Focused SOAP Note Health, Medicine, Nursing Essay Paper (Essay Sample)
Use the following case to complete a focused SOAP note. Incorporate answers to the questions into your SOAP write up.
Lou Brown is a 58-year-old white male who comes in with a cough for the past four days. He says that the cough has been intermittent. It started out as a dry cough but over the past two days, he has started coughing up thick pale-yellow phlegm. He thinks he has had a fever but he has not actually taken his temperature. He is a smoker but has not been smoking very much the past few days as that seems to make the cough worse. He has also felt very tired. He has taken Tylenol off and on and it does help slightly. About a week and a half ago, he played poker with some friends and one of them was sick. His wife accompanies him and when you ask them both, they deny that he has had any confusion.
PMH: History of Hypertension and Diabetes Mellitus Type 2. He admits he has not been going to his provider on a regular basis (thinks last time he went was about 7 months ago) but his provider had refilled his meds for a year, so he has not run out of them.
Medications: lisinopril 20 mg daily; metformin 500 mg twice daily
Social history: 40 pack year history of tobacco use (cigarettes); no alcohol or drugs.
Vitals: Ht: 5’4”; Wt: 190 lbs; BP: 150/94; P 88 R 26; Temp: 101.0 oral Pulse ox 96%
1. Please document the history questions you would ask the patient. What questions would you ask related to the current complaint? What questions would you ask related to his comorbidities?
2. What Physical Exam would you obtain? Describe what you would be looking for.
3. What labs/diagnostics would you order?
4. List your top four differential diagnoses. Explain your rationale for your top diagnosis.
5. What is a CURB Score?
6. When his labs come back, his CMP shows that his BUN is 21. Based on that information and on his presentation, what is his CURB score and how did you arrive at that score?
7. Based on his CURB score, should he be treated on an outpatient or inpatient basis?
8. His chest x-ray does indeed show infiltrates. What would be your treatment plan for him?
9. Name 3 health promotion topics that you should discuss with him.
10. What would your follow-up plan be?
Focused SOAP Note
Focused SOAP Note
LB, 58-year-old White Male
CC (chief complaint): Cough
HPI: LB is a 58-year-old white male who came to the clinic complaining of an intermittent cough that has been going on for the last four days. The cough started as a dry cough, but in the last two days, it has been a productive cough. The patient produces pale-yellow phlegm when he coughs and he feels tired. There is no specific time as to when the cough gets worse, but he claims to have used Tylenol occasionally and it relieved the cough.
Current Medications: The patient is currently on lisinopril 20 mg daily; metformin 500 mg twice daily medications.
PMHx: History of Hypertension and Diabetes Mellitus Type 2. He admits he has not been going to his caregiver on a regular basis (thinks last time he went was about 7 months ago) but his provider had refilled his meds for a year, so he has not run out of them.
Soc & Substance Hx: The patient admits to being a smoker and has been smoking the 40 pack cigarettes for the past one year. He, however, refutes taking alcohol of any other drugs.
* GENERAL: Ht: 5’4”; Wt: 190 lbs; BP: 150/94; P 88 R 26; Temp: 101.0 oral Pulse ox 96%
* HEENT: No visible head injuries, vision is okay, no hearing issues, no runny nose, uncontrollable coughing established.
* SKIN: Okay, with no rash or significant injury marks. No itching was reported, as well.
* CARDIOVASCULAR: No discomforts in the chest, and no edema.
* RESPIRATORY: The breathing pattern is okay. Signs of possible blockage due to sputum secretions.
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