Week 3 Problem-Focused SOAP Note Example<\/p>\n
Submit a problem-focused SOAP note for grading. You must use an actual patient from your clinical practicum who presents with one or more chief complaints.<\/p>\n
Use the format below for your SOAP note.<\/p>\n
Use the current APA format to style your paper and cite your sources. Review the rubric for more information on how your assignment will be graded.<\/p>\n
Problem-focused SOAP Note Format – Best Help Writing My 99 Papers\u2014owl Essay Samples<\/p>\n
Demographic Data<\/p>\n
Age, and gender (must be HIPAA compliant)
\nSubjective<\/p>\n
Chief Complaint (CC): A short statement about why they are there
\nHistory of Present Illness (HPI): Write your HPI in paragraph form. Start with the age, gender, and why they are there (example: 23-year-old female here for…). Elaborate using the acronym OLDCART: Onset, Location, Duration, Characteristics, Aggravating\/Alleviating Factors, Relieving Factors, Treatment
\nPast Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance
\nFamily Hx: any history of CA, DM, HTN, MI, CVA?
\nSocial Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc.
\nReview of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)
\nObjective<\/p>\n
Vital Signs
\nPhysical findings listed by body systems, not paragraph form- Highlight abnormal findings
\nAssessment (the diagnosis)<\/p>\n
At least Two (2) differential diagnoses (if applicable) with rationale and pertinent positives and negatives for each
\nFinal diagnosis with rationale, pertinent positives and negatives, and pathophysiological explanation
\nPlan<\/p>\n
Dx Plan (lab, x-ray)
\nTx Plan (meds): including medication(s) prescribed (if any), dosage, frequency, duration, and refill(s) (if any)
\nPt. Education, including specific medication teaching points
\nReferral\/Follow-up
\nHealth maintenance: including when screenings eye, dental, pap, vaccines, immunizations, etc. are next due (USPSTF guidelines)
\nReference<\/p>\n
Compare care given to the patient with the National Standards of Care\/National Guidelines. Cite accordingly.<\/p>\n
==================<\/p>\n
Problem-focused SOAP Note<\/p>\n
Demographic Data: 42-year-old female<\/p>\n
Subjective:<\/p>\n
Chief Complaint (CC): “I’ve had a terrible headache for the past three days.”<\/p>\n
History of Present Illness (HPI): 42-year-old female presents with a severe headache that began three days ago. The pain is localized to the right temporal region and described as throbbing and intense, rating 8\/10 on a pain scale. The headache is constant but worsens with bright lights and loud noises. The patient reports nausea but no vomiting. Over-the-counter ibuprofen provides minimal relief. She denies visual disturbances, fever, or neck stiffness. The patient has a history of occasional tension headaches but states this pain is different and more severe than her usual headaches.<\/p>\n
Past Medical History (PMH):<\/p>\n
Hypothyroidism, diagnosed 5 years ago, well-controlled on levothyroxine<\/p>\n
Seasonal allergies<\/p>\n
No prior surgeries<\/p>\n
Medications: Levothyroxine 100 mcg daily, loratadine 10 mg daily as needed<\/p>\n
Allergies: None known<\/p>\n
Immunizations: Up to date on Tdap and influenza vaccines<\/p>\n
Family History:<\/p>\n
Mother: Type 2 diabetes, hypertension<\/p>\n
Father: Myocardial infarction at age 60<\/p>\n
No family history of migraines or other neurological conditions<\/p>\n
Social History:<\/p>\n
Married, two children<\/p>\n
Works as an elementary school teacher<\/p>\n
Non-smoker, occasional alcohol use (1-2 glasses of wine per week)<\/p>\n
Exercises 2-3 times per week (walking, yoga)<\/p>\n
Balanced diet, but admits to increased stress and irregular meals in the past week due to end-of-year school activities<\/p>\n
Review of Systems (ROS):<\/p>\n
General: Denies fever, chills, or unexplained weight changes<\/p>\n
HEENT: Reports photophobia, denies vision changes or ear pain<\/p>\n
Cardiovascular: Denies chest pain or palpitations<\/p>\n
Respiratory: Denies shortness of breath or cough<\/p>\n
Gastrointestinal: Reports mild nausea, denies vomiting or changes in bowel habits<\/p>\n
Musculoskeletal: Denies joint pain or muscle weakness<\/p>\n
Neurological: Denies numbness, tingling, or weakness in extremities<\/p>\n
Psychiatric: Reports feeling anxious due to pain and work stress<\/p>\n
Objective:<\/p>\n
Vital Signs:<\/p>\n
Temperature: 37.0\u00b0C (98.6\u00b0F)<\/p>\n
Blood Pressure: 128\/82 mmHg<\/p>\n
Heart Rate: 76 bpm<\/p>\n
Respiratory Rate: 16 breaths\/min<\/p>\n
O2 Saturation: 99% on room air<\/p>\n
Physical Examination:<\/p>\n
General: Alert, oriented, in mild distress due to pain<\/p>\n
HEENT:<\/p>\n
Pupils equal, round, reactive to light<\/p>\n
Extraocular movements intact<\/p>\n
No conjunctival injection<\/p>\n
Tympanic membranes clear bilaterally<\/p>\n
Nasal passages patent, no discharge<\/p>\n
Oropharynx clear, no erythema<\/p>\n
Neck: Supple, no meningeal signs, no carotid bruits<\/p>\n
Cardiovascular: Regular rate and rhythm, no murmurs<\/p>\n
Respiratory: Clear to auscultation bilaterally<\/p>\n
Abdomen: Soft, non-tender, no organomegaly<\/p>\n
Musculoskeletal: Full range of motion in neck, no tenderness<\/p>\n
Neurological:<\/p>\n
Cranial nerves II-XII intact<\/p>\n
Strength 5\/5 in all extremities<\/p>\n
Sensation intact to light touch<\/p>\n
Reflexes 2+ and symmetric<\/p>\n
No pronator drift<\/p>\n
Negative Romberg test<\/p>\n
Assessment:<\/p>\n
Differential Diagnoses:<\/p>\n
Migraine without aura Rationale: Throbbing unilateral headache, photophobia, nausea, and no prior history of migraines. The pain is more severe than the patient’s usual tension headaches. Pertinent positives: Severe pain, photophobia, nausea Pertinent negatives: No visual aura, no family history of migraines<\/p>\n
Tension-type headache Rationale: Patient has a history of tension headaches and recent increased stress. Pertinent positives: History of tension headaches, recent stress Pertinent negatives: Pain quality and severity differ from usual tension headaches<\/p>\n
Final Diagnosis: Migraine without aura (newly diagnosed)<\/p>\n
Rationale: The patient’s symptoms are most consistent with a migraine headache. The unilateral, throbbing pain accompanied by photophobia and nausea are characteristic of migraines. The severity and quality of pain differ from her usual tension headaches, suggesting this is a new onset of migraines.<\/p>\n
Pathophysiological explanation: Migraines are believed to involve complex neurological processes, including activation of the trigeminovascular system and release of inflammatory neuropeptides. This leads to vasodilation and sensitization of pain pathways, resulting in the characteristic throbbing pain and associated symptoms (Goadsby et al., 2017).<\/p>\n
Plan:<\/p>\n
Diagnostic Plan:<\/p>\n
No immediate imaging studies indicated based on current presentation and absence of red flags<\/p>\n
Consider keeping a headache diary to track frequency, duration, and potential triggers<\/p>\n
Treatment Plan:<\/p>\n
Sumatriptan 50 mg orally at onset of migraine, may repeat in 2 hours if needed (not to exceed 200 mg in 24 hours)<\/p>\n
Ondansetron 4 mg orally as needed for nausea<\/p>\n
Continue over-the-counter ibuprofen 400 mg every 6 hours as needed for breakthrough pain<\/p>\n
Patient Education:<\/p>\n
Explain migraine diagnosis and management strategies<\/p>\n
Instruct on proper use of sumatriptan, including potential side effects and when to seek medical attention<\/p>\n
Discuss importance of identifying and avoiding potential triggers (e.g., certain foods, stress, irregular sleep)<\/p>\n
Emphasize the importance of maintaining a regular sleep schedule and stress management techniques<\/p>\n
Referral\/Follow-up:<\/p>\n
Follow-up appointment in 4 weeks to assess treatment efficacy and need for prophylactic therapy<\/p>\n
Provide patient with resources for migraine support groups and educational materials<\/p>\n
Health Maintenance:<\/p>\n
Due for mammogram screening in 3 years (age 45) per USPSTF guidelines<\/p>\n
Pap smear up to date, next due in 2 years<\/p>\n
Encourage annual influenza vaccine<\/p>\n
Dental check-up recommended within the next 6 months<\/p>\n
Reference: The care provided aligns with the American Headache Society’s guidelines for acute migraine treatment (Ailani et al., 2021). The choice of sumatriptan as first-line therapy for acute migraine attacks is supported by strong evidence. The emphasis on patient education and lifestyle modifications is consistent with current best practices in migraine management.<\/p>\n
References:<\/p>\n
Ailani, J., Burch, R.C., Robbins, M.S., et al. (2021) ‘The American Headache Society Consensus Statement: Update on integrating new migraine treatments into clinical practice’, Headache, 61(7), pp. 1021-1039.<\/p>\n
Goadsby, P.J., Holland, P.R., Martins-Oliveira, M., et al. (2017) ‘Pathophysiology of Migraine: A Disorder of Sensory Processing’, Physiological Reviews, 97(2), pp. 553-622.<\/p>\n
U.S. Preventive Services Task Force. (2023) ‘USPSTF A and B Recommendations’, Available at: https:\/\/www.uspreventiveservicestaskforce.org\/uspstf\/recommendation-topics\/uspstf-a-and-b-recommendations (Accessed: 20 July 2024).<\/p>\n","protected":false},"excerpt":{"rendered":"
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