Focused SOAP Note
Resources needed on some questions and week 4 assignment
Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Head, neck, and face disorders. In Advanced practice nursing in the care of older adults (2nd ed., pp. 127–151). F. A. Davis.
Goldberg, C. (2018b). The eye exam. In C. Goldberg, Practical guide to clinical medicine. Regents of the University of California. https://meded.ucsd.edu/clinicalmed/eyes.htm
Required Media (click to expand/reduce)
Doctors in Training [doctorsintraining]. (2016, October 18). PANCE and PANRE review course sample video—eye disorders part 1 [Video]. YouTube. https://youtu.be/lALqptCrPrs
Recommended Media (click to expand/reduce)
Engage-IL (Producer). (2017p). Nutrition for the older adult [Video]. https://engageil.com/modules/nutrition-for-the-older-adult/
Note: View the Nutrition for the Older Adult video module available in this free course.
Engage-IL (Producer). (2017q). The older adult with visual, hearing, and cognitive impairment [Video]. https://engageil.com/modules/the-older-adult-with-visual-hearing-and-cognitive-impairment/
Note: View The Older Adult with Visual, Hearing, and Cognitive Impairment video module available in this free course.
Engage-IL (Producer). (2017s). Oral health and the older adult [Video]. https://engageil.com/modules/oral-health-and-the-older-adult/
Note: View the Oral Health and the Older Adult video module available in this free course.
Assignment: Assessing, Diagnosing, and Treating Head, Neck, and Face Disorders
Photo Credit: Getty Images/Blend Images
Head, neck, and face disorders are common, and thus you will likely care for elderly patients with these disorders. In your role as an advanced practice nurse, you must be able not only to correctly assess and diagnose patients but also help patients manage the disorder by planning necessary treatments, assessments, and follow-up care.
To prepare:
• Review the case study provided by your Instructor.
• Reflect on the patient’s symptoms and aspects of disorders that may be present.
• Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the case.
• Access the Focused SOAP Note Template in this week’s Resources.
Instructions :
The Assignment:
Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:
• Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. Provide a review of systems.
• Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results?
• Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential in or out. Explain you critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
• Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.
• Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. Follow APA 7th edition formatting.
NOTE!!!!!!!
6540 NRNP Week 4 Begins Dec. 20 – Head, Neck, and Face Disorders
IMPORTANT FEEDBACK:
Please complete the required readings and media, use these in your references as appropriate.
Please review the Rubric provided in BB.
Submit in the Originality report section.
Just a reminder that you are responsible to read all the required readings for the week in BB, all the information & rubrics, as well as all of the feedback that I give you. The information that I provided included that soap notes are virtual: meaning that as the student you fill in any missing or pertinent information that you feel is important to the case (YES, you are ‘filling in the blanks” Use your experience with past patients to do this).
This would include VS (if not given) – you can choose a weight, and you will need to calculate the BMI – which is easy to do on your phone, ROS, PE, FH, SH, etc. You also need to provide a paragraph for diagnostics and lab results ( as an NP these are put at the end of the PE, not interspersed in the ROS or PE). This is a major difference between a nursing note and a medical note. I will take points off if there are lab results in the ROS or PE.
CHOICE CASE STUDY:
PLEASE CHOOSE ONE OF THE CASES BELOW FOR YOUR SOAP NOTE:
Week 4 Case 1
A 76-year-old woman presents today with complaints of nasal drainage, clearing of throat, and occasional nasal congestion, especially on waking in the morning. She has recently moved into an independent living center after living in her home for 40 years. She states that, although she has had these symptoms before, generally the symptoms appeared in the spring, and she associated the nasal drainage with pollination. Because it is winter, she could not identify the trigger of her symptoms.
Chief complaint: Persistent “runny nose” for 3-week duration, associated clearing of throat, and nasal congestion on awakening in the morning.
Objective data: Blood pressure (BP) 130/84, temperature 98.6, pulse 78, respiratory rate 20. WT:___ BMI:____
What further ROS questions will you want to ask her? List at least three.
What physical exam (PE) will you perform on this patient? List at least three.
What are the differential diagnoses that you are considering? Describe at least four.
What laboratory tests will help you rule out some of the differential diagnoses?
You have determined, by choosing your ROS, PE, and differential diagnosis, that this patient has allergic rhinitis (AR). Describe the treatment options for your diagnosis, and what specific information about the prescription will you give to this patient? List at least two treatment options: medications with dose, side effects and/or cautions in the older adult.
When will you have the patient follow up? Be specific.
Write a focused SOAP note for this case. Choose the ROS, PE, and medications you will use in your SOAP note.
Week 4 Case 2
CC: My wife seems to be having trouble hearing me when I talk. She is turning the TV up loud.
HPI: Mary is an 88-year-old African American (AA) female married for 50 years to Albert. Albert complains that Mary cannot hear or hears but does not understand (especially in a group); turns up radio or television louder to hear (also noted by family, friends, and neighbors); Mary complains of tinnitus; and she feels like people are “mumbling.”
PMH: Mary takes ramipril for hypertension (HTN), a baby aspirin for cardio protection, and a statin for hypercholesterolemia.
Vital signs are 120/88 P: 88 P02: 96% WT: 156 HT: 5’6” BMI:_____
ROS: Ask if Mary has had any exposure to ototoxic drugs or other otic damage in the past. Describe at least three.
PE: What examinations will you perform on the ear? Describe the areas of the ear you will evaluate and what you will expect to find.
Diagnostic Testing: Please describe at least three (3) methods to test for hearing.
You determine that Mary has a hearing deficit and tinnitus. What differential diagnoses do you want to consider? Describe at least three.
What will your treatment plan for this patient be?
What other recommendations will you make (i.e., screening)?
What referrals will you make?
Education: Name at least two things you will educate your patient about regarding their hearing.
Choose the ROS, PE, and DD and final diagnosis for this patient, and then write up your focused SOAP note.
Focused SOAP Note
Patient Information:
M, 88, F, AA
S (subjective)
CC (chief complaint): My wife seems to be having trouble hearing me when I talk. She is turning the TV up loud.
HPI (history of present illness): Mary is an 88-year-old African American (AA) female married for 50 years to Albert. Albert complains that Mary cannot hear or hears but does not understand (especially in a group); turns up radio or television louder to hear (also noted by family, friends, and neighbors); Mary complains of tinnitus; and she feels like people are “mumbling.”
Current Medications:
Ramipril
Baby aspirin
Statin
Allergies: No known drug or food allergies.
PMHx: Mary takes ramipril for hypertension (HTN), a baby aspirin for cardio protection, and a statin for hypercholesterolemia.
Soc and Substance Hx: Lives with the husband Albert who complains the wife cannot hear television or radio and she need to increase the volume. No history of drug and alcohol abuse.
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.
Surgical Hx: Prior surgical procedures.
Mental Hx: No history of depression, anxiety, or suicidal ideation.
Violence Hx: No history of physical violence at home or in the neighborhood. No history of sexual violence.
Reproductive Hx: The 88-year-old patient is above reproductive age. Her last menstrual date is not known. She is married but it is not clear if she is sexually active.
ROS (review of symptoms):
GENERAL: No unintentional weight loss of gain, fatigue, fever, chills, and body weakness.
HEENT:
• Eyes: No visual loss, double vision, or blurred vision.
• Ears, Nose, Throat: No hearing loss, nasal congestion, or sore throat.
SKIN: No itching, bruises, or lesions.
CARDIOVASCULAR: No chest pain, discomfort, edema, or chest pressure.
RESPIRATORY: No coughing, sputum, or shortness of breath.
GASTROINTESTINAL: No nausea, diarrhea, or vomiting. No abdominal pain or blood in the stool.
GENITOURINARY: No burning sensation on urination. Last menstrual period date is unknown.
NEUROLOGICAL: No dizziness, tingling in the extremities, or headache. No changes in bowel or bladder control.
MUSCULOSKELETAL: No joint or muscle pain, or stiffness.
HEMATOLOGIC: No bleeding, bruising, or signs of anemia.
LYMPHATICS: No history of splenectomy or enlarged nodes.
PSYCHIATRIC: No history of mania, depression, or anxiety.
ENDOCRINOLOGIC: No history of sweating, polyuria or polydipsia.
REPRODUCTIVE: No history of recent pregnancy, vaginal discharge or sexual intercourse.
ALLERGIES: No history rhinitis, hives, or eczema.
O (objective)
Physical exam:
120/88 P: 88 P02: 96% WT: 156 HT: 5’6”
Diagnostic results:
Otoscopy- examination of external ear, wax in the ear can be easily visualized.
Rinne’s test to check hearing loss
Weber’s test – these are tests to find out type of hearing loss based on clinical examination.
Pure tone audiometry- I will also get patient’s audiometry done.
Visualization of ear by x-ray, CT scan to assess for any blockage.
A (assessment)
Differential diagnoses:
Wax in the ear – mostly causes conductive deafness. Tinnitus may or may not be present. Ear wax is normally secreted to protect the ear and it naturally cleanses itself. Accumulation of too much wax can affect the ear causing hearing difficulty (Di Stadio et al., 2018). Wax in the ear is the most common cause of conductive hearing loss.
Meniere’s disease- deafness, tinnitus, and vertigo is present. The condition causes a ringing sound in the ear. It makes individuals experience hearing difficulty (Hannigan et al., 2019). Some of the causes of the condition include stress, fatigue, emotional distress, pressure changes, and other health complications.
Cerebellopontine angle tumor- these tumors also present with deafness and tinnitus. The most common condition is vestibular schwannoma. One of the common symptoms is the sudden loss of hearing capacity. The growth may cause pressure on the ear nerves leading to hearing loss.
Otosclerosis – the patient could be at risk of otosclerosis. Additional diagnostic tests are necessary to avert health complications (Mkrtchyan et al., 2021). The condition involves the inability of the bone to vibrate to allow the ear to detect sounds.
P (plan)
The patient should start the medication to fight the bacterial infection that can cause hearing loss. Gentamicin 10ml BID is effective to clear the ear for hearing loss problems.
Amikacin 250 mg/ml is an antibacterial used to treat infections that can cause hearing loss. The patient should be observed due to side effects such as diarrhea, dizziness, and numbness (Mkrtchyan et al., 2021).
Streptomycin is effective for the treatment of hearing loss since it causes less ototoxicity compared to other drugs.
A practitioner will carry out a physical examination to determine if the wax in the ear is causing hearing loss (Weiss et al., 2020). The treatment will include removing the wax and checking if the patient can improve on the hearing ability.
Reflection.
I learned that different causes of hearing loss can affect patients at different ages. I learned that effective diagnosis and treatment of hearing loss is effective for recovery. The recovery will require follow-up to ensure improvement (Weiss et al., 2020). I learned that patients can experience hearing loss due to old age. Appropriate diagnosis and treatment are effective for recovery.
The patient should adhere to the treatment and come back to the clinic for two weeks. The husband should ensure the wife is taking the medication and monitor the improvement. In case the patient does not improve, a CT scan could be necessary to examine the cause of the hearing loss.
During the treatment, it is effective to provide information to the patient to obtain informed consent. The patient should receive treatment without discrimination. Justice is a core value in the administration of care (McDermott-Levy et al., 2018). Veracity involves telling the patient the truth to ensure they know about their illness and appropriate treatment. The patient should be informed about the risk factors of hearing loss and the side effects of the medication (McDermott-Levy et al., 2018).
During the treatment, it is vital to examine the risk factors that can cause hearing loss. Elderly patients with diabetes or high blood pressure are at risk of hearing loss. A heart condition, stroke, or brain injury can lead to hearing loss (Di Stadio et al., 2018). Collaboration with other healthcare workers is effective in the recovery of the patient.
The patient should avoid risk factors that can cause adverse health outcomes. For instance, loud noises such as television or radio can affect the patient. The patient should avoid exposure to dust which can affect the patient or cause accumulation of wax.
The patient should adhere to treatment and come back for Assessment after two weeks.
References
Di Stadio, A., Dipietro, L., Ricci, G., Della Volpe, A., Minni, A., Greco, A., … & Ralli, M. (2018). Hearing loss, tinnitus, hyperacusis, and diplacusis in professional musicians: A systematic review. International journal of environmental research and public health, 15(10), 2120.
Hannigan, I. P., Welgampola, M. S., & Watson, S. R. (2019). Dissociation of caloric and head impulse tests: a marker of Meniere’s disease. Journal of Neurology, 1-9.
McDermott-Levy, R., Leffers, J., & Mayaka, J. (2018). Ethical principles and guidelines of global health nursing practice. Nursing outlook, 66(5), 473-481.
Mkrtchyan, N., Alciato, L., Kalamarides, M., Bernardeschi, D., Sterkers, O., Bernat, I., … & Lahlou, G. (2021). Hearing recovery after surgical resection of non-vestibular schwannoma cerebellopontine angle tumors. European Archives of Oto-Rhino-Laryngology, 1-10.
Weiss, R., Loth, A., Leinung, M., Balster, S., Hirth, D., Stöver, T., … & Kramer, S. (2020). A new adhesive bone conduction hearing system as a treatment option for transient hearing loss after middle ear surgery. European Archives of Oto-rhino-laryngology, 277(3), 751-759.
