Week_4_NURS6512_ComprehensiveSOAPExemplar.docx

    Comprehensive SOAP Exemplar

    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:

    1.) Norvasc 10mg daily

    2.) Combivent 2 puffs every 6 hours as needed

    3.) Advair 500/50 daily

    4.) Singulair 10mg daily

    5.) Over the counter Tylenol 325mg as needed

    6.) Over the counter Benefiber

    7.) 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):

    1.) Cholecystectomy 1994

    2.) 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):

    1.) Asthmatic exacerbation, moderate

    2.) Pulmonary Embolism

    3.) 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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