Clinical Case Presentations: Students must post one interesting case that he/she has seen in the clinical setting via Discussion Board in the online part of this course. The case should be an unusual diagnosis, or a complex case that required in-depth evaluation on the student’s part. The case should be posted in the SOAP format, with references for the patient diagnosis, differential diagnoses (there should be at least 3), and the treatment plan. Notes will be graded as “pass/fail”. In order to receive grade points for SOAP notes, the notes must be approved by the deadlines specified on the course assignments page. The student will lose the opportunity for points on any SOAP notes not approved by the specified deadlines. The posting does not have to be written in APA format, but should be written with correct spelling and grammar. References should be in APA format. The selected references should reflect current evidence – dated within the past 5 years.
Attached you will find some examples for you to have as a reference as well as the rubric.
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Patient Initials: CK |
Pt. Encounter Number: 1 |
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Age:72 |
Sex: M |
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Allergies: NKA Advanced Directives: NONE |
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SUBJECTIVE |
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CC: âAbdominal pain, fever, nausea and vomitingâ |
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HPI: |
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Current Medications: Lisinopril 10 mg PO daily for HTN Metformin 500 mg PO BID for Diabetes Zocor 20 mg PO daily for High cholesterol Advil 400 mg PO BID PRN for pain Vitamin D, Calcium and Fish oil PO daily |
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PMH Medication Intolerances: NONE Chronic Illnesses/Major traumas: HTN, DM, Hypercholesterolemia Hospitalizations/Surgeries: Back Surgery in 2003 |
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Family History: Mother: HTN, DM, Hypercholesterolemia, and stroke. Died at age 69. Father: Arthritis, HTN, DM, CAD, COPD and ESRD. |
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Social History: Truck driver, divorce, has two children and lives with girlfriend. Denies use of ETOH, but smokes 1pack cigarette per day. |
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ROS |
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General Patient states he is feeling weak, has hand tremors, fever, nausea, and vomiting. Denies epigastric pain, chills and night sweats. Weight change, fatigue, fever, chills, night sweats, energy level |
Cardiovascular Denies CP/SOB/Palpitations.â¨Chest pain, palpitations, PND, orthopnea, edema |
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Skin Denies rash, bruising or bleeding. Denies delayed healing or changes in skin color or moles. |
Respiratory Denies cough/wheezing. Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB |
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Eyes Denies blurry visson or eye pain⨠|
Gastrointestinal Patient has nausea, vomiting and abdominal pain |
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Ears Denies ear pain, hearing loss or ringing in ears. |
Genitourinary/Gynecological Denies frequency, urgency, dysuria. |
SOAP NOTE
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Nose/Mouth/Throat Denies sinus problems, nose bleeds, runny nose, throat pain, or dysphagia. |
Musculoskeletal Has joint pain and stiffness daily related to repair on his truck, takes OTC Advil every AM and PM. |
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Breast Denies any lumps, bumps, or changes. |
Neurological Patient has weakness and hand tremors. Denies dizziness, syncope, or neurological changes. |
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Heme/Lymph/Endo No lymph node swelling |
Psychiatric Denies depression, anxiety, insomnia. |
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OBJECTIVE |
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Weight 220 BMI 29 |
Temp 99.2 |
BP 145/82 |
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Height 6â1 |
Pulse 100 |
Resp 18 |
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PHYSICAL EXAMINATION |
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General Appearance Alert and oriented; answers questions appropriately and well develop. |
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Skin Intact, warm and dry with no bruising, lesions, or rashes. No cyanosis or clubbing noted. |
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HEENT Head: Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: conjunctivae, EOM and lids are normal. Pupils are equal, round, and reactive to light. Right eye exhibits no discharge. Left eye exhibits no discharge. No sclera icterus. 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. |
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Cardiovascular
RRR, S1 and S2. No S3, S4 rubs, murmurs, clicks, snaps or gallops noted. No thrills, heaves, or lifts with palpation. Peripheral Vascular: No cyanosis, clubbing. Radial pulses 3+ bilaterally. PT/DP pulse 2+ bilaterally. |
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Respiratory
Symmetrical chest expansion. Respirations regular and unlabored with diminished breath sound bilaterally. Lungs clear to auscultation bilaterally. No wheezing, rhonchi, or stridor. |
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Gastrointestinal
Abdominal flat, soft and non-distended. Bowel sounds present in all four quadrants. Abdominal tender to left lower quadrant with palpitation. |
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Breast
Free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin. |
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Genitourinary No bladder tenderness on palpation. |
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Musculoskeletal
Full ROM seen in all four extremities as the patient moved about the exam room |
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Neurological
Speech clear. Good tone. Balance stable; gait normal .⨠|
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Psychiatric
He alert and oriented x3. Patient has a normal mood and affect. His behavior is normal. Thought content normal. |
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CBC-pending CMP-pending Stool-occult⨠|
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Special Tests CT abdomen with oral contrast |
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Diagnosis |
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Differential Diagnoses o 1- Gastroenteritis o 2- Colitisâ¨o 3- Diverticulitis Diagnosisâ¨o Diverticulitis Plan:â¨ï§ï GI consultation for further evaluationâ¨ï§ï Medication: For nausea and vomiting- Zofran 4 mg SL every 6 hours as needed. For diverticulitis â Metronidazole 500 mg TID PO plus Ciprofloxacin 500mg BID PO for 10 days. · ï§ï ï Education: Diverticulitis can be caused by chronic Advil use. This wears the â¨intestinal lining and can cause inflammation. ⨠· ï§ï ï Non-medication treatments: High fiber diet ⨠· ï§ï ï Follow-up: Return to clinic if symptoms worsen. ED precautions reviewed with â¨patient. Lightheadedness, weakness, dizziness, severe abdominal pain, inability to telerate oral intake or failure to improve with outpatient management, the patient should go to nearest Emergency Room. ⨠|
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References References Buttaro, T. M., & Sandberg_Cook, J. (2013). Primary care. A collaborative practice. St. Louis: Mosby, Inc. Grossman, S. C., & Porth, C. M. (2014). Porth’s pathophysiology. Concepts of altered health states. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. MD, L. B. (2012). Bates’ guide to physical examination and history taking, 11th Edition. [VitalSource Bookshelf version]. Retrieved from http://digitalbookshelf.southuniversity.edu/books/9781469825106/outline/11 |
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Patient Initials: KL |
Pt. Encounter Number:1 |
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Date:02/04/2021 |
Age: 61 |
Sex: Female |
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Allergies: KNA Advanced Directives: NONE |
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SUBJECTIVE |
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CC: My blood pressure has been high lately. |
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61 y/o Hispanic female, who came to the consult complaining of high blood pressure readings at home during the past week. Patient states that usually the diastolic keeps higher than 140 mm/Hg, patient brought the list of the measures during the last week. Patient has four checking between 140-155mm/Hg, the systolic has been between 80 to 88 mm/Hg. Patient has previous medical history of HTN controlled with Lisinopril 5 mg PO daily. Client does not practice exercise or follows a healthy diet. She is AAO x 3, takes her own decisions, denies pain or any discomfort, denies visual or hearing issues, she is reporting good appetite and healthy sleeping, refers regular bowel movements and denies urinary discomfort.⨠|
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Current Medications: Losartan 50 mg PO daily for HTN⨠|
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Essential Primary Hypertensionâ¨Mammogram: – 2018 negativeâ¨Nutrition history: – Low sodium dietâ¨Developmental history: – Unremarkable.â¨Pap Smear: – 2019 negativeâ¨Blood transfusions: – Deniesâ¨Hospitalizations: – Deniesâ¨Childhood Illnesses: – Chicken pox⨠|
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Family History: mother: Deceased at 83, Heart Attack, Hypertension, Stroke father: Alive, Hypertensionâ¨sister (first): Alive, CHFâ¨brother (first): Alive, HTN, CVA |
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Social History: Tobacco: Never smokerâ¨Alcohol: Do not drink alcoholic beveragesâ¨Drug Abuse: Denies use of illicit drugsâ¨Safety: Household Smoke detector / Keep Firearms in home / Wear seatbeltsâ¨Sexual Activity: Not sexually activeâ¨Birth Gender: Femaleâ¨Others: Place of birth – Cuba⨠|
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ROS |
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General Denies fever, chills, fatigue or weight loss. Patient has good appetite and admits sleeping well. |
Cardiovascular Denies chest pain, syncope, lightheadedness, palpitations, lower extremities edema or claudication while walking. |
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Skin Denies rash, redness, ecchymosis, skin breakdown, edema, ulcer or any other skin lesion. |
Respiratory Denies SOB, fever, cough, hemoptysis, wheezing or cyanosis. |
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Eyes Patient Denies headache, hearing loss, odontalgia, difficulty swallowing, blurred vision or facial pain.⨠|
Gastrointestinal Denies abdominal pain, nausea, vomiting, diarrhea, constipation or blood in stools.⨠|
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Ears Patient Denies headache, hearing loss, odontalgia, difficulty swallowing, blurred vision or facial pain.⨠|
Genitourinary/Gynecological Denies dysuria, nocturia, frequency, incontinence, hematuria, burning or kidney stones. Denies breast discomfort or abnormal discharge from the nipples. |
SOAP NOTE
Nose/Mouth/Throat
Patient Denies headache, hearing loss, odontalgia, difficulty swallowing, blurred vision or facial pain.â¨
Musculoskeletal
Patient denies joint pain, weakness, muscle pain or stiffness.
Breast
Denies any symptoms
Neurological
Denies headache, weakness, seizure, dizziness, tremors, falls, numbness, paralysis or speech difficulty.â¨
Heme/Lymph/Endo
Denies any symtoms
Psychiatric
Denies any symptoms of depression, anxiety, agitation, memory loss, forgetful, insomnia or hallucinations. Denies suicidal thoughts.â¨
OBJECTIVE
Weight 64.5 BMI
Temp96.7
BP135/84
Height5â5
Pulse76
Resp19
PHYSICAL EXAMINATION
General Appearance
Patient is alert, awake, oriented x 3. Well developed, well nourished. No acute distress noted. No fevers. No weakness. Pleasant and cooperative during the examination. Head: Normocephalic, atraumatic.
Skin
Pink, intact, warm to touch, no rash, normal turgor and no abrasions.
HEENT
Head: Normocephalic, atraumatic.
Eyes: PERRL. Extraocular muscle movements intact. Sclera non-icteric. Conjunctiva clear. Nose: No external lesions, mucosae non-inflamed, septum is midline.â¨Ears: Non-bulging and pearl bilateral TMâs. Canals free of cerumen.â¨Throat: Mucosa non-inflamed, no tonsillar hypertrophy or exudate.
NECK: No lymphadenopathy, No masses, midline trachea. No carotids bruit. No jugular venous distention. Proper ROM.â¨
Cardiovascular
Regular rate and rhythm. S1 and S2 present. No murmur rubs or gallops. No S3. PMI non-displaced. No lower extremity edema. Peripheral pulses present and strong. EKG shows sinus rhythm. EKG shows sinus rhythm.
Respiratory No respiratory distress, unlabored respiratory effort, no wheezing or rhonchi, no use of accessory muscles to breathe. Vesicular murmur present bilaterally. No cyanosis.
Gastrointestinal Abdomen soft, non-tender, non-distended. No mases. Bowel sounds present in all 4 quadrants.
Breast
Soft, symmetric, no discoloration or abnormalities noted
Genitourinary
Gynecological exam deferred today by patient. No nodules felt on breasts. No skin changes or abnormal discharge from the nipples.â¨
Musculoskeletal
No clubbing, no joint swelling. No diminished ROM. Conserved
Neurological
AAO x 3. No cranial nerves deficits. No tremors, no gait imbalance, rigidity or myoclonus. No seizure activity. Strength 5 + on BUE/BLE. Tendon reflexes are intact bilaterally.â¨
Psychiatric
PSYCH: The patient is cooperative, no anxiety, no suicidal ideation, calmed. Affect appropriate. Good mood. No agitation or depression noted.â¨
Lab Tests
CMP, CBC, Lipid profile, Urinalysis.â¨
Special Tests
Diagnosis
· Primary Diagnosis-
Differential diagnosis:â¨
Acute pyelonephritis: Patient doesnât complaint of back pain, urgency, fever, malodorous urine, hematuria, chills, no PMHx of kidney stones or recent respiratory infections, which makes pyelonephritis a less likely diagnosis.â¨Hypothyroidism: There isnât generalized weakness, recent weight gain, cold intolerance, syncope, faintness, dry skin, anterior neck mass or pretibial edema, BMI is less than 25; which point far from Hypothyroidism diagnosis.â¨Hyperthyroidism: No tachycardia, no nervousness, no heat intolerance, no diarrhea, no insomnia, no, weight loss, no neck mass, no recent infections. All previously mentioned makes Hypothyroidism a less likely diagnosis.â¨Primary diagnosis:
1) Essential (primary) hypertension (I10): High blood pressure (BP), or hypertension, is defined by two levels by 2017 American College of Cardiology/American Heart Association (ACC/AHA) guidelines: (1) elevated BP, with a systolic pressure (SBP) between 120 and 129 mm Hg and diastolic pressure (DBP) less than 80 mm Hg, and (2) stage 1 hypertension, with an SBP of 130 to 139 mm Hg or a DBP of 80 to 89 mm Hg. Hypertension is the most common primary diagnosis in the United States. It affects approximately 86 million adults (â¥20 years) in the United States and is a major risk factor for stroke, myocardial infarction, vascular disease, and chronic kidney disease.
PLAN
Essential (primary) hypertension
Pharmacological:
Increase dose: Lisinopril 10 mg PO daily.
Non-pharmacological:
Low sodium diet.â¨Exercise 15 minutes at least 6 times a week.â¨Stress management or avoid stress.â¨Continue monitoring blood pressure at home, document and bring log to the consult.â¨Patient instructed to call/visit office if blood pressure higher then 140/90mm/Hg.â¨Avoid high-sodium foodsâ¨Avoid eating: Smoked, cured, salted, and canned meat, fish, and poultry, ham, bacon, hot dogs, and luncheon meats, regular, hard, and processed cheese and regular peanut butter. Crackers with salted tops, and other salted snack foods such as pretzels, chips, and salted popcorn. Frozen prepared meals, unless labeled low sodium. Canned and dried soups, broths, and bouillon, unless
labeled sodium-free or low-sodium. Canned vegetables, unless labeled sodium-free or low- sodium. French fries, pizza, tacos, and other fast foods. Pickles, olives, ketchup, and other condiments, especially soy sauce, unless labeled sodium-free or low-sodium.â¨FOLLOW UP:
Follow up next week to review treatment effectiveness and laboratory results.
References
Biondi, B., & Cooper, D. S. (2018). Subclinical hyperthyroidism. New England Journal of Medicine, 378(25), 2411-2419.
Drake, M. T. (2018, September). Hypothyroidism in Clinical Practice. In Mayo Clinic Proceedings (Vol. 93, No. 9, pp. 1169-1172). Elsevier.
Kolman, K. B. (2019). Cystitis and Pyelonephritis: Diagnosis, Treatment, and Prevention. Primary Care: Clinics in Office Practice, 46(2), 191-202.
Mancia, G. (2014). Hypertension: strengths and limitations of the JNC 8 hypertension guidelines. Nature Reviews Cardiology, 11(4), 189.
CASE PRESENTATION RUBRIC
Chief Complain and pertinent history-10% of total result
Pertinent exam and Diagnosis-10% of total result
Working diagnosis and supporting criteria 5% of total result
Management plan 5% total result
Epidemiological data-cited from literature-10% of total result
Evidence based rationale for treatment (literature based)-10% of total result
Analysis of self-care and family issues related to diagnosis and treatment plan-20% of total result
Evaluation parameters to be used (or were used) to determine outcomes-10% of total result
Identify major lessons learned and how it may affect your future practice-20% of total result.
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