Soap Note 1 Acute Conditions

Follow the MRU Soap Note Rubric as a guide:

Use APA format and must include minimum of 2 Scholarly Citations.

Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)

Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement.

Must use the sample templates for your soap note, keep this template for when you start clinicals. 

The use of tempates is ok with regards of Turn it in, but the Patient History, CC, HPI, The Assessment and Plan should be of your own work and individualized to your made up patient.

(Student Name)

Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor: Dr. David Trabanco DNP, APRN, AGNP-C, FNP-C

 

Soap Note # ____ Main Diagnosis ______________

 

PATIENT INFORMATION

Name:

Age:

Gender at Birth:

Gender Identity:

Source:

Allergies:

Current Medications:

·

PMH:

Immunizations:

Preventive Care:

Surgical History:

Family History:

Social History:

Sexual Orientation:

Nutrition History:

 

Subjective Data:

Chief Complaint:

Symptom analysis/HPI:

The patient is …

 

Review of Systems (ROS)

CONSTITUTIONAL:

NEUROLOGIC:

HEENT:

RESPIRATORY:

CARDIOVASCULAR:

GASTROINTESTINAL:

GENITOURINARY:

MUSCULOSKELETAL:

SKIN:

 

Objective Data:

VITAL SIGNS:

 

GENERAL APPREARANCE:

NEUROLOGIC:

HEENT:

CARDIOVASCULAR:

RESPIRATORY:

GASTROINTESTINAL:

MUSKULOSKELETAL:

INTEGUMENTARY:

 

ASSESSMENT:

Main Diagnosis

(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 6th or 7th Edition.

Differential diagnosis (minimum 3)

PLAN:

Labs and Diagnostic Test to be ordered (if applicable)

· –

· –

Pharmacological treatment:

Non-Pharmacologic treatment:

Education (provide the most relevant ones tailored to your patient)

 

Follow-ups/Referrals

References (in APA Style)

Examples

Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).

ISBN 978-0-8261-3424-0

Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010

(25th ed.). Print (The 5-Minute Consult Series).

(Student Name)

Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor: Dr. David Trabanco DNP, APRN, AGNP-C, FNP-C

 

Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension)

 

PATIENT INFORMATION

Name: Mr. DT

Age: 68-year-old

Gender at Birth: Male

Gender Identity: Male

Source: Patient

Allergies: PCN, Iodine

Current Medications:

 Atorvastatin tab 20 mg, 1-tab PO at bedtime

 ASA 81mg po daily

 Multi-Vitamin Centrum Silver

PMH: Hypercholesterolemia

Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.

Preventive Care: Coloscopy 5 years ago (Negative)

Surgical History: Appendectomy 47 years ago.

 

 

 

Family History: Father- died 81 does not report information

Mother-alive, 88 years old, Diabetes Mellitus, HTN

Daughter-alive, 34 years old, healthy

Social History: No smoking history or illicit drug use, occasional alcoholic beverage

consumption on social celebrations. Retired, widow, he lives alone.

Sexual Orientation: Straight

Nutrition History: Diets off and on, Does not each seafood

 

Subjective Data:

Chief Complaint: “headaches” that started two weeks ago

Symptom analysis/HPI:

The patient is 65 years old male who complaining of episodes of headaches and on 3 different

occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100

respectively). Patient noticed the problem started two weeks ago and sometimes it is

accompanied by dizziness. He states that he has been under stress in his workplace for the last

month. Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.

 

Review of Systems (ROS)

CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss.

NEUROLOGIC: Headache and dizziness as describe above. Denies changes in LOC. Denies

history of tremors or seizures.

HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in

vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or

 

 

 

drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain,

hoarseness, difficulty swallowing.

RESPIRATORY: Patient denies shortness of breath, cough or hemoptysis.

CARDIOVASCULAR: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal

dyspnea.

GASTROINTESTINAL: Denies abdominal pain or discomfort. Denies flatulence, nausea,

vomiting or

diarrhea.

GENITOURINARY: Denies hematuria, dysuria or change in urinary frequency. Denies

difficulty starting/stopping stream of urine or incontinence.

MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound.

SKIN: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.

 

Objective Data:

VITAL SIGNS: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room

air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 2/10.

 

GENERAL APPREARANCE: The patient is alert and oriented x 3. No acute distress noted.

NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation

intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5.

HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no

tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye

movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema,

 

 

 

or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary

sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without

lesions,. Lids non-remarkable and appropriate for race.

 

Neck: supple without cervical lymphadenopathy, no jugular vein distention, no thyroid swelling

or masses.

CARDIOVASCULAR: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary

refill < 2 sec.

RESPIRATORY: No dyspnea or use of accessory muscles observed. No egophony, whispered

pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on

auscultation.

GASTROINTESTINAL: No mass or hernia observed. Upon auscultation, bowel sounds

present in all four quadrants, no bruits over renal and aorta arteries. Abdomen soft non-tender, no

guarding, no rebound no distention or organomegaly noted on palpation

MUSKULOSKELETAL: No pain to palpation. Active and passive ROM within normal limits,

no stiffness.

INTEGUMENTARY: intact, no lesions or rashes, no cyanosis or jaundice.

 

ASSESSMENT:

Main Diagnosis

Essential (Primary) Hypertension (ICD10 I10): Given the symptoms and high blood pressure

(156/92 mmhg), classified as stage 2. Once the organic cause of hypertension has been ruled out,

such as renal, adrenal or thyroid, this diagnosis is confirmed (Codina Leik, 2015). Diagnosis is

 

 

 

based on the clinical evaluation through history, physical examination, and routine laboratory

tests to assess risk factors, reveal identifiable causes and detect target-organ damage, including

evidence of cardiovascular disease (Domino et al,. 2017).

 

Differential diagnosis:

 Renal artery stenosis (ICD10 I70.1)

 Chronic kidney disease (ICD10 I12.9)

 Hyperthyroidism (ICD10 E05.90)

PLAN:

 

Labs and Diagnostic Test to be ordered:

 CMP

 Complete blood count (CBC)

 Lipid profile

 Thyroid-stimulating hormone (TSH)

 Urinalysis with Micro

 Electrocardiogram (EKG 12 lead)

 

Pharmacological treatment:

 Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily.

 Lisinopril 10mg PO Daily

 

 

 

 

Non-Pharmacologic treatment:

 Weight loss

 Healthy diet (DASH dietary pattern): Diet rich in fruits, vegetables, whole grains, and

low-fat dairy products with reduced content of saturated and trans l fat

 Reduced intake of dietary sodium: <1,500 mg/d is optimal goal but at least 1,000 mg/d

reduction in most adults

 Enhanced intake of dietary potassium

 Regular physical activity (Aerobic): 90–150 min/wk

 Measures to release stress and effective coping mechanisms.

Education

 Provide with nutrition/dietary information.

 Daily blood pressure monitoring log at home twice a day for 7 days, keep a record, bring

the record on the next visit with her PCP

 Instruction about medication intake compliance.

 Education of possible complications such as stroke, heart attack, and other problems.

 Patient was educated on course of hypertension, as well as warning signs and symptoms,

which could indicate the need to attend the E.R/U.C. Answered all pt.

questions/concerns. Pt verbalizes understanding to all

Follow-ups/Referrals

 Follow up appointment 1 weeks for managing blood pressure and to evaluate current

hypotensive therapy.

 No referrals needed at this time.

 

 

 

References

Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).

ISBN 978-0-8261-3424-0

Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010

(25th ed.). Print (The 5-Minute Consult Series).

 
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