SOAP Note on Three Case Studies

NU610 Unit 1 Case Studies APA 7TH EDITION
Instructions
Review the following case studies.
In a Word file construct a subjective data set for each case from the information provided.
Structure the subjective data set in the format provided in your lecture materials.
Submit the Word file containing your 3 subjective data sets into Canvas.
To support your success on the assignment the SOAP Note Assignment Instructions are attached here for your review of how to structure a subjective data set
Case 1
A 50-year-old man comes to your office for a routine physical examination. He is a new patient to your practice. He states his father died at the age of 73 of a heart attack. His mother is alive at the age of 80. He has hypertension, which he takes chlorthalidone 25 mg PO daily. Takes Tylenol as needed for pain. Denies seasonal or drug allergies. He has two younger siblings with no known chronic medical conditions. Last eye and dental exam two years ago. He is married in a monogamous relationship without children. Has a high school diploma. Works full-time for local landscaping business. He does not smoke, drink alcohol, use any recreational drugs and does not exercise. He denies fever, chills, weight loss or weight gain. He denies hearing changes, headaches or dizziness. He reports some visual changes when reading close-up. He denies shortness of breath, dyspnea on exertion, swelling or chest pain. He reports increase urination and thirst. Denies abdominal pain, nausea, vomiting or changes in appetite. He reports daily BM. Denies rashes or bug bites. Uses sunscreen daily due to working outside. Denies anxiety or depression. On examination his blood pressure is 126/82, pulse is 80 beats/min, respiratory rate is 18. Height is 67 inches and weight is 190lbs. Does not appear in acute distress, responses are appropriate and appears reliable source. Alert, oriented to person, place, time and situation. Well-nourished, skin warm, dry and intact. Normocephalic. Pupils size 3 mm, equal and reactive to light. Extraocular eye movements intact to six directions. Tympanic membranes gray with adequate cone of light bilaterally. Mucous membranes pink and moist. No palpable masses, thyromegaly, lymphadenopathy or JVD. Regular heart rate and rhythm, S1 and S2. No bruits auscultated. Capillary refill less than 3 seconds. Breath sounds clear bilaterally to auscultation. No use of accessory muscles or purse lip-breathing. Soft, non-tender, non-distended, normoactive bowel sound. No organomegaly or guarding. Denies numbness or tingling. He reports he has not had HIV or PSA screenings.
Case 2
A 40-year-old woman presents with 10 episodes of watery, non-bloody diarrhea that started last night. She vomited twice last night but has been able to tolerate liquids today. She is complaining of intermittent abdominal cramping, rating pain 4 out of 10. She also reports having muscle aches, weakness, headache, and low-grade fever of 99.7 at home. She states her son has had the same symptoms that started this morning. She has no significant medical history, denies surgeries, and does
not take any prescribed medications. Last wellness examination was 2 years ago when cervical screening was completed. She does not smoke, use alcohol, or illicit drugs. She does report that her and her family returned home yesterday after spending a week in Cancun. On examination she is not in acute distress, blood pressure is 110/60, pulse 98, respiratory rate is 16, and temperature is 99.1. Bowel sounds are hyperactive, and her abdomen is mildly tender throughout but there is no rebound tenderness and no guarding. Her mucous membranes are dry. A rectal examination is normal, and stool is guaiac negative. Reports trying Pepto-Bismol this morning without relief. Denies food, seasonal or drug allergies. Last menses 3 weeks ago, currently single and not sexually active. Heart rate regular rate and rhythm with
S1 and S2. Breath sounds clear to auscultation bilaterally with symmetrical chest expansion. Alert and oriented, does not appear acutely ill. Needs a work excuse, works part-time at community college.
Case 3
A 40-year-old single male presents to your office complaining of left knee pain that has started last night. He says that the pain started suddenly and was severe within about 3 hours’ time. He denies injury, fever, systemic symptoms, or prior episodes. He has a history of hypertension and does take hydrochlorothiazide 12.5 mg PO daily to control it. He admits to consuming a large amount of wine with dinner last night. He currently is not working. Has allergy to Percocet which he reports reaction is urticaria. Upon examination his temperature is 98, pulse is 90, respirations are 22 and blood pressure is 129/88. Heart and lung examinations are unremarkable. The patient is reluctant to flex the left knee and does wince with pain at touch. He has passive range of motion. The knee is edematous, hot to touch, and has erythema of the overlying skin. No crepitation or deformity is apparent. No other joints are involved. Inguinal lymph notes are not enlarged. He denies trauma or previous injury to his left knee. He denies weight loss or weight gain. He reports in the past having swelling to his big toe that went away on its own. He tried ibuprofen without relief of the pain this morning. Rates the pain about six out of ten that is constant. Denies any family history of joint or musculoskeletal issues. He denies smoking or illicit drug use. Was recently seen in the office 6 months ago for wellness exam with normal blood pressure reading and A1c. He is alert and oriented to self, place, time and situation. Well-nourished on exam reports eating keto diet. Thoughts are coherent, mood and affect appropriate.
NU610 Unit 1 Assignment - Case Studies Rubric
NU610 Unit 1 Assignment - Case Studies Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeSubjective Data
40 pts
Highly Proficient
Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are well written with few to no omissions or misclassifications of data from the case for all 3 cases.
32 pts
Proficient
Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are well written with few to no omissions or misclassifications of data from the case for 2 of the 3 cases.
24 pts
Marginally Proficient
Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are well written with few to no omissions or misclassifications of data from the case for 1 of the 3 cases.
16 pts
Approaching Proficiency
Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are documented partially correct for all of the cases.
8 pts
Not Proficient
Elements of subjective data (CC, HPI, PMH, Allergy identification, Medication Reconciliation, Social History, Family History, Health Promotion, and ROS) are not documented partially correct for any of the cases.
0 pts
Not Evident
An assignment submission is not located.
40 pts
Total Points: 40
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