Focused SOAP Note
Student’s Name
Institutional Affiliation
Course
Professor’s Name
Date
Patient Information:
J, 71, F, Race
S (subjective)
CC (chief complaint): Fatigue, thinning hair, and dry skin.
HPI (history of present illness): Ms. Juggenmeir is a 71-year-old Female who comes into your office with concerns of fatigue and dry skin. She is a retired Banker. She is alert awake oriented to time, place, situation, ambulatory, and lives by herself. She does report increased fatigue no matter how much sleep she gets. She is also concerned that she may need to come off one of her meds because her hair is thinning. She had labs done and was informed they would review results at this visit. Other pertinent diagnoses include Hypertension, Hyperlipidemia, and Vitamin D deficiency. She admits to not taking her vitamin D daily as prescribed.
Current Medications:
Women’s One A Day-Multivitamin daily
Chlorthalidone 25mg daily
Fish Oil 1 tablet daily
Amlodipine 5mg p.o. daily
Losartan 100mg p.o. daily
Atorvastatin 40mg p.o. at bedtime daily
Aspirin 81mg p.o. daily
Ergocalciferol 50,000 units PO once a month
Allergies: I.V. Contrast, ACE Inhibitors reactions.
PMHx: Hypertension, Hyperlipidemia, Vitamin D deficiency.
Soc and Substance Hx: Retired banker who lives by herself.
Fam Hx: No significant family history.
Surgical Hx: Prior surgical procedures.
Mental Hx: No past diagnosis of mental illness.
Violence Hx: No history of violence.
Reproductive Hx: No significant reproductive history.
ROS (review of symptoms):
GENERAL: No unintended weight loss, gain or fatigue.
HEENT:
• EyesNo visual loss or sclera.
• Ears, Nose, Throat: No hearing loss, running nose or sore throat.
SKIN: No lesions or itching.
CARDIOVASCULAR: No chest pains or discomfort.
RESPIRATORY: No shortness of breath of sputum.
GASTROINTESTINAL: No nausea, diarrhea, vomiting or blood in the stool.
GENITOURINARY: No burning sensation on urination.
NEUROLOGICAL: No history numbness, headache, stroke, or malfunctioning nerves.
MUSCULOSKELETAL: No back or muscle pain.
HEMATOLOGIC: No bleeding or bruising.
LYMPHATICS: No history of splenectomy.
PSYCHIATRIC: No history of mental illness or anxiety.
ENDOCRINOLOGIC: No sweating or reports of polyuria or polydipsia.
REPRODUCTIVE: No recent pregnancy or menstrual cycle. Last menstrual period is unknown.
ALLERGIES: No history of rhinitis or eczema.
O (objective)
Physical exam:
Vital signs: BP 137/82, HR 89, RR 20, Temp 98.1
Diagnostic tests:
CXR- Last CXR showed no cardiopulmonary findings. WNL
TSH/Free T4, T3- as noted below in lab results.
Basic Metabolic Panel and CBC as shown below.
Vitamin D Level- as noted below in lab results.
Diagnostic results:
Test Result Reference Range
GLUCOSE 85 65-99
SODIUM 134 135-146
POTASSIUM 4.2 3.5-5.3
CHLORIDE 104 98-110
CARBON DIOXIDE 29 19-30
CALCIUM 9.0 8.6- 10.3 BUN 20 7-25
CREATININE 1.01 0.70-1.25
GLOMERULAR FILTRATION RATE (eGFR) 76 >or=60 mL/min/1.73m2
TSH 23 0.4-4.0 FREE T4 0.05 0.9-2.4 mcg/dl T3 3.0 2.0-4.4 ng/dl
Vitamin D 1,25 OH 14 36-144
WBC 7.3 3.4- 10.8 RBC 4.31 135-146
HEMOGLOBIN 14 13-17.2
HEMATOCRIT 42% 36-50 MCV 90 80-100
MCHC 34 32-36
PLATELET 272 150-400
Ms. Juggenmeir is a 71 y/o female who is alert awake oriented to time, place, situation. She makes no unusual motor movements and demonstrates no tics. She denies any visual or auditory hallucinations. She denies any suicidal thoughts or ideations. She denies any falls or pain.
A (assessment)
Differential diagnoses:
Alopecia
Alopecia is an autoimmune condition that causes the hair to start thinning. The amount of hair loss is different in different people (Strazzulla et al., 2018). The condition may be hereditary, hormonal disturbance, or childbirth illness. The hair can grow back with the help of immune-suppressing medication (Strazzulla et al., 2018).
Hyponatremia
Hyponatremia is a condition that occurs when the sodium levels in the body are too low. Low sodium levels cause the body cells to start swelling (George et al., 2018). The common causes of the condition include heart failure, diarrhea, diuretic use, renal disease, or liver disease. The disease is life-threatening and appropriate action is needed to counter the symptoms (George et al., 2018).
Autoimmune Thyroiditis
The condition occurs when the immune system attacks the thyroid gland leading to swelling. The swelling affects the ability to produce hormones as required (Koehler et al., 2019). The symptoms include fatigue, pale and dry skin, unexplained weight gain, memory lapses, increased sensitivity to cold, and constipation (Koehler et al., 2019). Patients should get immediate care to avoid deterioration and worse health complications.
P (plan)
The patient will require additional diagnostic tests to examine the immune system. A referral to a physician for the FT3 test and T4 test is necessary to examine the severity of the condition (Kennedy-Malone et al., 2019). For instance, a rheumatologist effectively examines conditions relating to autoimmune attacks.
The patient will require immunotherapy drugs such as immunosuppressant drugs. It is important to take care of the patient to ensure their health is not exposed to infections due to suppressed immunity. A physician should educate the patient about the illness and the appropriate interventions (Koehler et al., 2019). The patient should be under the watch of a physician in the ward and be discharged after a week when the immune attack subsides. The patient should take medication and return to the clinic after two weeks. The autoimmune conditions require appropriate intervention. The patient should continue taking the current medication.
The patient should receive information that vitamin D deficiency is one of the major causes of hair thinning (Koehler et al., 2019). Vitamin D is essential in stimulating hair follicles. The deficiency causes alopecia which leads to hair thinning in various patches.
The treatment plan should include vitamin D supplements. The supplements will restore the hair and strengthen the bones. It is essential to suspend Chlorthalidone since the condition reduces water and salt in the body. The drug could be a contributing factor to conditions such as hyponatremia.
Patient education should include providing information on the risk factors such as salt intake (Munshi et al., 2019). The patient should take less than 2,300 milligrams (mg) daily. Eat healthy foods such as whole grains, fruits, and fish are important. Taking food with potassium is crucial in lowering blood pressure. The patient should maintain an optimal body weight height ratio. Excess weight can cause diabetes or high blood pressure (American Diabetes Association, 2020). The patient should exercise regularly to lower the risk of obesity, stress, and high blood pressure.
Reflection
I learned that the condition requires appropriate interventions since it can be life-threatening. I learned that patients with various autoimmune disorders should get an appropriate checkup to avoid deterioration of the condition.
Health promotion should include eating a healthy diet, reducing salt intake, and exercising regularly. The patient should suspend Chlorthalidone medication since it can contribute to one of the conditions.
Provision of care should respect the cultural background, age, and religious beliefs. The patient requires adequate care and checkup since the age may pose various health risks.
References
American Diabetes Association. (2020). Glycemic targets: Standards of medical care in diabetes—2020. Diabetes Care, 43(Suppl. 1), S66–S76. https://doi.org/10.2337/dc20-S006
George, J. C., Zafar, W., Bucaloiu, I. D., & Chang, A. R. (2018). Risk factors and outcomes of rapid correction of severe hyponatremia. Clinical Journal of the American Society of Nephrology, 13(7), 984-992.
Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Endocrine, metabolic, and nutritional disorders. In Advanced practice nursing in the care of older adults (2nd ed., pp. 361–406). F. A. Davis.
Koehler, V. F., Filmann, N., & Mann, W. A. (2019). Vitamin D status and thyroid autoantibodies in autoimmune thyroiditis. Hormone and Metabolic Research, 51(12), 792-797.
Munshi, M., Nathan, D. M., Schmader, K. E., Mulder, J. E., & Givens, J. (2019). Treatment of type 2 diabetes mellitus in the older patient. UpToDate. Retrieved June 8, 2020, from https://www.uptodate.com/contents/treatment-of-type-2-diabetes-mellitus-in-the-older-patient
Strazzulla, L. C., Wang, E. H. C., Avila, L., Sicco, K. L., Brinster, N., Christiano, A. M., & Shapiro, J. (2018). Alopecia areata: disease characteristics, clinical evaluation, and new perspectives on pathogenesis. Journal of the American Academy of Dermatology, 78(1), 1-12.
—
NRNP_6540_Week9_Assignment_Rubric
• Grid View
• List View
Excellent Good Fair Poor
Create documentation in the Focused SOAP Note Template about the patient in the case study to which you were assigned.
In the Subjective section, provide:
• Chief complaint
• History of present illness (HPI)
• Current medications, checked against Beers Criteria
• Allergies
• Patient medical history (PMHx)
• Review of systems 9 (9%) – 10 (10%)
The response throughly and accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A thorough cross-check of medications against the Beers Criteria has been completed and appropriate alternative drugs recommended if applicable. 8 (8%) – 8 (8%)
The response accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A cross-check of medications against the Beers Criteria has been completed and appropriate alternative drugs recommended if applicable. 7 (7%) – 7 (7%)
The response describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis, but is somewhat vague or contains minor innacuracies. A cross-check of medications against the Beers Criteria has been completed but alternatives may be missing. 0 (0%) – 6 (6%)
The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A cross-check of medications against the Beers Criteria has not been completed. Or, subjective documentation is missing.
