To prepare: Fill out the Template Focused Soap Note
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 prescriiption 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.
Case Study
CC: Mrs. L., a 68-year-old woman, presents to your office today with a complaint of feeling tired all the time and now, more recently, feeling weak and like “I can’t catch my breath sometimes.”
HPI: She has been healthy except for high cholesterol, managed by Lipitor. Her husband died 9 months ago, and she has attributed her fatigue to dealing with his death but realizes that she is feeling worse and not better as time passes.
No known drug allergies.
Medications: Takes only Lipitor.
Past surgical history: Appendectomy in childhood; hysterectomy for uterine myoma 10 years ago.
No significant medical history. Has two daughters living nearby.
Blood pressure (BP) 106/70 mm Hg, heart rate (HR) 108 beats/min and regular, respiratory rate 18 breaths/min and afebrile, body mass index (BMI) 22 (10-pound weight loss since the death of husband).
A slender, quiet-spoken older woman appearing tired.
PE: Conjunctiva pale, mucous membranes moist. No lymphadenopathy of the neck or femoral area.
Heart tachyarrhythmia with regular rate, soft midsystolic murmur. Chest (CTA), good air movement.
Abdomen soft, bowel sounds × 4.
Diagnostics:
Urine dipstick negative.
The results of a colonoscopy show a neoplasm in the colon.
Address the following in your SOAP note:
What additional subjective data are you seeking?
What additional objective data will you be assessing for?
What medical history would you obtain from the patient? List at least three.
What tests will you order? Describe at least four lab tests.
What are the differential diagnoses that you are considering? Describe two.
What is your plan of care? List at least two diagnostic tests you will order to evaluate the cause of her condition.
