NRNP Focused SOAP NoteASSESSING, DIAGNOSING, AND TREATING MUSCULOSKELETAL AND NEUROLOGIC DISORDERS
Consider the example of Sue from the case study in Chapter 13 of your textbook:
Sue is a 68-year-old healthy woman with no significant medical history. She is in the office today with complaint of intractable nausea and vomiting for the past 5 weeks with an 11-pound weight loss. On review of systems she also has noted a dull, persistent headache, difficulty with concentration, and some blurred vision. (Kennedy-Malone et al., 2019, p. 359)
Sue also has a notable family history of diabetes and heart attack. How would you, as an advanced practice nurse, assess, diagnose, and treat Sue? What specific considerations related to the older adult population would you need to consider? Keep these thoughts in mind as you examine this week’s case study.
Reference:
Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. G. (2019). Advanced practice nursing in the care of older adults (2nd ed., p. 359). F. A. Davis.
RESOURCES
• Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Musculoskeletal disorders. In Advanced practice nursing in the care of older adults (2nd ed., pp. 305–327). F. A. Davis.
• Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Central and peripheral nervous system disorders. In Advanced practice nursing in the care of older adults (2nd ed., pp. 328–360). F. A. Davis.
• Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Appendix B: Laboratory Values in the Older Adult. In Advanced practice nursing in the care of older adults (2nd ed., pp. 505–506). F. A. Davis.
Note: See the labs that are relevant to this week’s topics.
• Hammond, L., & Moseley, K. (2019). Medication and fall safety for older adultsLinks to an external site.. Nursing Made Incredibly Easy!, 17(3), 16–19. https://doi.org/10.1097/01.Nme.0000554604.14103.50
• U.S. Preventive Services Task Force. (2018). Clinical Summary: Falls prevention in community-dwelling older adults: InterventionsLinks to an external site.. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/falls-prevention-in-older-adults-interventions
• Document: Focused SOAP Note Template (Word Document)
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
WEEKLY RESOURCES
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.
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.
Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S (subjective)
CC (chief complaint): a BRIEF statement identifying why the patient is here, stated in the patient’s own words (for instance “headache,” NOT “bad headache for 3 days”).
HPI (history of present illness): 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 over the counter (OTC) or homeopathic products.
Allergies: Include medication, food, and environmental allergies separately, including a description of what the allergy is (i.e., angioedema, anaphylaxis, etc.). This will help determine a true reaction versus 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 and Substance Hx: Include occupation and major hobbies, family status, tobacco and alcohol use (previous and current use), and 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.
Surgical Hx: Prior surgical procedures.
Mental Hx: Diagnosis and treatment. Current concerns (anxiety and/or depression). History of self-harm practices and/or suicidal or homicidal ideation.
Violence Hx: Concern or issues about safety (personal, home, community, sexual (current and historical).
Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse (oral, anal, vaginal, other, any sexual concerns).
ROS (review of symptoms): 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 (eyes, ears, nose, and throat):
• Etc.:
Note: You should list these in bullet format, and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT:
• Eyes: No visual loss, blurred vision, double vision or yellow sclerae.
• Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Last menstrual period (LMP), MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
REPRODUCTIVE: Not pregnant and no recent pregnancy. No reports of vaginal or penile discharge. Not sexually active.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
O (objective)
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 (assessment)
Differential diagnoses: List a minimum of three 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.
P (plan)
Includes documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, and any planned follow up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.
Also included in this section is the reflection. Reflect on this case, and discuss what you learned, including any “aha” moments or connections you made.
Also include in your reflection, a discussion related to health promotion and disease prevention taking into consideration patient factors (such as, age, ethnic group, etc.), PMH, and other risk factors (e.g., socio-economic, cultural background, etc.).
References
You are required to include 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 to use correct APA 7th edition formatting.
ChatGPT
Patient Information:
Initials: S.S, Age: 68, Sex: Female, Race: White
S (subjective)
CC (chief complaint): Nausea and vomiting for the past 5 weeks with an 11-pound weight loss, dull, persistent headache, difficulty with concentration, and some blurred vision.
HPI (history of present illness): The patient, S.S, is a 68-year-old female with no significant medical history. She is presenting with symptoms of intractable nausea and vomiting for the past 5 weeks with an 11-pound weight loss, dull, persistent headache, difficulty with concentration, and some blurred vision. The patient reports feeling weak and tired. She has been taking OTC medication for nausea and vomiting, but it has not helped. She has not seen a doctor for these symptoms.
PMH (past medical history): None reported.
FH (family history): Diabetes and heart attack.
Meds (medications): None reported.
Allergies: None reported.
ROS (review of systems):
Constitutional: Weakness, fatigue, and unintentional weight loss.
Eyes: Blurred vision.
Head: Dull, persistent headache.
Neurological: Difficulty with concentration.
GI: Nausea and vomiting.
O (objective)
Physical examination:
Vital signs: Blood pressure: 135/85 mmHg, heart rate: 80 beats per minute, respiratory rate: 18 breaths per minute, temperature: 98.6°F, and oxygen saturation: 98% on room air.
General: The patient appears to be weak and tired.
Eyes: Pupils are equal and reactive to light, extraocular movements are intact.
Head: Normocephalic, atraumatic.
Neurological: Alert and oriented to person, place, and time. No focal neurological deficits.
GI: Abdomen soft, non-tender, and non-distended.
A (assessment)
Differential Diagnosis:
Brain tumor: This is a top priority differential diagnosis as the patient has a dull, persistent headache, blurred vision, and difficulty with concentration. Further diagnostic tests like brain imaging would be needed to confirm or rule out this diagnosis.
Migraine: This is a possible differential diagnosis as the patient is presenting with a headache and blurred vision. However, there is no history of migraines or a family history of migraines.
Gastrointestinal disorder: This is a possible differential diagnosis as the patient is presenting with intractable nausea and vomiting and an 11-pound weight loss. Further diagnostic tests like blood tests and imaging of the GI tract would be needed to confirm or rule out this diagnosis.
Primary Diagnosis: Brain tumor. Pertinent positives: Dull, persistent headache, blurred vision, and difficulty with concentration.
Pertinent negatives: No focal neurological deficits, no history of migraines or a family history of migraines.
Plan:
Diagnostic studies: MRI of the brain and CBC, CMP, LFTs, and UA will be ordered.
Referrals: Referral to a neurologist for further Assessment and management.
Therapeutic interventions: Antiemetic medication, as needed for nausea and vomiting, and steroid medication, as needed for brain edema.
Education: Educate the patient and her family on the diagnosis and treatment options. Provide instructions on medication administration and side effects.
Disposition: The patient will be referred to a neurologist for further Assessment and management.
Follow-up: The patient will follow up with the neurologist in 2 weeks.
Health promotion and disease prevention: Encourage the patient to maintain a healthy lifestyle, including regular exercise and a balanced diet. Also, encourage the patient to have regular check-ups and cancer screenings.
References
American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society, 67(4), 674-694. doi: 10.1111/jgs.15767
Boudreau, R. M., Hanlon, J. T., Roumani, Y. F., Studenski, S. A., Ruby, C. M., Wright, R. M., … & Shorr, R. I. (2018). Central nervous system medication use and incident mobility limitation in community elders: The Health, Aging, and Body Composition study. Pharmacoepidemiology and Drug Safety, 27(2), 196-205. doi: 10.1002/pds.4363
Eidsvik, S., Rinholm, M., Reikerås, O., & Røkkum, M. (2019). Effects of a new balance orthotic device on perceived instability, balance confidence, and postural sway in elderly persons with instability: a randomized controlled trial. Journal of Foot and Ankle Research, 12(1), 1-11. doi: 10.1186/s13047-019-0352-2
Kuo, P. L., Lin, H. T., & Yang, C. T. (2019). The effect of nurse-led home exercise program on improving physical performance in older adults with osteoarthritis: a randomized controlled trial. Clinical Interventions in Aging, 14, 323-331. doi: 10.2147/CIA.S196982
U.S. Preventive Services Task Force.
