Make A SOAP Note Not A Narrative Essay: Ankle Pain

Note:  Your Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to the Comprehensive SOAP Template in the attachments below for guidance.

CASE: Ankle Pain

A 46-year-old female

Comprehensive SOAP Template

Patient Initials: _______ Age: _______ Gender: _______

Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.

O = onset of symptom (acute/gradual)

L= location

D= duration (recent/chronic)

C= character

A= associated symptoms/aggravating factors

R= relieving factors

T= treatments previously tried – response? Why discontinued?

S= severity

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.

History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list:

1. Location

2. Quality

3. Quantity or severity

4. Timing, including onset, duration, and frequency

5. Setting in which it occurs

6. Factors that have aggravated or relieved the symptom

7. Associated manifestations

Medications: Include over-the-counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.

Allergies: Include specific reactions to medications, foods, insects, and environmental factors. Identify if it is an allergy or intolerance.

Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations., and

Past Surgical History (PSH): Include dates, indications, and types of operations.

Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, sexual function, and. risky sexual behaviors.

Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.

Immunization History: Include last Tdap, Flu, pneumonia, etc.

Significant Family History: Include history of parents, grandparents, siblings, and children.

Lifestyle: Include cultural factors, economic factors, safety, and support systems and sexual preference.

Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses). Remember that the information you include in this section is based on what the patient tells you. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text

General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.

HEENT:

Neck:

Breasts:

Respiratory:

Cardiovascular/Peripheral Vascular:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Psychiatric:

Neurological:

Skin: Hematologic:

Endocrine:

Allergic/Immunologic:

OBJECTIVE DATA: From head-to-toe, include what you see, hear, and feel when doing your physical exam.. Do not use “WNL” or “normal.” You must describe what you see.

Physical Exam:

Vital signs: Include vital signs, ht, wt, and BMI. Pulse Ox, Pain level.

General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of consciousness, and affect and reactions to people and things.

HEENT:

Neck:

Chest

Lungs:

Heart

Peripheral Vascular: Abdomen:

Genital/Rectal:

Musculoskeletal:

Neurological:

Skin:

Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses IF YOU ALREADY HAVE RESULTS.

ASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least three differential diagnoses, each of which must be supported with evidence and guidelines. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled. These should also be included in your treatment plan.

PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

Treatment Plan: If applicable, include both pharmacological and non-pharmacological strategies, alternative therapies, follow-up recommendations, referrals, consultations, and any additional labs, x-ray, or other diagnostics. Support the treatment plan with evidence and guidelines.

Health Promotion: Include exercise, diet, and safety recommendations, as well as any other health promotion strategies for the patient/family. Support the health promotion recommendations and strategies with evidence and guidelines.

Disease Prevention: As appropriate for the patient’s age, include disease prevention recommendations and strategies such as fasting lipid profile, mammography, colonoscopy, immunizations, etc. Support the disease prevention recommendations and strategies with evidence and guidelines.

REFLECTION: Reflect on your clinical experience, and consider the following questions: What did you learn from this experience? What would you do differently? Do you agree with your preceptor based on the evidence? This is worth 25 points!

References: Should use two peer-reviewed journal articles or references to support your reflection and differentials as well as any textbooks used.

reports pain in both of her ankles, but she is more concerned about her right ankle. She was playing soccer over the weekend and heard a “pop.” She is able to bear weight, but it is uncomfortable. In determining the cause of the ankle pain, based on your knowledge of anatomy, what foot structures are likely involved? What other symptoms need to be explored? What are your differential diagnoses for ankle pain? What physical examination will you perform? What special maneuvers will you perform? Should you apply the Ottowa ankle rules to determine if you need additional testing?

 

To prepare:

With regard to the case study you were assigned:

·         Review this week’s Learning Resources, and consider the insights they provide about the case study.

·         Consider what history would be necessary to collect from the patient in the case study you were assigned.

·         Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?

·         Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

Address all these in the SOAP Note not an Narrative Essay (Follow the SOAP Note Template on the attachment):

1.     A description of the health history you would need to collect from the patient in the case study to which you were assigned.

2.     Explain what physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis.

3.     List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.

4.     Include how the patient X-ray (in the attachment below)  helped you to refine the differential diagnosis

5. Please address also all the questions on the case above in the SOAP note.

 

REMINDER:Please make a SOAP NOTE for this case. Make your own patient’s data, applicable health history, review of systems, P.E., labs, differential diagnosis, final diagnosis etc. Incorporate the data from the case in the SOAP note that you will do… This is not a narrative essay ok…. I need SOAP note (Nurse Practitioner/RN/MD  makes SOAP note)… Be guided with the SOAP Note in the templates/exemplar… Don’t copy paste. Formulate your own… Don’t forget to cite the Five different possible conditions (Differential diagnosis) and have Reference lists too.

 

Resources:

·         Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

o    Review of Chapter 4, “Vital Signs and Pain Assessment” (pp. 50-63)

o    Chapter 21, “Musculoskeletal System” (pp. 501-543)

This chapter describes the process of assessing the musculoskeletal system. In addition, the authors explore the anatomy and physiology of the musculoskeletal system.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

o    Chapter 22, “Limb Pain” (pp. 356-374)

This chapter outlines how to take a focused history and perform a physical exam to determine the cause of limb pain. It includes a discussion of the most common tests used to assess musculoskeletal disorders.

o    Chapter 24, “Low Back Pain (Acute)” (pp. 288-300)

The focus of this chapter is the identification of the causes of lower back pain. It includes suggested physical exams and potential diagnoses.

Sullivan, D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis.

o    Chapter 2, “The Comprehensive History and Physical Exam” (“Muscle Strength Grading”; p. 26)

o    Chapter 4, “Pediatric Preventative Care Visits” (“Documentation of Important Components of Age Specific Physical Exams and Sports Pediatric Sports Participation Physical Exam”; pp. 78–79)

Note: Download this Adult Examination Checklist and Physical Exam Summary: Abdomen to use during your practice musculoskeletal examination.

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Adult examination checklist: Guide for musculoskeletal assessment. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
This Adult Examination Checklist: Guide for Musculoskeletal Assessment was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical exam summary: Musculoskeletal system. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
This Musculoskeletal System Physical Exam Summary was published as a companion to Seidel’s guide to physical examination(8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/

Katz, J. N., Lyons, N., Wolff, L. S., Silverman, J., Emrani, P., Holt, H. L., & …Losina, E. (2011). Medical decision-making among Hispanics and non-Hispanic Whites with chronic back and knee pain: A qualitative study. BMC Musculoskeletal Disorders, 12(1), 78–85.
Retrieved from the Walden Library databases.

This study examines the medical decision making among Hispanics and non-Hispanic whites. The authors also analyze the preferred information sources used for making decisions in these populations.

Vismara, L., Menegoni, F., Zaina, F., Galli, M., Negrini, S., & Capodaglio, P. (2010). Effect of obesity and low back pain on spinal mobility: A cross sectional study in women. Journal of Neuroengineering & Rehabilitation, 7(1), 71–83.
Retrieved from the Walden Library databases.

In this study, the authors explore the effect of obesity and chronic low back pain on spinal mobility. The authors use range of motion as a metric of spinal mobility.

University of Virginia. (n.d.). Introduction to radiology: An online interactive tutorial. Retrieved fromhttp://www.med-ed.virginia.edu/courses/rad/index.html
This website provides an introduction to radiology and imaging. For this week, focus on skeletal trauma in musculoskeletal radiology.

Media

Online media for Seidel’s Guide to Physical Examination

In addition to this week’s resources, it is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapter 21 that relate to the assessment of the musculoskeletal system. Refer to the Week 4 Learning Resources area for access instructions on https://evolve.elsevier.com/.

·         LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2009). DeGowin’s diagnostic examination (9th ed.). New York, NY: McGraw Hill Medical.

 

o    Chapter 13, “The Spine, Pelvis, and Extremities” (pp. 585–682)

In this chapter, the authors explain the physiology of the spine, pelvis, and extremities. The chapter also describes how to examine the spine, pelvis, and extremities.