Under is an instance to comply with :
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Complete SOAP Exemplar
Goal: To demonstrate what each section of the SOAP note should embody. Keep in mind that Nurse Practitioners deal with sufferers in a holistic method and your SOAP note should replicate that premise.
Affected person Initials: _______ Age: _______ Gender: _______
SUBJECTIVE DATA:
Chief Grievance (CC): Coughing up phlegm and fever
Historical past of Current Sickness (HPI): Eddie Myers is a 58 yr outdated African American male who presents immediately with a productive cough x three days, fever, muscle aches, loss of style and scent for the final three days. He reported that the “chilly seems like it’s descending into his chest and he can’t eat a lot”. The cough is nagging and productive. He introduced in just a few paper towels with expectorated phlegm – yellow/inexperienced in coloration. He has related signs of dyspnea of exertion and fatigue. His Tmax was reported to be 100.three, final evening. He has been taking Tylenol 325mg about each 6 hours and the fever breaks, however returns after the medicine wears off. He rated the severity of her symptom discomfort at eight/10.
Drugs:
1.) Norvasc 10mg each day
2.) Combivent 2 puffs each 6 hours as wanted
three.) Advair 500/50 each day
four.) Singulair 10mg each day
5.) Over the counter Tylenol 325mg as wanted
6.) Over the counter Benefiber
7.) Flonase 1 spray each evening as wanted for allergic rhinitis signs
Allergy symptoms:
Sulfa medicine – rash
Cipro-headache
Previous Medical Historical past (PMH):
1.) Bronchial asthma
2.) Hypertension
three.) Osteopenia
four.) Allergic rhinitis
5.) Prostate Most cancers
Previous Surgical Historical past (PSH):
1.) Cholecystectomy 1994
2.) Prostatectomy 1986
Sexual/Reproductive Historical past:
Heterosexual
Private/Social Historical past:
He has by no means smoked
Dipped tobacco for 25 years, now not dipping
Denied ETOH or illicit drug use.
Immunization Historical past:
Covid Vaccine #1 three/2/2021 #2 four/2/2021 Moderna
Influenza Vaccination 10/three/2020
PNV 9/18/2018
Tdap eight/22/2017
Shingles three/22/2016
Vital Household Historical past:
One sister – with diabetes, dx at age 65
One brother–with prostate CA, dx at age 62. He has 2 daughters, each in 30’s, wholesome, dwelling in close by neighborhood.
Way of life:
He works FT as Xray Tech; widowed x eight years; lives in the metropolis, reasonable crime space, with good public transportation. He’s a university grad, owns his house and financially secure.
He has a major care nurse practitioner supplier and goes for annual and routine care twice yearly and as wanted for episodic care. He has medical insurance coverage however usually asks for drug samples for price financial savings. He has a nutritious diet and consuming sample. There are sources and neighborhood teams in his space at the senior heart however he doesn’t attend. He enjoys golf and strolling. He has an excellent Help system composed of household and associates.
Overview of Techniques:
Basic: + fatigue since the sickness began; + fever, no chills or evening sweats; no current weight features of losses of significance.
HEENT: no adjustments in imaginative and prescient or listening to; he does put on glasses and his final eye examination was 6 months in the past. He reported no historical past of glaucoma, diplopia, floaters, extreme tearing or photophobia. He does have bilateral small cataracts which are being adopted by his ophthalmologist. He has had no current ear infections, tinnitus, or discharge from the ears. He reported no sense of scent. He has not had any episodes of epistaxis. He doesn’t have a historical past of nasal polyps or current sinus an infection. He has historical past of allergic rhinitis that’s seasonal. His final dental examination was 1/2020. He denied ulceration, lesions, gingivitis, gum bleeding, and has no dental home equipment. He has had no problem chewing or swallowing.
Neck: Denies ache, damage, or historical past of disc illness or compression..
Breasts:. Denies historical past of lesions, plenty or rashes.
Respiratory: + cough and sputum manufacturing; denied hemoptysis, no problem respiration at relaxation; + dyspnea on exertion; he has historical past of bronchial asthma and neighborhood acquired pneumonia 2015. Final PPD was 2015. Final CXR – 1 month in the past.
CV: denies chest discomfort, palpitations, historical past of murmur; no historical past of arrhythmias, orthopnea, paroxysmal nocturnal dyspnea, edema, or claudication. Date of final ECG/cardiac work up is unknown by affected person.
GI: denies nausea or vomiting, reflux managed, Denies abd ache, no adjustments in bowel/bladder sample. He makes use of fiber as a each day laxative to forestall constipation.
GU: denies change in her urinary sample, dysuria, or incontinence. He’s heterosexual. No denies historical past of STD’s or HPV. He’s sexually lively together with his very long time girlfriend of four years.
MS: he denies arthralgia/myalgia, no arthritis, gout or limitation in her vary of movement by report. denies historical past of trauma or fractures.
Psych: denies historical past of anxiousness or despair. No sleep disturbance, delusions or psychological well being historical past. He denied suicidal/homicidal historical past.
Neuro: denies syncopal episodes or dizziness, no paresthesia, head aches. denies change in reminiscence or considering patterns; no twitches or irregular actions; denies historical past of gait disturbance or issues with coordination. denies falls or seizure historical past.
Integument/Heme/Lymph: denies rashes, itching, or bruising. She makes use of lotion to forestall dry pores and skin. He denies historical past of pores and skin most cancers or lesion elimination. She has no bleeding issues, clotting difficulties or historical past of transfusions.
Endocrine: He denies polyuria/polyphagia/polydipsia. Denies fatigue, warmth or chilly intolerances, shedding of hair, unintentional weight acquire or weight reduction.
Allergic/Immunologic: He has hx of allergic rhinitis, however no recognized immune deficiencies. His final HIV take a look at was 2 years in the past.
OBJECTIVE DATA
Bodily Examination:
Very important indicators: B/P 144/98, left arm, sitting, common cuff; P 90 and common; T 99.9 Orally; RR 16; non-labored; Wt: 221 lbs; Ht: 5’5; BMI 36.78
Basic: A&O x3, NAD, seems mildly uncomfortable
HEENT: PERRLA, EOMI, oronasopharynx is evident
Neck: Carotids no bruit, jvd or thyromegally
Chest/Lungs: Lungs pos wheezing, pos for scattered rhonchi
Coronary heart/Peripheral Vascular: RRR with out murmur, rub or gallop; pulses+2 bilat pedal and +2 radial
ABD: nabs x four, no organomegaly; gentle suprapubic tenderness – diffuse – no rebound
Genital/Rectal: pt declined for this examination
Musculoskeletal: symmetric muscle improvement – some age associated atrophy; muscle strengths 5/5 all teams.
Neuro: CN II – XII grossly intact, DTR’s intact
Pores and skin/Lymph Nodes: No edema, clubbing, or cyanosis; no palpable nodes
Diagnostics/Lab Checks and Outcomes:
CBC – WBC 15,000 with + left shift
SAO2 – 98%
Covid PCR-neg
Influenza- neg
Radiology:
CXR – cardiomegaly with air trapping and elevated AP diameter
ECG
Regular sinus rhythm
Spirometry- FEV1 65%
Assessment:
Differential Prognosis (DDx):
1.) Asthmatic exacerbation, reasonable
2.) Pulmonary Embolism
three.) Lung Most cancers
Major Diagnoses:
1.) Asthmatic Exacerbation, reasonable
PLAN: [This section is not required for the assignments in this course, but will be required for future courses.]
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