Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples

Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples

SOAP Note and Differential Diagnoses for iHuman Case.

Use this week’s iHuman case titled “Jack Baldwin VE” and create a SOAP note with a treatment plan (located at the bottom of the SOAP note.

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Provide a subjective, objective, assessment, and plan (SOAP) note on this patient and your treatment plan using the SOAP note template. Remember to keep the patient’s identity private; use the minimal amount of information possible to get the idea across. Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples

Provide a reference for your treatment plan (in APA format). The reference may come from a journal, a book, etc.

Cite all sources using APA format.

Include three differential diagnoses and support your diagnoses with supporting literature.

 

 

Episodic SOAP Note Sample

 

Note: For purposes of this sample SOAP note comments on what is required for each section have been left in place. You would not leave these in an official SOAP note.

 

Name:  K. P. Date: 09/03/20xx Time: 0800
Age: 34 Sex: Male
SUBJECTIVE
CC:  

 

“I have a burning red rash on my back.”

 

Reason given by the patient for seeking medical care “in quotes”

HPI:  

34 year old male presents to office with a linear vesicular rash to the right side of his back. Patient states he began to feel a tingling and burning sensation to the area approximately 48 hours age, and then blisters appeared 24 hours ago. Patients states he now feels a constant sharp, burning pain in the area. He states the patin is often as 8 or 10 out of 10 severity. He complains of generalized malaise and reports a low grade fever no higher than 100.1 F. The pain worsens with touch and movement. Patient has been controlling pain with Tylenol 650 mg PO and he states it helps moderately. Patient reports having chicken pox when he was age 5.

Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness.

Medications: (list with reason for med )

 

Benicar 10 mg PO daily for HTN

 

PMH

 

Allergies:  NKDA   Medication Intolerances: None

 

Chronic Illnesses/Major traumas: Patient has a significant history for hypertension Chronic Health Problems:

1. HTN (401.1) – controlled

 

Hospitalizations/Surgeries: None

 

Other: 

Immunizations: Up to date on all immunizations. Flu shot in October 2012 and plans to get the Flu vaccine this year. Tetanus booster vaccine in 2010.

 

Environmental hazards: Patient denies any environmental hazards.

 

Safety meaures: Patient states “I always wear my seatbelt”.

 

Exercise and leisure: Walks occasionally for exercise.

 

Sleep: Denies any issues with sleeping.

 

 

Diet: Drinks one cup of coffee a day, otherwise drinks water or tea. 24-hour recall: Breakfast – bacon and eggs with a black coffee; Lunch – ham sandwich with tea; Dinner – salad with steak.

 

“Have you every been told that you have:  Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.”

Family History

 

No pertinent family history reported.

 

Does your mother, father or siblings have any medical or psychiatric illnesses?  Anyone diagnosed with: lung disease, heart disease, htn, cancer, TB, DM, or kidney disease.

 

Social History

 

No relevant social history; denies use of tobacco, alcohol, or illicit drugs.

 

Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, marijuana.  Safety status

 

ROS
General 

Reports pain and rash on the right side of back. Otherwise no complaints at this time.

 

Weight change, fatigue, fever, chills, night sweats,  energy level

Cardiovascular

 

 

Chest pain, palpitations, PND, orthopnea, edema

 

Skin

Complains of rash to middle of right side of back.

Complains of sharp, burning pain to the area. Denies bruising or other abnormalities to skin, hair, or nails.

Delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles

Respiratory

 

 

 

 

Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB

Eyes

 

Corrective lenses, blurring, visual changes of any kind

Gastrointestinal

 

Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools

Ears

 

Ear pain, hearing loss, ringing in ears, discharge

 

Genitourinary/Gynecological

 

Urgency, frequency burning, change in color of urine. Contraception, sexual activity, STDS’    Fe: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx;Male: prostate,

PSA, urinary complaints

Nose/Mouth/Throat

 

Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain

Musculoskeletal

 

Back pain, joint swelling, stiffness or pain, fracture hx, osteoporosis

Breast

 

SBE, lumps, bumps or changes

Neurological

 

Syncope, seizures, transient paralysis, weakness, paresthesias, black out spells

 

 

Heme/Lymph/Endo

Complains fo generalized malaise. Denies any heat or cold intolerance, thyroid enlargement or tenderness, unexpected weight changes, or abnormal distribution in body hair.

 

HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance

Psychiatric

 

 

 

 

 

Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx

OBJECTIVE
Weight: 182 lbs       BMI: 24.0 Temp: 99.2 F BP: 122/84 (left arm)
Height: 6’1” Pulse: 82 per minute Resp: 18, O2 sat 100% on RA
General Appearance

34 year old white male who appears his stated age. He is not in distress. He makes eye contact and responds to questions appropriately. Alert and oriented X3, well groomed, well nourished and hydrated. Patient is appropriately dressed and cooperative in regards to all aspects of the examination.

 

Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first, then brighter later.

Skin

Rash present to mid-back on the right side at location of 6th rib, bright red, linear form, with vesicular type blisters present. Blisters intact, no exudate or crusting present. Approximately 7 inches in length. Does not cross midline. No other lesions, bruises, or suspicious moles present. No nail pitting or clubbing.

 

Skin is brown, warm, dry, clean and intact. No rashes or lesions noted.

HEENT

 

Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes:  PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation.

Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules.

Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.

Cardiovascular

PMI noted at 5th ICS MCL. RRR, S1 and S2 present. No S3, S4, murmurs, or bruits noted. No palpable thrills, lifts, or heaves.

 

S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.

Respiratory

Summetrical thoracis expansion. A:P / 2:1. Tactile fremitus equal bilaterally. Resonance noted to all fields with percussion. Clear to auscultation with no adventitous sounds bilaterally.

 

Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.

Gastrointestinal

 

Abdomen obese; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly.

Breast

 

Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin.

Genitourinary/ Gynecological

 

Bladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink

 

and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT.

Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness. 

No adnexal masses or tenderness. Ovaries are non-palpable.

(Male:  both testes palpable, no masses or lesions, no hernia, no uretheral discharge. )

(Rectal as appropriate:  no evidence of hemorrhoids, fissures, bleeding or masses—Males: prostrate is smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm).

Musculoskeletal

 

Full ROM seen in all 4 extremities as patient moved about the exam room.

Neurological 

 

Speech clear. Good tone. Posture erect. Balance stable; gait normal.

Psychiatric

 

Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately. Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples

Lab Tests

None

 

Urinalysis – pending

Urine culture – pending

Wet prep – pending

 

Special Tests

None

 

 Diagnosis
 Differential Diagnosis

o    1- Herpes zoster without mention of complication (053.9) o     2- Rash and other nonspecific skin eruption (782.1) o     3- Other malaise and fatigue (780.79)

 

Presumptive Diagnosis o         1- Herpes zoster without mention of complication (053.9)

 

 

Plan/Therapeutics
                        o    Plan:

§  Diagnois: Herpes zoster without mention of complication (053.9)

§  Further testing: None

§  Medication:  Valtrex 1000 mg PO q8h X 7 days

§  Education: Continue using Tylenol 650 mg PO to manage pain. Limit Tylenol to less than 4 g per day. May also place a cool compress to area to ease pain. Vesicles may burst and then crust over. Thepain should ease within two to three days. It may take up to six weeks for the raash to completely heal. Monitor for s/s of infection (increased redness, fever, pain, or purulent, fould smelling drainage). Advise that a person sho has never had chicken pox may contract chicken pos by exposure to the shingles rash. Avoid contact with infants, children, pregnant women, and adults who have never had chicken pox, until blisters are completely dry. It is also important to avoid people with weakened immune systems. It is possible to have shingles flair up again in the future. Stress and a lowered immune system may precipitate a flair up. You can protect your immune system with a healthy lifestyle, and keeping your stress at manageable levels can reduce your chances of getting shingles and other

Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples

illnesses.

§  Non-medication treatments: Maintain adequate hydratin b continuing to drink 68 glasses of water a day. Continue participating in workout regimen.

§  Return to clinic: RTC in one week if pain persists or s/s of infection occur. Overwise, PRN.

 

 Evaluation of  patient encounter
Evaluate your patient encounter here.

 

Please note that your SOAP note has several areas that have required information.  The HPI is one of them.  The HPI must include:

History of Present Illness:  “O-P-Q-R-S-T” questions

Onset and circumstances of Occurrence of symptom(s)

Provocative and Palliative factors

Quality and/or Quantity of symptom

Region of body andRadiation to other areas

Severity of symptom (0 to 10 scale, if applicable) and associated Symptoms

Time (duration) and Temporal associations (what is going on when symptom occurs

In addition, “normal” is not acceptable you must describe what you are seeing.  I know that normal is used in charting–but you are learning and so you are required to do the ideal and the ideal is describing what you see and completing a total ROS on every patient. Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples

 

 

Week 7 I Human Soap note

Patient’s Initials: J.B.

Age: 50years old

Sex: Male

Date: 02/06/20xx

 Subjective

Chief Complaint (CC): “severe left groin pain for 6 hours”

HPI: Mr. Baldwin is a 50-year old male who experienced the sudden onset of severe pain in his left groin radiating to his testicles after moving a refrigerator 6 hours ago. The pain is severe, constant, and feels “like something is tearing inside.” He is nauseated, has vomited once but denies dysuria, hematuria, back/leg pain, numbness, or weakness. The physical exam is significant for tachycardia, hypertension, diaphoresis, and severe pain in a swollen left groin. Tenderness is appreciated in the left inguinal canal; the scrotum is swollen on the left side; the testicles are normal in size and nontender to palpation.

Past Medical History

Allergies: NKDA

Medications: Lisinopril 10mg by mouth daily

Surgical History and Procedure: None

Chronic Illness/Major Traumas: Hypertension I10 (“ICD-10 Code Lookup”, 2016)

Kidney stone 20.0 (“ICD-10 Code Lookup”, 2016)

 

Family History

Father: Hypertension, CAD, prostate cancer

Mother: Hypothyroidism, breast cancer

Siblings: None

Social History Marital status/personal support system: Married x 20 years without kid. Housing: Condominium Occupation: Accountant Tobacco use: Smokes 1 ppd; Alcohol: 1 to 2 drinks/day; History of: narcotic abuse (Percocet) Sexual history: Monogamous Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples

.Review of Systems

General (-) Fatigue, (-) weight loss, (-) chills, (-) fever, (-) night sweats, (-) change in energy level

Skin (-) delayed healing, (-) rashes, (-) bruising, (-) bleeding or skin discolorations, (-) any changes in lesions or moles

Eyes(-) Corrective lenses, (-) blurring, (-) change in vision Ears (-) ear pain, (-) hearing loss, (-) discharge Nose/Mouth, Throat (-) Sinus problems, (-) dysphagia, (-) nose bleeds or discharge, (-)dental disease, (-) hoarseness, (-) throat pain

Heme/Lymph/Endo (-) HIV, (-) blood transfusion hx (-), cold intolerance, (-) bruising, (-) night sweats, (-) increase hunger/thirst

Cardiovascular (-) chest pain, (-) palpitations, (-) edema, (-) PND, (-) orthopnea Respiratory (-) cough, (-) wheeze, (-) hemoptysis, (-) dyspnea, (-)  pneumonia hx, (-) TB

Gastrointestinal (-) Abdominal pain, (+) Nausea, (+) vomiting, diarrhea(-),  (-) constipation, (-) hepatitis, (-) hemorrhoids, (-)eating disorders, (-) ulcers, (-) black tarry stools

Genitourinary/Gynecological: (-) urgency, (-) frequency, (-) hesitancy, (-) dysuria, (-) hematuria (+) sexual activity, (-) STDS

Rectal Denies any bleeding or pain Musculoskeletal (-) back pain, (-) swelling of joints, (-) fracture history Neurological Denies weakness or numbness, (-) headache, (-) Syncope, (-) seizures, (-) transient paralysis, (-) weakness, (-) paresthesias, (-) black out spells

Psychiatric (-) depression, (-) anxiety, (-) sleeping difficulties, (-) suicidal ideation/attempts, (-) previous dx

Objective

Weight:  180.0 lbs.                BMI:   24.4                 Temp: 99 (Oral)       BP: 170/94

Height:  6’0”                          Pulse: 130bmp (tachycardia)                     RR: 18bpm, oxygen saturation is 98%, RA.

General Appearance: A healthy appearing adult male with acute distress. He is well-groomed, fit, and cheerful, he is alert and orientedx4, can answer any question by himself..

Skin: Warm, diaphoresis, (-) Delayed healing, (-) rashes, (-) bruising, (-) bleeding or skin discolorations, (-)any changes in lesions or moles No

HEENT: Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.

Lymph Nodes: Deferred

Carotids: (-) JVD, (-) bruits

Cardiovascular: Tachycardia, S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.

Respiratory: Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.

Gastrointestinal: Abdomen flat; BS hyper active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly.

Genitourinary: Bladder is non-distended; no CVA tenderness. The left groin region is visibly swollen and indurated to palpation. Right side normal. There is tenderness within the left inguinal canal; right inguinal canal normal. The scrotum is swollen on left side. The testicles are normal in size and nontender to palpation. Normal penile shaft, without lesions or discharge. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation.No uretheral discharge. Rectal as appropriate: no evidence of hemorrhoids, fissures, bleeding or masses. Prostrate is smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm. Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples

Musculoskeletal: Full ROM seen in all 4 extremities as patient moved about the exam room.

Neurological: Speech clear. Good tone. Posture erect. Balance stable; gait normal.

Psychiatric: Alert and oriented to person only. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; can’t answer questions appropriately.

 

Lab result

White blood cells (WBCs) 19500 mm3 4,000-10,000
Red Blood Cell Count (RBC) 5.0 million/µl 4.5-5.9(♂), 4.0-5.2(♀), adults
Hemoglobin (Hgb) 14.2 g/dl 14-18(♂), 12-16(♀), adults
Hematocrit (Hct) 45 % 42-54(♂), 37-47(♀), adults
Mean corpuscular volume (MCV) 92 fl 82-103, adults
Mean corpuscular hemoglobin (MCH) 30 µm3 26-34, adults
Mean corpuscular hemoglobin concentration (MCHC) 33 % 30-37, adults
Platelets (thrombocytes) 310 k/dL 150-399, adults
Red cell distribution width (RDW) 13.0 % 11.5-14.5, adults
Neutrophils 73 % 46-78, adult
Lymphocytes 24 % 18-52, adult
Monocytes 1 % 3-10, adult
Eosinophils 1 % 0-6, adult
Basophils 1 % 0-3, adult
Segmented neutrophils 71 % 36-72, adult
Band Cells 2 % 0-6, adult
Color light amber Interpreted by physician
Clarity clear clear
Odor normal slightly nutty
pH 5.1 4.5-8
Protein 1 mg/dL 0-8
Specific gravity 1.013 1.002-1.030
Osmolarity > 400 mOsm/L >400
Leukocyte esterase negative negative
Nitrites negative 0
Ketones negative negative
Bilirubin negative negative
Blood (heme) negative negative
Urobilinogen 1.0 EU/dL 0.2-1.0
Crystals none Interpreted by physician
Casts none hyaline casts/lpf 0-4
Glucose, urine negative negative
White blood cells (WBCs) 0-1 hpf 0-5
Red blood cells (RBCs) 0-1 hpf 0-5
Red blood cell casts none none
SQEP none lpf <5
Bacteria negative negative on spun specimen
Creatinine 7 5-19
Occult blood negative negative

 

Name Value Units Reference Range
Sodium (Na+) 141 mmol/L 135-145
Potassium (K+) 4.0 mmol/L 3.5 to 5.1
Chloride (Cl-) 99 mmol/L 95-102(1mo-adult), 91-118(1d-1mo)
Carbon dioxide, total (CO2) 25 mmol/L 22-29(15y-adult), 20-28(1y-15y)
Glucose (BG/Glu) 85 mg/dL 70-110(fasting), 70-200(non-fasting)
Urea nitrogen (BUN) 15 mg/dL 8-21(15y-adult), 5-18(1mo-15y)
Creatinine (Cr) 0.8 mg/dL 0.6-1.3(♂), 0.5-1.1(♀)
Calcium (Ca2+) 9.6 mg/dL 8.7-10.7(1 mo-adult), 8.7-11.9
*Anion Gap 17 mEq/L 10-20 [(Na+ – (Cl- + HCO3-)]

 

Scrotal ultrasound reveals the following:

Loop of bowel in the left scrotum

Normal blood flow to each testicle

Normal testicular size bilaterally (Fischbach & Dunning, 2014).

Diagnosis:

Hernia inguinal K40 (“ICD-10 Code Lookup”, 2016)

Evidenced by Inguinal or scrotal nonreducible mass with severe pain, vomiting, and constipation and scrotal ultrasound result (Fischbach & Dunning, 2014).

Differential diagnosis

Testicular torsion: sudden onset of pain which is exquisite tenderness; and a high-riding, horizontally displaced testis (Goolsby & Grubbs, 2015).

Epididymitis: fever, Swelling and tenderness of the scrotum (usually located on one side), patient may get relief with elevation of scrotum, which is positive Prehn’s sign. The other symptoms include urethral discharge, dysuria, hematuria (Cash, 2014)

Kidney Stone: Add Ct scan to determine the stone size, if the test of urine positive for renal calculi. Treatment of kidney stone includes: pain management such as ibuprofen (Motrin, Advil), Zofran 4mg every 6 hours as needed for controlling nausea/vomiting, helping with passing the stone by using Tamsulosin (Flomax) 0.4mg daily to ease urination (Buttaro, Trybulski & Bailey, 2013). Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples

Plan of Care:

Cancer-screening modalities for gender/age: prostate exam (Buttaro, Trybulski & Bailey, 2013).

Recommend smoking cessation – patient not ready (Buttaro, Trybulski & Bailey, 2013).

Fitness: encouraging increasing exercise (Buttaro, Trybulski & Bailey, 2013).

Nutrition: recommending better choices when eats out (Buttaro, Trybulski & Bailey, 2013).

Truss can be used to groin hernias. Educate patient to avoid heavy lifting, and gently reduce a groin hernia when the individual lies supine with hips flexed to relax the abdominal muscles (Cash, 2014).

Surgery is an effective treatment, laparoscopy or through an open procedure or mesh repair depending the size of the hernia, and the onset of strangulation. It should be surgical intervention if patient get strangulated hernias (Cash, 2014).

Schedule the patient to return to the office if fever, severe pain, or strangulation happens. Postoperative evaluation for hernia recurrences as needed (Cash, 2014).

 

 

References

Buttaro, T., Trybulski, J., Bailey,P., & Sandberg-Cook, J. (2013). Primary care: A collaborative                practice (4rd ed.). St. Louis, Mo.: Mosby/Elsevier.

Cash, J. C. (2014). Family Practice Guidelines, Third Edition, 3rd Edition. [South University]. Retrieved from https://digitalbookshelf.southuniversity.edu/#/books/9780826168757/

Fischbach, F. T., & Dunning, M. B. (2014). A manual of laboratory and diagnostic tests.                Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Goolsby, M. J., & Grubbs, L. (2015). Advanced assessment: Interpreting findings and formulating differential diagnoses. Philadelphia, PA: F.A. Davis Company.

ICD-10 Code Lookup. (2016). In CMS.gov. Retrieved on November 21, 2016, from             https://www.cms.gov/medicare-coverage-database/staticpages/icd-10-code-lookup.aspx Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples