NURS 6512: Advanced Health Assessment and Diagnostic Reasoning

Comprehensive SOAP Exemplar

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Purpose: To demonstrate what each section of the SOAP note should include. Remember that Nurse Practitioners treat patients in a holistic manner and your SOAP note should reflect that premise.

 

Patient Initials: _______                 Age: _______                                   Gender: _______

 

SUBJECTIVE DATA:

 

Chief Complaint (CC): Coughing up phlegm and fever

 

History of Present Illness (HPI): Eddie Myers is a 58 year old African American male who presents today with a productive cough x 3 days, fever, muscle aches, loss of taste and smell for the last three days. He reported that the “cold feels like it is descending into his chest and he can’t eat much”. The cough is nagging and productive. He brought in a few paper towels with expectorated phlegm – yellow/green in color. He has associated symptoms of dyspnea of exertion and fatigue. His Tmax was reported to be 100.3, last night. He has been taking Tylenol 325mg about every 6 hours and the fever breaks, but returns after the medication wears off. He rated the severity of her symptom discomfort at 8/10.

 

Medications:

• Norvasc 10mg daily
• Combivent 2 puffs every 6 hours as needed
• Advair 500/50 daily
• Singulair 10mg daily
• Over the counter Tylenol 325mg as needed
• Over the counter Benefiber
• Flonase 1 spray each night as needed for allergic rhinitis symptoms

 

Allergies:

Sulfa drugs – rash

Cipro-headache

 

Past Medical History (PMH):

1.) Asthma

2.) Hypertension

3.) Osteopenia

4.) Allergic rhinitis

5.) Prostate Cancer

 

Past Surgical History (PSH):

• Cholecystectomy 1994
• Prostatectomy 1986

 

Sexual/Reproductive History:

Heterosexual

 

Personal/Social History:

He has never smoked

Dipped tobacco for 25 years, no longer dipping

Denied ETOH or illicit drug use.

 

Immunization History:

Covid Vaccine #1 3/2/2021 #2 4/2/2021 Moderna

Influenza Vaccination 10/3/2020

PNV 9/18/2018

Tdap 8/22/2017

Shingles 3/22/2016

 

Significant Family History:

One sister – with diabetes, dx at age 65

One brother–with prostate CA, dx at age 62. He has 2 daughters, both in 30’s, healthy, living in nearby neighborhood.

 

Lifestyle:

He works FT as Xray Tech; widowed x 8 years; lives in the city, moderate crime area, with good public transportation. He is a college grad, owns his home and financially stable.

 

He has a primary care nurse practitioner provider and goes for annual and routine care twice annually and as needed for episodic care. He has medical insurance but often asks for drug samples for cost savings. He has a healthy diet and eating pattern. There are resources and community groups in his area at the senior center but he does not attend. He enjoys golf and walking. He has a good support system composed of family and friends.

 

Review of Systems:

 

General: + fatigue since the illness started; + fever, no chills or night sweats; no recent weight gains of losses of significance.

 

HEENT: no changes in vision or hearing; he does wear glasses and his last eye exam was 6 months ago. He reported no history of glaucoma, diplopia, floaters, excessive tearing or photophobia. He does have bilateral small cataracts that are being followed by his ophthalmologist. He has had no recent ear infections, tinnitus, or discharge from the ears. He reported no sense of smell. He has not had any episodes of epistaxis. He does not have a history of nasal polyps or recent sinus infection. He has history of allergic rhinitis that is seasonal. His last dental exam was 1/2020. He denied ulceration, lesions, gingivitis, gum bleeding, and has no dental appliances. He has had no difficulty chewing or swallowing.

 

Neck: Denies pain, injury, or history of disc disease or compression..

 

Breasts:. Denies history of lesions, masses or rashes.

 

Respiratory: + cough and sputum production; denied hemoptysis, no difficulty breathing at rest; + dyspnea on exertion; he has history of asthma and community acquired pneumonia 2015. Last PPD was 2015. Last CXR – 1 month ago.

 

CV: denies chest discomfort, palpitations, history of murmur; no history of arrhythmias, orthopnea, paroxysmal nocturnal dyspnea, edema, or claudication. Date of last ECG/cardiac work up is unknown by patient.

 

GI: denies nausea or vomiting, reflux controlled, Denies abd pain, no changes in bowel/bladder pattern. He uses fiber as a daily laxative to prevent constipation.

 

GU: denies change in her urinary pattern, dysuria, or incontinence. He is heterosexual. No denies history of STD’s or HPV. He is sexually active with his long time girlfriend of 4 years.

 

MS: he denies arthralgia/myalgia, no arthritis, gout or limitation in her range of motion by report. denies history of trauma or fractures.

 

Psych: denies history of anxiety or depression. No sleep disturbance, delusions or mental health history. He denied suicidal/homicidal history.

 

Neuro: denies syncopal episodes or dizziness, no paresthesia, head aches. denies change in memory or thinking patterns; no twitches or abnormal movements; denies history of gait disturbance or problems with coordination. denies falls or seizure history.

 

Integument/Heme/Lymph: denies rashes, itching, or bruising. She uses lotion to prevent dry skin. He denies history of skin cancer or lesion removal. She has no bleeding disorders, clotting difficulties or history of transfusions.

 

Endocrine: He denies polyuria/polyphagia/polydipsia. Denies fatigue, heat or cold intolerances, shedding of hair, unintentional weight gain or weight loss.

 

Allergic/Immunologic: He has hx of allergic rhinitis, but no known immune deficiencies. His last HIV test was 2 years ago.

 

 

OBJECTIVE DATA

 

Physical Exam:

Vital signs: B/P 144/98, left arm, sitting, regular cuff; P 90 and regular; T 99.9 Orally; RR 16; non-labored; Wt: 221 lbs; Ht: 5’5; BMI 36.78

General: A&O x3, NAD, appears mildly uncomfortable

HEENT: PERRLA, EOMI, oronasopharynx is clear

Neck: Carotids no bruit, jvd or thyromegally

Chest/Lungs: Lungs pos wheezing, pos for scattered rhonchi

Heart/Peripheral Vascular: RRR without murmur, rub or gallop; pulses+2 bilat pedal and +2 radial

ABD:  nabs x 4, no organomegaly; mild suprapubic tenderness – diffuse – no rebound

Genital/Rectal: pt declined for this exam

Musculoskeletal: symmetric muscle development – some age related atrophy; muscle strengths 5/5 all groups.

Neuro: CN II – XII grossly intact, DTR’s intact

Skin/Lymph Nodes: No edema, clubbing, or cyanosis; no palpable nodes

 

 

Diagnostics/Lab Tests and Results:

CBC – WBC 15,000 with + left shift

SAO2 – 98%

Covid PCR-neg

Influenza- neg

Radiology:

CXR – cardiomegaly with air trapping and increased AP diameter

ECG

Normal sinus rhythm

Spirometry- FEV1 65%

 

Assessment:

 

Differential Diagnosis (DDx):

• Asthmatic exacerbation, moderate
• Pulmonary Embolism
• Lung Cancer

 

Primary Diagnoses:

 

1.) Asthmatic Exacerbation, moderate

 

PLAN: [This section is not required for the assignments in this course, but will be required for future courses.]

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SAMPLE SOLUTION: NURS 6512: Advanced Health Assessment and Diagnostic Reasoning

Patient Information:

 

Initials: M.G

 Age: 47 years Sex: Female Race: Caucasian S.

CC: “I’m experiencing pain in the joint of my right wrist, as well as tingling and numbness in my right hand and right index finger”

 

HPI: M.G. is a Caucasian female who is 47 years old and has come with symptoms of discomfort in the joint of her right wrist. There is numbness in the thumb, index and middle fingers, according to her, which she attributes to the discomfort. The symptoms began appearing around two weeks ago and came on gradually at first. On a scale from 0 to 10, she gives the pain in her wrist a score of 2 while it is motionless, but it rises to a score of 7 when she is moving the joint. The pain is characterized as aching and radiates down the ventral side of the forearm toward the elbow. The pain is made worse by repeated motion of the joint, particularly while she is styling the hair, which is one of the activities that she often engages in. Taking ibuprofen and resting the affected joint are both effective ways to alleviate the pain. She said that she is experiencing a great deal of frustration as a result of the sensations because she’s a hairdresser, and the discomfort leads her to drop her hair styling items.

Current Medication:

 

 

Ibuprofen 400 mg PO PRN

Allergies: Allergic to cats and dust. NKDA

 

PMHx: Asthma

 

Soc Hx: M.G. is a professional hairdresser who works in a hair salon. She admitts to using alcohol on an occasional basis in the past. He denies having a history of using illegal substances and smoking cigarettes. She has been married for three years and now resides with her husband and their three children. Swimming and watching television are two of her favorite things to do in her spare time.

Fam Hx: Father: Hypertension Mother: Hypothyroidism Brother: obesity Sister: healthy

ROS

 

GENERAL: denies fever, chills, weakness, recent weight change, or loss of appetite

HEENT: Head: denies headache or injury. Eye: denies eye pain, eye discharge, visual loss, or blurred vision. Ear: denies ear pain, ear discharge, tinnitus, or loss of hearing. Nose: denies runny nose or nasal congestion. Throat: denies sore throat or difficulty in swallowing.

SKIN: denies itching and rash

CARDIOVASCULAR: denies chest pain, palpitations, or edema,

RESPIRATORY: denies cough, shortness of breath, or wheezing

 

GASTROINTESTINAL: denies abdominal pain, nausea, vomiting , diarrhea, or heartburn

GENITOURINARY: denies incontinence, dysuria, or hematuria

NEUROLOGICAL: Reports numbness and tingling on thumb, index finger, and middle finger. denies dizziness, headache, ataxia, or vertigo.

MUSCULOSKELETAL: Reports right wrist joint pain. Denies muscle pain, back pain, joint swelling, or joint stiffness.

HEMATOLOGIC: denies bleeding, anemia, or easy bruising.

LMPHATICS: denies swollen lymph nodes or history of splenectomy

PSYCHIATRY: denies depression, anxiety, or history of mental illness.

ENDOCRINOLOGIC: denies polyuria, polydipsia, excessive sweating, or heat or cold intolerance ALLERGIES: denies asthma, hives, rhinitis, or eczema.

O.

Vital signs: BP- 116/69 mmHg, HR-79, RR-17, Temp- 98.0, SpO2-97%, Ht- 5’4”, Wt- 143 lbs., BMI-21.3

General– well-groomed and well-nourished. Alert and oriented x3. Maintains eye contact. Clear and coherent speech.

HEENT: Head: normocephalic, atraumatic, normal hair distribution, no edema. Eye: white sclera, pink conjunctiva, no eye discharge. Normal visual acuity, extraocular movements intact, PERRLA. Ear: No abnormalities in external auditory canal. Tympanic membrane clear and not bulging. Throat: moist and pink oral mucous membrane, the uvula in the midline. No erythema or edema in posterior pharynx.

Musculoskeletal: weakened right thumb abduction, reduced strength at 3/5.No joint edema, and all her limbs are present. Phalen sign and Hoffmann-Tinel sign test positive. Other limb’s muscle strength is 5/5.

 

 

Skin: it is warm, dry skin, no lesions or rash noted

Cardiovascular: S₁ and S₂ noted, no gallops, murmurs or rubs. Capillaryrefill less than 3 seconds.

Gastrointestinal: soft, warm abdomen, no abnormalities. Normoactive bowel sounds in all quadrants.

Genitourinary: normal external genitalia, no vaginal discharge. Non-palpable bladder, no suprapubic tenderness.

Neurological: alert and is oriented to person, place, and time. Cooperative. Cranial nerves grossly intact with normal reflexes.

Diagnostic tests:

Nerve conduction test- positive

A.

Differential diagnosis

Carpal tunnel syndrome– This is a collection of symptoms and indicators that are typical of the condition that results from pressure being placed on the median nerve inside the carpal tunnel. Numbness and paresthesia are symptoms that are associated with this condition, along with discomfort in the area where the median nerve is located (Genova et al., 2020). The patient, M.G, came in complaining of pain in the right wrist joint, as well as tingling and numbness in the thumb, index, and middle fingers. During the assessment, tenderness was noted at the region above the patient’s carpal tunnel on her right wrist. Reduced strength of 3/5 was also noted right thumb and weakness noted on abduction 

Thoracic outlet syndrome– This is the name given to a collection of conditions that are brought on by the squeezing of the blood vessels and nerves in the thoracic outlet region of the body. The area that may be affected by thoracic outlet syndrome is the region that can be found between the first rib and the collarbone. The most common causes include blunt force trauma, traumas that occur over and over again, pregnancy, and anatomical anomalies such having an extra rib. On the side that is afflicted, symptoms include discomfort in the shoulder and neck as well as tingling or numbness in the fingers (Illig et al., 2021). Patient M.G. states that she is experiencing tingling in her fingers, but she does not have any discomfort in her shoulders or neck.

Wrist Tendonitis– This condition is characterized by inflammation in the tendons that run from the bones in the hand down to the muscles in the forearm. It is possible that making a fist, lifting things, or doing other activities that require repetitive wrist motion will hurt. The tendons in the wrist are typically subjected to excessive strain, which leads to this condition (Shim et al., 2018). Tendinitis is more likely to develop in individuals who participate in activities that place a significant amount of strain on their wrists.

 

References

Genova, A., Dix, O., Saefan, A., Thakur, M., & Hassan, A. (2020). Carpal tunnel syndrome: A review of literature. Cureus. https://doi.org/10.7759/cureus.7333

Illig, K. A., Rodriguez-Zoppi, E., Bland, T., Muftah, M., & Jospitre, E. (2021). The incidence of thoracic outlet syndrome. Annals of Vascular Surgery, 70, 263-272. https://doi.org/10.1016/j.avsg.2020.07.029

Shim, M. R. (2018). Unusual etiology of acute wrist pain: Acute calcific tendonitis of the flexor carpi Ulnaris mimicking an infection. Case Reports in Orthopedics, 2018, 1-3. https://doi.org/10.1155/2018/2520548