NURS 6512 Episodic/Focused SOAP Note Example [Solved]
NUR 6512: Episodic/Focused SOAP Note Assignment Instructions Overview
In this assignment, you will have the opportunity to practice creating an Episodic/Focused SOAP Note for a patient presenting with head, eyes, ears, nose, and throat (HEENT) symptoms. You will apply your knowledge of the HEENT assessment and differential diagnosis to provide comprehensive care to the patient. Additionally, you will identify possible conditions and justify your choices using evidence-based guidelines. Your goal is to accurately document the patient’s history, perform a focused physical examination, and formulate a differential diagnosis based on the presented case.
Understanding Episodic/Focused SOAP Notes on HEENT:
Episodic/Focused SOAP Notes are a structured way of documenting patient assessments, allowing healthcare providers to collect essential information systematically. For this assignment, we will focus on the HEENT region, which includes the head, eyes, ears, nose, and throat.
If you want to master the art of writing SOAP notes in nursing, you can check out our expert guide on How to Write SOAP Notes in Nursing to enhance your clinical documentation skills while excelling in your academic journey.
The Student’s Role:
As a student in NUR 6512, you will:
- Review the Case Study: Familiarize yourself with the provided case study, which outlines the patient’s background, chief complaint, and relevant medical history. Pay close attention to the patient’s symptoms and any cues that may hint at a potential diagnosis.
- Understand the Episodic/Focused SOAP Note Format: Gain a comprehensive understanding of the Episodic/Focused SOAP Note format, which includes sections for Subjective data (S), Objective data (O), Assessment (A), and Plan (P). You will focus primarily on the S and O sections in this assignment.
- Patient Assessment and Documentation: Assume the role of a healthcare provider and document the patient’s history, focusing on the LOCATES mnemonic (Location, Onset, Character, Associated signs and symptoms, Timing, Exacerbating/relieving factors, Severity). Include the patient’s age, race, and gender in your documentation.Conduct a thorough physical examination of the patient, documenting findings from head to toe, with specific emphasis on the HEENT system. Avoid using terms like “WNL” or “normal.” Instead, provide detailed descriptions of what you observe, hear, and feel.
- Differential Diagnosis: Generate a list of at least three possible differential diagnoses based on the patient’s presenting symptoms and physical examination findings. Your primary or presumptive diagnosis should be at the top of the list. Provide evidence-based justification for each potential diagnosis, drawing upon knowledge from the provided resources.
- Diagnostic Results: If necessary, include any hypothetical diagnostic tests that might be appropriate for confirming or ruling out the differential diagnoses. Support your choices with evidence from the literature and guidelines.
- Assignment Submission: Organize your findings and document them in the Episodic/Focused SOAP Note template provided in the assignment resources. Ensure that you adhere to the format guidelines and provide clear and detailed information.
Patient Information:
Initials: R.H. Age: 50 Sex: Male Race: Not specified
CC: “Nasal congestion, sneezing, rhinorrhea, and postnasal drainage”
HPI: Mr. Richard (R.H.) is a 50-year-old male presenting with symptoms of nasal congestion, sneezing, rhinorrhea, and postnasal drainage. The location of the presenting illness is primarily in the head and neck region. He has been experiencing these symptoms for the past 5 days, along with itching in his nose, eyes, palate, and ears. During the examination, he was observed touching his nose bridge frequently. He reports having taken Mucinex OTC for the past two nights to alleviate his symptoms of nighttime breathing difficulties but with only minimal improvement. On examination, R.H. appears alert and oriented. His nasal mucosa is pale and boggy, with clear thin secretions. An enlarged nasal turbinate obstructs his airway, but his lung examination is unremarkable. His tonsils are not enlarged, but his throat displays mild erythema.
- Location: Head and neck
- Onset: 5 days ago
- Character: Nasal congestion, sneezing, rhinorrhea, postnasal drainage, itching in nose, eyes, palate, and ears
- Associated signs and symptoms: Pale, boggy nasal mucosa, clear thin secretions, enlarged nasal turbinate obstructing airway flow, mildly erythematous throat
- Timing: Persistent symptoms, worsened during sleep
- Exacerbating/relieving factors: Symptoms worsen during sleep, minimal improvement with Mucinex OTC
- Severity: 7/10 pain scale
Current Medications:
R.H. is currently taking Mucinex OTC for his symptoms, but the dosage, frequency, and length of use are not specified.
Allergies:
R.H. reports an allergy to pollen, which causes angioedema.
PMHx:
R.D. received the Moderna mRNA vaccine on October 1st, 2021, and has no recent major illnesses or surgeries.
Soc Hx:
Occupation: Tax attorney in New York.
Hobbies: Golfing, DIY carpentry projects, occasional skydiving.
Marital Status: Married for 23 years.
Family: One daughter in college.
Tobacco & Alcohol Use:
- Denies tobacco use.
- Occasional alcohol consumption.
- History of marijuana use in his 20s.
Health Promotion:
- Reports maintaining a healthy diet.
- Does not consistently use protective equipment during carpentry.
Fam Hx:
- Father: Deceased at 82, congestive heart failure, hypertension.
- Mother: Alive at 76, dementia, hypertension.
- Grandparents: Deceased at ages 86 and 89, with no significant health issues except for arthritis in his grandfather.
- Wife and daughter: No significant medical history.
ROS:
GENERAL: Denies weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: Denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: Denies hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: Denies rash or itching.
CARDIOVASCULAR: Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: Denies shortness of breath, cough, or sputum.
GASTROINTESTINAL: Denies anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
GENITOURINARY: Denies burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: Denies muscle, back pain, joint pain, or stiffness.
HEMATOLOGIC: Denies anemia, bleeding, or bruising.
LYMPHATICS: Denies enlarged nodes. No history of splenectomy.
PSYCHIATRIC: Denies history of depression or anxiety.
ENDOCRINOLOGIC: Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: Denies history of asthma, hives, eczema, or rhinitis.
O.
Physical exam:
GENERAL: The patient is a 50-year-old male, alert, and oriented, with no signs of distress.
VITAL SIGNS:
- Blood Pressure: 100/80 mm Hg
- Heart Rate: 79 bpm
- Respiratory Rate: 15 breaths per minute
- Temperature: 97.6°F
- Weight: 120 lbs
- Height: 6’2″
- BMI: 37
HEAD: No visible abnormalities, swelling, trauma, or lesions.
EYES: Pupils are round, reactive to light, and equal in size. Slight redness observed.
EARS: No visible ear abnormalities.
NOSE: Pale and boggy mucosa. Enlarged nasal turbinate with clear thin secretions present.
MOUTH AND THROAT: Throat appears mildly erythematous, tonsils not enlarged. No lesions or tonsillar exudate visible.
NECK: Range of motion is normal, with no visible signs of trauma.
RESPIRATORY: Abnormal wheezing sounds are heard during breathing.
CARDIOVASCULAR: S2 is louder than S1.
ABDOMEN: No specific abdominal-related complaints, thus no abdominal examination was performed.
EXTREMITIES: No visible deformities, swelling, or abnormalities.
SKIN: Skin is free from discoloration, lesions, or rashes.
NEUROLOGICAL: No neurological complaints presented, thus neurological examination was not performed.
PAIN ASSESSMENT: Patient reports no pain.
Diagnostic results:
No diagnostic tests were conducted for this patient.
A.
Differential Diagnoses:
- Allergic Rhinitis: Symptoms such as nasal congestion, sneezing, rhinorrhea, and itching in the nose, eyes, palate, and ears are indicative of allergic rhinitis. The patient’s response to environmental allergens, along with the presence of pale, boggy nasal mucosa and clear thin secretions, supports this diagnosis (Liva et al., 2021).
- Non-Allergic Rhinitis: While similar to allergic rhinitis, non-allergic rhinitis may be triggered by non-allergic factors such as humidity, irritants, or medications. The patient’s minimal response to Mucinex OTC suggests this as a differential diagnosis (Liva et al., 2021).
- Viral Rhinitis (Common Cold): Viral rhinitis can present with symptoms of nasal congestion, sneezing, rhinorrhea, and postnasal drainage. The patient’s mild erythematous throat and lack of significant improvement with Mucinex OTC make this a possibility (Negmurodovich, 2021).
- Vasomotor Rhinitis: Vasomotor rhinitis may cause symptoms similar to allergic rhinitis but is triggered by environmental factors. If no allergic or viral etiology is found, this could be considered as a differential diagnosis (Negmurodovich, 2021).
- Sinusitis: The persistence of an enlarged nasal turbinate obstructing airway flow suggests the possibility of sinusitis, which can lead to symptoms like postnasal drainage and facial discomfort and pressure (Kumar et al., 2022).
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