Health Assessment SOAP Note
Week 7 Announcement:
Assessment of the Heart, Lungs, and Peripheral Vascular System
This week, you will evaluate abnormal findings in the area of the Chest and Lungs. In addition, you will appraise health assessment techniques and diagnoses for the heart, lungs and peripheral vascular system.
Assignment 1: Digital Clinical Experience: In this DCE Assignment, you will conduct a focused exam related to chest pain using the simulation tool, Shadow Health. Consider how a patient’s initial symptoms can result in very different diagnoses when further assessment is conducted.
In a Focus note, include General Assessment, Heart, Lungs and Affected System. Use Scholarly references, Peer-reviewed articles, Research Articles, Professional Organization Recommendations and Walden’s Library or your current text book. When documenting your Focus note, refer to SOAP note Template, this will ensure you include all required information. Review Rubric before submission.
Subjective Documentation in Provider Notes
Subjective narrative documentation in Provider Notes is detailed and organized and includes:
Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS)
ROS: covers all body systems that may help you formulate a list of differential diagnoses. You should list each system as follows:
General: Head: EENT: etc.
Objective Documentation in Provider Notes –
Physical exam: Document in a systematic order starting from head-to-toe, include what you see, hear, and feel when doing your physical exam using medical terminology/jargon. Document all normal and abnormal exam findings. Do not use “WNL” or “normal”.
You only need to examine the systems that are pertinent to the CC, HPI, and History.
Diagnostic result – Include any pertinent labs, x-rays, or diagnostic test that would be appropriate to support the differential diagnoses mentioned
The body is constantly sending signals about its health. One of the most easily recognized signals is pain. Musculoskeletal conditions comprise one of the leading causes of severe long-term pain in patients. The musculoskeletal system is an elaborate system of interconnected levers that provides the body with support and mobility. Because of the interconnectedness of the musculoskeletal system, identifying the causes of pain can be challenging. Accurately interpreting the cause of musculoskeletal pain requires an assessment process informed by patient history and physical exams.
In this Assignment help – Discussion, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.
To prepare:
By Day 1 of this week, you will be assigned to one of the following specific case studies for this Assignment help – Discussion. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
Your Assignment help – Discussion post should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style Assignment help – Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.
Review the following case studies:
Case 1: Back Pain
Photo Credit: University of Virginia. (n.d.). Lumbar Spine Anatomy [Photograph]. Retrieved from http://www.med-ed.virginia.edu/courses/rad/ext/5lumbar/01anatomy.html. Used with permission of University of Virginia.
A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg. In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved? How would you test for each of them? What other symptoms need to be explored? What are your differential diagnoses for acute low back pain? Consider the possible origins using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework. What physical examination will you perform? What special maneuvers will you perform?
Case 2: Ankle Pain
Photo Credit: University of Virginia. (n.d.). Lateral view of ankle showing Boehler’s angle [Photograph]. Retrieved from http://www.med-ed.virginia.edu/courses/rad/ext/8ankle/01anatomy.html. Used with permission of University of Virginia.
A 46-year-old female 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 Ottawa ankle rules to determine if you need additional testing?
Case 3: Knee Pain
Photo Credit: University of Virginia. (n.d.). Normal Knee Anatomy [Photograph]. Retrieved from http://www.med-ed.virginia.edu/courses/rad/ext/7knee/01anatomy.html. Used with permission of University of Virginia.
A 15-year-old male reports dull pain in both knees. Sometimes one or both knees click, and the patient describes a catching sensation under the patella. In determining the causes of the knee pain, what additional history do you need? What categories can you use to differentiate knee pain? What are your specific differential diagnoses for knee pain? What physical examination will you perform? What anatomic structures are you assessing as part of the physical examination? What special maneuvers will you perform?
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.
Note: Before you submit your initial post, replace the subject line (“Assignment help – Discussion – Week 8”) with “Review of Case Study ___.” Fill in the blank with the number of the case study you were assigned.
By Day 3 of Week 8
Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
Note: For this Assignment help – Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Assignment help – Discussion Question” link, and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!
Read a selection of your colleagues’ responses.
By Day 6 of Week 8
Respond to at least two of your colleagues on 2 different days who were assigned different case studies than you. Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition, and justify your reasoning
Health Assessment SOAP Note
Patient Information:
Initials – BM Age – 46 Sex – F Race – White
S.
CC: “Both ankles hurt, but the pain in the right one is severe.”
HPI: BM is a 46-year old white female who reports to the healthcare facility complaining of pain in both ankles. She is concerned about the sharp pain in the right ankle. She was playing soccer over the weekend when she heard a pop. She can bear the weight, but she is uncomfortable with the weight. The pain subsides upon taking medication, but it worsens later. The patient indicates the severity of the pain to be 8 out of 10.
Current Medications:
Ibuprofen 800mg OTC Q4H PRN for 2 days
One-A-Day Women multivitamin one tablet daily
Ferrous sulfate 325mg daily
Allergies:
Penicillin allergy
NKDA
The patient denies seasonal allergies.
PMHx:
She was diagnosed with anemia six months ago.
Appendectomy at 31 years and knee surgery at 26 years.
Soc Hx:
The patient is a librarian at a local university. She loves hiking and playing soccer. She is a single parent and a mother to two sons, 12 and 15 years old. She separated from the husband five years ago. She denies tobacco or ETOH abuse. She attends a mass at a local catholic church weekly.
Fam Hx:
Fam Hx: Both parents are alive and healthy. The father has hypertension. Her two brothers are healthy, with no significant health issues. The children are healthy.
ROS:
GENERAL:
The patient denies weight loss or gains for the last year—no weakness, fatigue, or fever.
HEENT: Eyes – No vision problems, sensitivity to light, or yellow sclera.
Ears – No hearing problems, discharge, or pain.
Nose – No nasal congestion or running nose.
Throat – No swollen lymph nodes, tonsils, or difficulty in swallowing.
SKIN: No bruises, lesions, open wounds, dry plaques, itchiness, or skin rashes.
CARDIOVASCULAR: No angina, chest tightness, palpitations, or edema.
RESPIRATORY: The patient denies difficulty in breathing, coughing, sputum, or shortness of breath.
GASTROINTESTINAL: No nausea, vomiting, diarrhea, or blood in the stool.
GENITOURINARY: No difficulty or pain in passing urine.
NEUROLOGICAL: The patient denies a problem with bladder or bowel control, headache, dizziness, seizures, or falls.
MUSCULOSKELETAL: The patient denies focal weakness, joint swelling, or bone fracture. She complains that both ankles hurt, and the pain in the right one is severe.
HEMATOLOGIC: She denies bleeding gums. She suffered anemia, but the condition is under control.
LYMPHATICS: The patient denies enlarged lymph nodes.
PSYCHIATRIC: No history of depression, insomnia, or anxiety.
ENDOCRINOLOGIC: No history of urgent need to urinate or excessive sweating at night.
ALLERGIES:
Penicillin allergy
NKDA
The patient denies seasonal allergies.
O.
Physical exam:
Vital signs: B/P 126/72, Pulse 68, Temp 98.08F orally, RR 19, non-labored, SpO2: 98 room air, H 5’6, W 110lbs.
Neurological: A&O * 4. Present and cooperative. She was dressed for the occasion.
HEENT: Normocephalic and atraumatic. No conjunctiva erythema. Oropharynx red. Moist mucus membrane.
Neck: No pain or swelling. Supple, no JVD. Trachea midline.
Chest/lungs: Clear to auscultation bilaterally.
Heart: Regular heart rhythm. No murmurs, palpitation, and normal capillary refill.
ABD: Soft and tender, no palpable hepatosplenomegaly.
Genital/Rectal: continent of bladder and bowel.
Musculoskeletal: Ankles aching with the right ankle in severe pain. Able to bear weight but uncomfortable.
Skin: The skin is dry and warm. 2*1.5cm ecchymosis on mid-lateral malleolus area on both ankles. No lesions, dry plaques.
Diagnostic Tests:
Anterior drawer test – the screening test is essential for a lateral ankle sprain or a suspected ATFL injury (Hsu & Anderson, 2016).
Inversion test – The test evaluates the laxity of the calcaneofibular ligament (Nery et al., 2016).
Imaging studies:
Ankle X-ray series is essential if there is a pain in the malleolar zone. It should also be carried out if there is bone tenderness along the distal of the posterior edge or the inability to bear weight (Hunt et al., 2016).
A.
Differential Diagnoses:
a) Grade 2 lateral ankle sprain – The condition occurs during sporting activities that lead to straining or injury of the ligaments and causing an audible pop. It causes pain and swelling. Ecchymosis may delay for a day or two (Hunt et al., 2016). An ankle sprain occurs upon injury on the ligaments. It causes symptoms, including pain, swelling, and soreness (Vuurberg et al., 2018). Based on the symptoms and reports from the patient, an ankle sprain is a primary diagnosis. An anteroposterior X-ray on the ankle will reveal the extent of the injury on the ligament.
Most people treat the condition at home with pain relievers, ice, and rest. Severe pain requires a medical evaluation. Medical attention helps assess the pain’s extent and provide the necessary treatment (Vuurberg et al., 2018). The medical evaluation is necessary to examine the condition and prescribe the appropriate medication.
b) Achillies tendinitis inflammation – The condition affects the Achilles tendons, causing pain and swelling where the tendon inserts in the calcaneus tendons. It causes a sense of tightness that leads to difficulty in walking (Hsu & Anderson, 2016). The area of pain and tenderness involves the mid-lateral area of the ankle. The swelling of the Achilles tendon can be assessed from the ankle’s posterior part (Hunt et al., 2016). The condition is selected since it mirrors the patient’s symptoms, including pain and difficulty in bearing weight.
c) Ankle fracture – The condition involves a fracture of one of the bones such as the tibia, fibula, and talus. The condition can trigger immediate severe pain, bruising, deformity, inability to bear weight, and tenderness (Vuurberg et al., 2018). The severity of the fracture will determine the level of pain or the inability to walk or bear weight. The common causes of an ankle fracture include twisting or rotating of the ankle, stress from tripping, or falling (Vuurberg et al., 2018). The condition requires immediate treatment, such as the application of casters. Regular X-rays are necessary to ensure the ankle is stable (Hunt et al., 2016). The condition symptoms include immediate severe pain and inability to bear weight, which is similar to the patient’s complaints.
d) Anterior impingement – The condition is also known as the footballer’s ankle. The major symptoms include pain and inflammation. It causes difficulty in bearing weight. It decreases the ankle’s range of motion (Hsu & Anderson, 2016). The condition affects dorsiflexion (Hsu & Anderson, 2016). The condition was selected since the patient is having difficulty bearing weight and is experiencing pain.
e) Plantar fasciitis – Plantar fasciitis is an inflammation of the thick band of tissues connecting the heel to the bones. It causes a stabbing pain on the heel that can worsen in the morning (Hunt et al., 2016). The major causes include the ligament’s strain injury, such as excessive running, jumping injury, and inadequate footgear. Pain is severe during walking or standing (Hunt et al., 2016). The pain subsides with non-weight bearing activities. The purpose of selecting the condition is because the patient is experiencing pain while walking or bearing the weight.
References
Hsu, A., & Anderson, R. B. (2016). Foot and ankle injuries in American football. Am J Orthop, 45(6), 358-367.
Hunt, K. J., Hurwit, D., Robell, K., Gatewood, C., Botser, I. B., & Matheson, G. (2017). Incidence and epidemiology of foot and ankle injuries in elite collegiate athletes. The American Journal of Sports Medicine, 45(2), 426-433.
Nery, C., Raduan, F., & Baumfeld, D. (2016). Foot and ankle injuries in professional soccer players: diagnosis, treatment, and expectations. Foot and Ankle Clinics, 21(2), 391-403.
Vuurberg, G., Hoorntje, A., Wink, L. M., Van Der Doelen, B. F., Van Den Bekerom, M. P., Dekker, R., … & Smithuis, F. F. (2018). Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. British Journal of Sports Medicine, 52(15), 956-956.
