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Unit 4 SOAP Note
SOAP NOTE

This Assignment will help develop skills to perform an integrated history and physical examination for individuals across the lifespan.

Considerations of lifestyle practices, cultural/ethnic differences, and developmental variations will be incorporated into the plan of care.

Use critical thinking and diagnostic reasoning skills to formulate differential diagnoses, medical diagnoses, and an evidence-based action plan.

Included are the sections 1 and 2 of the SOAP Note that needs to be use.
I. Biographical Data
Name: L.W.______________________________________________

Date 03/12/2015 Time 05:30 P.M.

Address: 17023 NW 22nd St.
Pembroke Pines FL 33028

Phone number: (305) 640-8600

Primary language: English

Authorized representative: M. W. (Son)

Birthdate 02/28/1956

Age 60 Gender M ? F ? Marital Status S ? M ? D ? W ?

Place of Birth: Winter Haven, FL. U.S.A.

Race: Caucasian

Ethnic/Cultural Origin:

Lives With a 26 years old son__________________________

Education (highest level completed): Master of Science in Nursing

Occupation: Registered Nurse___________________________

Source of history: Self_________________________________

Source of referral: Insurance Company Plan___________

Reliability: Intelligent, coherent, reliable and articulate.

2. Chief Complaint (Reason for Seeking Health Care):

As stated by patient: “Suspicious lesion on left ear, it could be a mole, skin cancer or a staph infection”.

3. History of Present Illness
History of Present Illness: A well-organized, chronological record of client’s reason for seeking care, from time of onset to present. Please include the 8 critical characteristics using the PQRSTU pneumonic

P- provocative or pallative (What brings it on?; What makes it better or worse?)
Q- quality or quantity (Describe the character and location of the symptoms; How does it look, feel, sound?)
R – region or radiation (Where is it?; Does the symptom radiate to other areas of the body?).
S- severity (Ask the patient to quantify the symptom(s) on a scale of 0-10).
T – timing (Inquire about time of onset, duration, frequency, etc.)
U- Understand Patient’s Perception of the problem (What do you think it means?)

If Pain asses: location, quality, quantity or severity, timing {when did it start, how long does it last, how often does it come}, setting, aggravating or relieving factors, associated manifestations. Include pertinent positives and pertinent negatives.

Patient states that she noticed a suspicion lesion on her left ear lobe. As stated by the patient this is the second time that she gets a lesion similar to this one. She’s coming to see the doctor because this is the second time that this happens and she wanted to see the dermatologist but she was told by her insurance provider that she has to see the PCP first.
Patient stated that the first time was six months ago but that this time she’s concerned because when she scratches it, it starts to bleeds. As sated by the patient, the first lesion is completely healed and all she has is a small bump on the upper lobe of the left ear.
“I am concerned this time because even though the lesion is small, approximately 3 mm in size, is read, is rise, and of irregular shape, and I told you before it bleeds every time I scratches it. I need a referral to the dermatologist.” The contributing factor as stated by the patient is that it can be occupational in nature because she works on the phone all day and she lifts the phone with her left hand and put it on the left ear and she is concerned that it could be staph infection from the phones at work (hospital). Patient stated that the first one was six months ago and she related it to the same contributing factor.

When patient was asked if there’s any other associated factors patient stated that she’s also concerned that it could also be cancer. Patient stated, “I’m afraid that it might be cancer from the sun because I do a lot of gardening. I use sunscreen, but put I do not do sunscreen on my ears. I keep my hair on a ponytail so my ears are exposed to the sun. In addition, when I’m driving sunlight is always on the driving side, and my ears are vulnerable to the sunlight exposure.” Patient restated, “I think it could be a staph infection that I could have gotten it from the phones of work, I keep using the phone on the affected ear, I just want to see the Dermatologist.”

4. Past Medical History (childhood illnesses, immunizations, medical illnesses, surgical history, OB/GYN, psychiatric, hospitalizations, injuries, sexual history, immunizations, screenings):
History of chickenpox, mump, and German measles. Received vaccination for polio and the Hepatitis B vaccination series. Four (4) prior hospitalizations: C-Section in1987 (27 years old Female), C-Section in 1988 (26 years old Male) C-Section in 1995 (19 years old Female) and underwent laparoscopic surgery for right ovary cyst removal 1n 1994.

OB history Gravida: 3. Term: 3. Preterm: 0. Ab/incomplete (# abortions or miscarriages): 0. # Children Living: 3.

Medications: Occasionally vitamins if remembers. Denies herbal supplements.

Allergies: No known allergies to medications or any food product.

Tobacco, alcohol and drug use: Denies ever used any drugs. Smoked tobacco cigarettes from the age of 19 to the age of 27 (7 years). Drinks 1-2 Glasses of wine after work to relax.

4. Family History

?—–? ?—–? Grandparents

?—–? Parents Father
Deceased at 65 with lung and bladder cancer/History of heavy smoker.
Mother Deceased at 81 Medical history of a stroke and dementia.

?—–O—–? Patient/Siblings
Sister Hypertension / Brother alcoholism
Deceased brother of congenital heart disease.

?——–O Patient/Spouse
?—–O—–O Children

KEY:

??deceased male????????living male
? deceased female O living female

Personal and Social History (personality, interests, sources of support, coping style, strengths, fears, occupation, education, home situation, significant others, stress factors, military service, job history, finances, retirement, leisure, hobbies, spirituality, ADLs, lifestyle habits {diet, exercise, use of coffee, tea, caffeine}, safety measures, alternative health care practices):

Lives with her 26-year-old son who is her supportive family member. Bright, outgoing, desires to complete her ARNP. Part time time student works full time at a local hospital. Hobbies enjoys relaxing in the pool, gardening and swimming, no other type of exercise. Attends Christian church occasionally. She is very careful and knowledgeable about nutrition and follows a Gluten free diet. No use of caffeine, coffee, tea. Gave up caffeine and drinks warm water with lemon in AM instead. In the evenings drinks 1-2 glasses of wine after work. Uses seat belt while in a car.

II. Review of Systems:

Weight: 123 lbs. Height: 5’ 11’’ BMI: 23.2 (Normal 18.5 to 24.9)

General (weight gain or loss, fatigue, weakness or malaise, fever, chills, sweats, night sweats): Denies any fatigue, weakness or malaise, fever, chills, sweats, night sweats states that loss 25 Lbs. in a Gluten Free Diet as suggested by her son who went on a gluten free diet and loss weight and was feeling better _________________________

Skin: Refer to History of Present Illness (HPI). Denies any other rashes, acne, and recent changes in moles, lumps, pruritis, hair loss, dermatitis, eczema, and psoriasis. States that she has sun spots. Reports sun exposure due to gardening and driving.

Head: Denies any headaches, dizziness, blurred vision, diplopia, seizures. Denies any diabetic seizures.

Eyes: Last eye exam 2 years ago, readers were recommended but does not used them. Denies any changes in vision acuity. Denies redness of eyes, nor discharge, crusting, swelling, itchiness.

Ears: Refer to History of Present Illness (HPI). Denies any loss of hearing. Denies drainage from either ear. Denies tinnitus, vertigo.

Nose: Denies epistaxis, postnasal drip, runny nose, sneezing, history of trauma, polyps.

Throat: States last dental exam last month (April 2015) has all her teeth, history of a few root canals, no caries, no mouth lesions or soreness. Denies sore throat. Denies sore or bleeding gums.

Neck: Denies lumps, swollen nodes, difficulty swallowing.

Breasts: Mammogram yearly and self-exam monthly. Denies lumps or discharge.

Respiratory: Denies wheezing or labored breathing. Denies sputum, hemoptysis, labored breathing, night sweats, and history of asthma. Denies, chest pain, recurrent infections, and exposure to irritants, secondhand smoke, and apnea. States, “I never had a chest X-Ray done in my live

Cardiovascular: Denies, history of chest pain. Denies palpitations, history of syncope, murmur. Has never had EKG. Denies history of hypertension, shortness of breath.

Gastrointestinal: States that she loss 25 Lbs. in a Gluten Free Diet Denies nausea, vomiting, diarrhea, constipation, appetite change. Good appetite, no indigestion. Denies history of ulcers or colitis, or IBS. Denies hemorrhoids, reflux, or pain. Has bowel movement every day.

Urinary: Denies frequency, pain, burning, hematuria, dysuria, nocturia, polyuria, incontinence, and recurrent infections.

Genital: Postmenopausal, last menses at age 45. Patient states, “ I did not have any post menopausal symptoms nor any post menopausal bleeding. Denies history of infections, drainage, pain, and hernia.

Peripheral Vascular: Denies history of leg pain, lower extremity edema, trauma, varicosities, discoloration, phlebitis, claudication, cramping, sensitivity to temp changes.

Musculoskeletal: Denies history of arthritis, joint stiffness, swelling, pain, and back pain.

Psychiatric: Denies history of depression, mental disorders, and suicidal ideation. Has never seen counselor or therapist. Denies history of anxiety, hallucinations, memory disturbances, or previous psych treatment.

Neurologic: Denies history of fainting, dizziness, seizures, loss of feeling, numbness, tingling, weakness, tremor, vertigo. Patient stated that she has some memory changes that are age related. Denies sensory deficit. States no problem with smell, taste, facial movements, and swallowing.

Hematologic: Denies, history of bleeding disorders. Denies history of anemia, transfusions, tattoos, body piercings, unusually easy bruising, lymph node enlargement, fever, and chills.

Endocrine: Denies cold-heat intolerance, history of thyroid disease, osteoporosis, and history of diabetes.
Reference:

Jarvis, C. (2015). Physical Examination & Health Assessment (7th Edition). St. Louis,
Mo: Saunders.

III. Assessment
A: Differential Diagnosis (include rationales and cite sources)

1.
2.
3.

B: Nursing Diagnosis

1.

C: Medical Diagnosis

IV. PLAN
A: Orders

1. Prescriptions with dosage, route, duration, and amount prescribed and if refills provided

2. Diagnostic testing
3. Problem oriented education

4. Health promotion/maintenance needs

B: Follow-up plans (When will you schedule a follow-up appointment and what will you address in the subsequent visit — F/U in 2 weeks; plan to check annual labs on RTC (return to clinic).

V. Nursing theory and application: Select a nursing theory and apply this to your patient’s plan and evaluation (brief statement).
VI. Developmental stage: Identify the developmental state and provide rationales to support acquisition of skills in the stage (brief statement).

VII. Cultural characteristics, diversity, sensitivity, and ethical considerations
Discuss culturally diverse considerations you identified for this patient. Cultural diversity is a general term that can include gender, religious beliefs, culture, race, economic status, age, etc. Discuss one ethical standard relevant to the care of this patient.

VIII. Evaluation of care: Provide a brief statement sharing your thoughts about the visit and/or patient. Please share what you should have done differently.

References: Please include a minimum of three references. The reference list must be in APA format. All sources must be within 5 years of publication.