ranked differential diagnoses considered and evidence that critical thinking was utilized. Evidence-based research with listing reference used for each, as applied to subjective and objective assessments (30 – 28.8 points) SOAP Note: Acute Problem-Based Assessment Essay.||Minimum of 3 differential diagnoses selected utilized evidence-based research and critical thinking process. Evidence-based research with listing reference used for each, as applied to subjective and objective assessments (28.6 – 26.4 points)||Limited differential diagnoses (less than 3 considered) and /or minimally applicable differentials or ranked order based on evidence and critical thinking process of subjective and objective assessment. Limited reference use for one or more differential (26.2 – 24 points)||Lacks appropriate differential diagnoses and/or unacceptable for subjective and objective assessment. Lacking EBP use and use of references (< 24 – 0 points)|
|Holistic plan of care is coherent, complete, and individualized for priority differential.
EBP Guideline applied (20 points)
|DO NOT INCLUDE MEDICATIONS.
Plan is appropriate for highest priority differential diagnosis chosen and accurately addresses the problem identified. Plan is economically sound. Evidence of correct application of evidence-based guideline(s) to assessment and plan to include prevention, health promotion patient education, future diagnostic testing, and follow-up recommendations Plan is individualized to the patient’s age, physical ability, literacy, culture, religion, family, environment, education, and/or any other identified concerns uncovered in assessment. Proper APA format and style, and listed on reference page for EBP guideline use (20 – 19.2 points)
|DO NOT INCLUDE MEDICATIONS.
Plan is appropriate and meets the “exceptional” criteria but is more “generic” rather than individualized to the patient. Proper APA format and style, and listed on reference page for EBP guideline use (19-17.6 points)
|DO NOT INCLUDE MEDICATIONS.
Plan is inadequate to fully address the identified primary problem, expansive or overwhelming for the patient or healthcare system OR Needs to consider alternative features for optimal outcomes. Limited application of guideline or improper APA format and style in body or on reference page (17.4-16 points)
|DO NOT INCLUDE MEDICATIONS.
Plan is inappropriate, lacking essential components related to final diagnoses, or neglects patient education and follow-up. No reference provided and/or improper citation use – does not meet APA style and format. Failed to exclude OTC or prescription use medications (< 16 – 0 points)
See comments throughout the document.
|T=100 points||Final Grade: 89%|
Per the template…
PMH: List each known health condition and include date of initial dx, if known
PSH: List each w/date of surgery
Please follow the template….
Review of Systems: Pertinent to problem goes above in the HPI, all others go here as appropriate. See AHA textbook for details. SOAP Note: Acute Problem-Based Assessment Essay.
Did you mean to document smirking? Perhaps was the patient grimacing from her abdominal pain?
Write a holistic plan of care for the one selected highest priority differential above. Include a minimum of two evidence-based guideline used to guide your POC.
Primary Language: ___________________ Interpreter ID: ______________________
Date of Visit: _______________
Visit Method: Face-to-Face __________________ or Telehealth _______________
Site of visit: Out-patient Primary Care (internal medicine or family practice) _________, Urgent care _____, Skilled Nursing Facility_______, Other (specify) _______________.
Chief complaint: Fever and a productive cough with difficulty in breathing on attempting physical activity for the past one week. The cough has been there for the last four months and has progressively worsened.
History of present illness: The patient is a 65 year-old Caucasian male presenting with a complaint of fever, dyspnea on exertion, and a progressively worsening productive cough that brings forth whitish-yellow phlegm. He reports a previous history of these symptoms, having experienced them before at a lesser degree. He first noticed the current symptoms about five months ago when the cough started. SOAP Note: Acute Problem-Based Assessment Essay. It has been progressively worsening ever since. However, one week ago he started having fever and difficulty in breathing on attempting physical activity. The cough is located deep inside the chest and is intermittent in duration. It is a deep crackling cough with copious sputum. The cough is aggravated by activity, smoking and smoke and relieved by rest and taking homeopathic chamomile tea. The timing of the cough is mostly at night but it is still present to a lesser extent during the day. The patient rates its severity at 7/10. He denies chest pains, wheezing, or tightness of the chest.
FH: Both of his parents are deceased. The father died of a heart attack (MI) while the mother died of complications of diabetes mellitus. His father was also hypertensive. He has two siblings. The brother is hypertensive and the sister has type II diabetes and hypertension on medication. He is a father of two children, both of which are in good health so far. SOAP Note: Acute Problem-Based Assessment Essay.
Social History (detailed): The patient admits to smoking at least one pack of cigarettes per day since 1980 or the last 40 years. He has led a sedentary lifestyle most of his life since he was a manager at a local car assembly plant. His hobbies include watching movies and reading books. He admits to taking etoh over the weekends with friends in moderate quantities. He is living in a suburban neighborhood with adequate amenities, clean air, and security. He is still married with two adult children and lives with his wife. He has college education and is now retired on pension. He is an avowed atheist and loves meat and all meat products. He admits to detesting vegetables but occasionally takes “a fruit here and there”. He denies ever abusing any substance.
Allergies: NKDA, no food allergies or allergies to environmental irritants such as dust, pollen, or smoke.
Health Maintenance/Immunizations: He reports having all his required immunizations as a child. His last Tdp booster injection was in 2015, his pneumococcal vaccine was in 2019, and his latest influenza vaccination was in January 2020.
Sexual preference and practices: He is heterosexual, married and with two children.
Review of Systems:
General: He denies having any weakness or fatigue but reports fever. Denies recent weight loss.
HEENT: He denies diplopia, tearing, or blurred vision. Denies otorrhea, earache, or tinnitus. Also denies sneezing, rhinorrhea, or epistaxis. He does not have a sore throat or dysphagia. SOAP Note: Acute Problem-Based Assessment Essay.
Integumentary: He denies any rashes or itching.
Gastrointestinal: Denies nausea, vomiting, or diarrhea. He reports no change in his bowel habits and had his last bowel movement the previous night.
Cardiovascular: He denies palpitations, chest pain, or cold extremities.
Genitourinary: Denies frequency of micturition, dysuria, or any discharge.
Neurological: Denies having any fainting attacks, gait problems or paraesthesia. He also denies bladder and bowel incontinence.
Musculoskeletal: Denies arthralgia, myalgia, and joint stiffness. He does not have back pain.
Endocrinologic: He denies polydipsia and polyphagia. He also denies excessive diaphoresis, heat intolerance, or hormonal therapy.
Lymphatics: He denies lymphadenopathy or a history of splenectomy.
Hematologic: Denies a history of clotting or blood disorders.
Psychiatric: Denies ever having depression, anxiety, r any other mental condition.
Allergic/ Immunologic: Denies hives, asthma, eczema, or immunosuppression. He last got tested for HIV in 2010 and the test was negative.
General: A&O x 3. He is dressed appropriately for the weather and time of the day. He has no apparent gait disturbance or any notable tics and mannerisms. Vital signs: T 98.9°F; BP 135/75 mmHg; RR 19/ min; PR 82 b/m; SpO2 94%; Wt 110 kg; Ht 1.82 m; BMI 33.2 kg/m2. SOAP Note: Acute Problem-Based Assessment Essay.
HEENT: Head atraumatic and normocephalic. PERRLA. EOMI. No otorrhea and no cerumen in external auditory canal. Non-tender pinna and tragus. Tympanic membranes intact with no fluid levels visible bilaterally. Nasal turbinates not swollen. No evidence of polyps or rhinorrhea. Teeth have no cavities and oropharynx is moist. The throat is not erythematous and there is no exudate present.
Respiratory: Coarse crackles present. Reduced breath sounds over lung fields. The expiration phase is prolonged. Faint forced expiratory wheezes apparent at lung bases bilaterally. Breathing not labored.
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Cardiovascular: S1 & S2 audible with no murmurs or bruit. No pedal edema.
Health Promotion/ Disease Prevention: primary, secondary and/or tertiary
American Thoracic Society (2015). ICD-10-CM Coding for pulmonary medicine American Thoracic Society clinical practice committee webinar. https://www.thoracic.org/professionals/clinical-resources/resources-for-practices/ats-coding-billing-issues/resources/icd10-pulmonary-webinar.pdf
Global Initiative for Chronic Obstructive Lung Disease [GOLD] (2017). Pocket guide to COPD diagnosis, management, and prevention: A guide for health care professionals. https://goldcopd.org/wp-content/uploads/2016/12/wms-GOLD-2017-Pocket-Guide.pdf
Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8th ed. McGraw-Hill Education.
Katzung, B.G. (Ed) (2018). Basic and clinical pharmacology, 14th ed. McGraw-Hill Education. SOAP Note: Acute Problem-Based Assessment Essay.