formulate differential diagnoses, medical diagnoses, and an evidence-based action plan.
Unit 4: Cranial Nerves, Thyroid, Neck, and Regional Lymphatics
Assignment 1: Comprehensive SOAP Note
This Assignment will help develop skills to perform an integrated history and physical examination for individuals across the lifespan.
Considerations of lifestyle practices, cultural/ethnic differences, and developmental variations will be incorporated into the plan of care.
Use critical thinking and diagnostic reasoning skills to formulate differential diagnoses, medical diagnoses, and an evidence-based action plan.
Include sections 1 and 2 of the SOAP note with recommendations (incorrect or omitted data) based on feedback provided for the previous sections of the SOAP note.
Complete the Comprehensive SOAP Note.
MN552 Advanced Health Assessment
Unit 4 Comprehensive SOAP Note Written Guide
SOAP Note Written Guide
This guide will assist you to document history data, and perform a comprehensive physical exam in an organized and systematic manner.Please include a heart exam and lung exam on all clients regardless of the reason for seeking care.So, if someone presented with cough and cold symptoms, you would examine the General appearance, HEENT, Neck, Heart and Lungs for a focused/episodic exam.However, this Assignment requires assessment of all body systems.The pertinent positive findings should be relevant to the chief complaint and health history data. Please follow the guide and include all previous sections of the SOAP Note with corrections based on feedback, as well as the Objective and Plan sections.
I. Subjective Data
A:Biographical Data
B: Source of history and reliability
C:Chief Complaint
D:History of Present Illness (HPI)
E: Past Medical History
F:Family History
G:Social History (alcohol, drug, or tobacco use)
H.Lifestyle Patterns
I:Allergies
J:Current Medications
Review of Symptoms
Symptoms to Inquire About
(please see page 54–56 in Jarvis textbook)
Document pertinent negatives and/or positives
The first system is addressed to provide a guide
General
Wgt Δ; weakness; fatigue; fevers
Pertinent Negatives: No weight gain or losses; no weaknesses, fatigue, or fevers
Pertinent Positives:Positive weight gain over past 2 months with fatigue and weakness; no fevers
Skin
Rash; lumps; sores; itching; dryness; color change; Δ in hair/nails
Head
Headache; head injury; dizziness or vertigo
Eyes
Vision Δ; eye pain, redness or swelling, corrective lenses; last eye exam; excessive tearing; double vision; blurred vision; scotoma
Ears
Hearing Δ; tinnitus; earaches; infections; discharge, hearing loss, hearing aid use
Nose/
Sinuses
Colds; congestion;nasal obstruction, discharge; itching; hay fever or allergies; nosebleeds;change in sense of smell; sinus pain
Throat/
Mouth
Bleeding gums; mouth pain, tooth ache, lesions in mouth or tongue, dentures; last dental exam; sore tongue; dry mouth; sore throats; hoarse; tonsillectomy; altered taste
Neck
Lumps; enlarged or tender nodes, swollen glands; goiter; pain; neck stiffness; limitation of motion
Breasts
Lumps; pain; discomfort; nipple discharge, rash, surgeries, history of breast disease; performs self-breast exams and how often, last mammogram; any tenderness, lumps, swelling, or rash of axilla area
Pulmonary
Cough—productive/non-productive; hemoptysis; dyspnea; wheezing; pleuritic pains; any H/O lung disease; toxin or pollution exposure; last Chest X-RAY, TB skin test
Cardiac
Chest pain or discomfort; palpitations; dyspnea; orthopnea; edema, cyanosis, nocturia; H/O murmurs, hypertension, anemia, or CAD
G/I
Appetite Δ; jaundice; nausea/emesis; dysphagia; heartburn; pain; belching/flatulence; Δ in bowel habits; hematochezia; melena; hemorrhoids; constipation; diarrhea; food intolerance
GU
Frequency; nocturia; urgency; dysuria; hematuria; incontinence
Females: Use of kegal exercises after childbirth; use of birth control methods; HIV exposure; Menarche; frequency/duration of menses; dysmenorrhea; PMS symptoms: bleeding between menses or after intercourse; LMP; vaginal discharge; itching; sores; lumps Menopause; hot flashes; post-menopausal bleeding;
MALES:caliber of urinary stream; hesitancy; dribbling; hernia, Sexual habits; interest; function; satisfaction; Discharge from or sores on penis; HIV exposure; testicular pain/masses; testicular exam and how often
Peripheral Vascular
Claudication; coldness, tingling, and numbness; leg cramps; varicose veins; H/O blood clots, discoloration of hands, ulcers
Musculo-skeletal
Muscle or joint pain or cramps; joint stiffness; H/O arthritis or Gout; limitation of movement; H/O disk disease
Neuro
Syncope; seizures; weakness; paralysis; stroke, numbness/tingling; tremors or tics; involuntary movements; coordination problems;memory disorder or mood change; H/O mental disorders or hallucinations
Heme
Hx of anemia; easy bruising or bleeding; blood transfusions or reactions; lymph node swelling; exposure to toxic agents or radiation
Endo
Heat or cold intolerance; excessive sweating; polydipsia; polyphagia; polyuria;glove or shoe size; H/O diabetes, thyroid disease; or hormone replacement; abnormal hair distribution
Psych
Nervousness/anxiety; depression; memory changes; suicide attempts;H/O mental illnesses
II.Objective Data
General:
Skin:
HEENT & Sinuses:
Neck & Regional Lymph Nodes:
Breasts:
Lungs & Thorax:
Heart:
Gastrointestinal:
Genitourinary:
Extremities (Peripheral Vascular):
Musculoskeletal:
Neurological:
III.Assessment
A: Differential Diagnosis (include rationales and cite sources)
1.
2.
3.
B:Nursing Diagnosis
1.
C:Medical Diagnosis
IV. PLAN
A:Orders
1. Prescriptions with dosage, route, duration, and amount prescribed and if refills provided
2. Diagnostic testing
3. Problem oriented education
4. Health Promotion/Maintenance Needs
B:Follow-Up Plans (When will you schedule a follow-up appointment and what will you address in the subsequent visit —F/U in 2 weeks; Plan to check annual labs on RTC(return to clinic).
V.Nursing Theory & Application: Select a Nursing Theory and apply this to your patient’s plan and evaluation (brief statement).
VI.Developmental Stage:Identify the developmental state and provide rational to support acquisition of skills in the stage (brief statement).
VII.Cultural Characteristics, Diversity, Sensitivity & Ethical Considerations
Discuss culturally diverse considerations you identified for this patient.Cultural Diversity is a general term that can include gender, religious beliefs, culture, race, economic status, age, and etc.Discuss one ethical standard relevant to the care of this patient.
VIII.Evaluation of Care:Provide a brief statement sharing your thoughts about the visit and/or patient.Please share what you should have done differently.
References:Please include a minimum of three references.The reference list must be in APA format.All sources must be within 5 years of publication.
