Exercise Content
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Chief Complaint: “I fell down in my house a week ago and my knee is still hurting”.
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History of Present Illness: Mr. Brown is 45-year-old male teacher who presents to the clinic with symptoms of right knee pain related to a fall sustained at home one week ago while he was coming down the stairs. Patient states that he tripped and during the fall, the right knee twisted and was caught between two bars of the stair wells. Immediately after the fall, the pain was sharp and stabbing, and he was unable to walk straight and apply weight on the knee. He applied ice and took 800mg of Motrin and went to bed. Patient states he did not want to go to the emergency department because of the long wait. After 24 hours he applied warm compresses intermittently and took extra strength Tylenol as needed. Mitigating factors include ES Tylenol, heat application, and resting the knee. However, sometimes the pain is so severe that even Tylenol does not help. Aggravating factors are standing too long, bending the knee, and climbing stairs. He describes the pain as sharp, and annoying at the same time. At present time he feels like “something is not right inside the knee”. Level of pain is 8/10. He denies previous musculoskeletal injuries. Patient also reports shortness of breath but denies chest pain.
PMH: Asthma, bipolar disorder. Left knee anterior crucial ligament (ACL) 10 years ago from basketball injury.
Past surgical history: Right hip replacement 15 years ago from kick boxing.
Medications/OTC: Theophylline, Prednisone, Singular, Geodon, Prozac, Benadryl.
Allergies: NKA.
Past family history: One brother with asthma, and another brother with bipolar. Maternal aunt with DM type II.
Health Maintenance: Immunization up to date.
Social history: Patient does not smoke, drink or use recreational drugs. He maintains a regular diet and exercises 3 times a week. He has been married for 10 years and lives with his wife and one adult son, and one teenage daughter. He is a mathematics teacher in the same high school where he attends clinic. He sleeps well.
With the information provided above, please continue the patient’s soap note to include:
Subjective: A thorough review of systems
Objective: A thorough physical examination
Primary diagnosis
3 differential diagnosis with one citation for each ddx (APA formatted).
Laboratory tests
Diagnostic testing
Management plan
Medications
Non-pharmacological approach
Follow up
Patient education and Health promotion
References: A minimum of 3 different references are required for this assignment. All references must be properly APA formatted.
This assignment will be graded according to the rubric. Please have the Rubric handy when you are writing the soap note.
SOAP NOTE RUBRIC
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Criteria
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Points
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Competent
|
Need Improvement
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Not Acceptable
|
Score
|
|
Subjective (35 points)
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Provides complete, concise, and accurate information which is well organized and easy to understand.
|
Provides most of the pertinent information but is not well organized and/or is slightly challenging to understand. May be missing pertinent negative information (e.g., patient denies…).
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Limited or no summary of pertinent information, is organized poorly, contains inaccurate information, and/or is difficult to understand.
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|
Chief complaint
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|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
5
|
5
|
|
|
|
|
|
|
3
|
|
|
|
|
|
|
|
1
|
|
HPI
|
|
|
|
|
|
|
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10
|
10
|
|
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8
|
|
|
|
6
|
|
Relevant PMH & FH
|
5
5
3
1
|
ROS
|
10
10
8
6
|
Currents: Allergies, Meds/OTCs, Tobacco, Immunizations, Diet, Exercise, Sleep
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5
5
3
1
|
Objective (40 points)
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Provides complete, concise, and accurate information which is well organized and easy to understand.
|
Provides most of the pertinent information but is not well organized and/or is slightly challenging to understand. May be missing pertinent negative information (e.g., patient denies)
|
Limited or no summary of pertinent information, is organized poorly, contains inaccurate information, and/or is difficult to understand.
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|
General survey (Describe the state of the patient at the time of the examination)
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10
10
8
6
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Vital signs, wt., BMI
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10
10
8
6
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Physical exam-systematic, organized and thorough and related to the reason of the visit
|
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20
|
20
18
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16
|
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Diagnosis/ Differentials Diagnosis (10 points)
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Main diagnosis/ Differentials Diagnosis is supported by the objective and subjective assessment and rationale for choosing the diagnosis is supported by the evidence
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Main diagnosis/ Differentials Diagnosis is supported by the objective and subjective assessment but the rationale for choosing the diagnosis is not supported by the evidence
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Main diagnosis/ Differentials Diagnosis is not supported by the objective and subjective assessment and the rationale for choosing the diagnosis is not supported by the evidence
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|
Diagnosis/ (Assessment)
|
5
5
3
1
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List of differentials supported by S+O findings (5 points)
Must provide 3 differential diagnoses with one citation for each diagnosis.
|
5
5
3
1
|
Plan of care (10 Points)
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Complete and appropriate plan for the main problem and other active problems. Includes pharmacologic and/or non-pharmacologic and/or complete sig components.
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Mostly complete and appropriate plan for the main problem and other active problems. May be missing appropriate non-pharmacologic treatments and/or sig components.
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Missing or inappropriate treatment plan for the main problem and other active problems.
|
|
Diagnostic tests/therapies/medications
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5
5
3
1
|
Follow-up/Pt. Education and Health Promotion
|
5
5
3
1
|
References
(5 Points)
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Provides a complete and appropriate list of references that are in APA format.
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References listed are appropriate (i.e. guidelines or primary), but not complete and some may be missing. Not APA formatted.
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References missing or very limited. References listed are inappropriate (i.e. tertiary) and/or not relevant.
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References
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5
5
3
1
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Total
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100
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Comment:
Below is how an example of how a reference list looks like:
References
American Lung Association. (2009). Chronic obstructive pulmonary disease (COPD) fact sheet.
Retrieved on March 8, 2013, from
http://www.lung.org/lung-
disease/copd/resources/facts-figures/COPD-Fact-Sheet.html
American Lung Association. (2010). The promise of research. Retrieved on March 12, 2013,
from
http://www.lung.org/finding-cures/research-news/promise-of-research/por-fall-
2010/promise-of-research-fall2010
Buttaro, T. M., Trybulski, J., Bailey, P. P., & Sandberg-Cook, J. (2012). Primary care: a
collaborative practice. St. Louis, Mo.: Elsevier/Mosby.
Durairaj, L. (2010). Disparities in lung disease: Ethnic & racial clues. Retrieved on March 7,
2013, from
http://www.lung.org/assets/documents/publications/research-
awardsnationwide/RAN0405_LR
Miravitlles, M. et al. (2010). Cost of chronic bronchitis and copd: 1-year follow-up study.
Retrieved on March 8, 2013, from https://journal.publications.chestnet.org/data/Journals/CHEST/21990/784
National Guideline Clearinghouse. (2010). Management of uncomplicated acute bronchitis in
adults. Retrieved on March7, 2013, from
http://www.lung.org/finding-cures/research-news/promise-of-research/past-issues/por-spr
Niederman, M., S. et al. (2012). Treatment cost of acute exacerbations of chronic bronchitis.
Retrieved on March 11, 2013, http://www.ncbi.nlm.nih.gov/pubmed/10321424
Poole P, H. (2012). Prophylactic antibiotic therapy for chronic bronchitis and chronic
obstructive pulmonary disease (COPD) (Protocol), Retrieved on March 11, 2013, from http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009764/pdf
South Carolina Department of Health and Environmental Control. (2010). Identification and
elimination of health disparities among populations. Retrieved on March 8, 2013, from http://www.scdhec.gov/health/chcdp/tobacco/goal4.htm
Thomas, M. (2012). Acute bronchitis in adults. Retrieved on March 2, 2013, from
http://www.uptodate.com/contents/acute-bronchitis-in-
adults?source=search_result&search=bronchitis&selectedTitle=1%7E150
1
SOAPNOTE 6
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Name: L. A
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Date: 03-16-2020
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Age: 19
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Sex: M
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SUBJECTIVE
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CC:
Sore throat, fever, and dysphagia
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HPI
:
M. R is African American Male. He is a student of business school. He stated that he has a fever frequently for 4-5 days, and he also has a sore and painful throat. He added that the pain radiates to his ear too. He says that it is difficult for him to eat his regular meals.
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Medications
No current medications.
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PMH Comment by Extra, Carmante: Immunization missing
Allergies: No food and drug allergies.
Medication Intolerances: N/A
Chronic Illnesses/Major traumas: None Comment by Extra, Carmante: Should be right arm fracture secondary to sport
Past Hospitalizations/Surgeries: The patient was hospitalized four years back when he fractured his arm while playing football.
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Family History
The patient’s father is hypertensive for the last five years.
The patient’s mother has diabetes mellitus for the last six years.
The patient has no siblings.
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Social History Comment by Extra, Carmante: Diet, exercise and sleep missing.
Missed sexual history.
He is single and lives with his parents. The patient does not have any siblings. He denies use of alcohol and tobacco.
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ROS
Comment by Extra, Carmante: Missing breast, heme, endo, GU, and psychiatric
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General
The patient has swelling around his face and neck. He also reported fever but denies chills, night sweats, fatigue. He also denies any weight loss episodes. Comment by Extra, Carmante: This should be the patient reports…
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Cardiovascular
No history of cardiac issues, chest pain, or palpitations.
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Skin
Skin is intact; no lesions, itchiness, or redness seen.
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Respiratory
He denies any SOB, difficulty in breathing, or excess sputum production.
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Eyes
He refuses to have any vision issues like blur vision or glaucoma. Comment by Extra, Carmante: Proper denies
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Gastrointestinal
The patient denies diarrhea, vomiting, loss of appetite.
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Ears
The patient mentioned that he has ear pain but refuses to have any discharge from the ears.
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Lymph nodes cervical lymph nodes are swollen. Comment by Extra, Carmante: The heading is Heme/Endo/Lymph.
Heme and endo missing
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Nose/Mouth/Throat
No running nose, difficulty in opening full mouth, painful throat.
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Musculoskeletal
Denies muscle or joints pain while performing ROM.
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Neurological
The patient refuses coordination difficulties, paralysis, tremors, and seizures. Comment by Extra, Carmante: Denies is the proper term
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OBJECTIVE Comment by Extra, Carmante: Missing examination of breast, GU, musculoskeletal, neuro, and psychiatric.
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Weight: 174 pounds BMI: 23.1
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Temp: 103oF
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BP: 121/80
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Height: 6’2’’
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Pulse: 71
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Resp: 20
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General Appearance
A cooperative African American young boy. Well oriented to time, place, and person.
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Skin
Skin is warm to touch because of fever, no rashes or redness.
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HEENT Comment by Extra, Carmante: You did not examine the neck and the thyroid.
Any lymphadenopathy for a patient with sore throat?
Normocephalic and atraumatic head. No lesions were found with equal distribution of hair. Swelling on the face is seen, especially on the right side. Eyes: no vision issues, the conjunctiva is pink, and sclera appears white. The pain in the ear is about 5/10 on the pain scale. Nose: Nose Bridge is in the midline; the nasopharynx is moist. Mouth and throat: sore throat with enlarged tonsils that are covered with four yellow patches. Foul oral smell and drooling were seen. Comment by Extra, Carmante: You need to examine bilateral ears. Comment by Extra, Carmante: remove Comment by Extra, Carmante: How is the dentition?
How is the tongue.
Is patient able to swallow?
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Cardiovascular
S1 is greater than S2. Comment by Extra, Carmante: You need to be thorough
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Respiratory
Lung sounds are normal without any wheezing or rales. Resonance is present in all lung fields during percussion. Comment by Extra, Carmante:
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Gastrointestinal
The abdomen is non-tender; no distension and bowel sounds are present in all four abdominal quadrants.
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Lab tests:
Throat swab test: positive indicates streptococci.
CBC: raised neutrophils
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Diagnosis
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Diagnosis:
· Acute tonsillitis is the infectious state of tonsils. Bacterial and viral infections both may lead to tonsillitis. Acute tonsillitis symptoms may last about 3 -5 days, with symptoms like odynophagia, dysphagia, drooling, bad breath, ear pain, pain, and edema in the throat. Fever, chills, swollen glands in the neck, blisters, or ulcers in the mouth or throat are also associated with tonsillitis. (Perry, 1998). Therefore, the patient’s symptoms and lab results indicate that the patient is suffering from acute tonsillitis.
Differential Diagnosis:
· Pharyngitis is the inflammation of the pharynx. Bacterial or viral infections can cause it. Sneezing, runny nose, fever, chills, general malaise are symptoms associated with pharyngitis (Weber, 2014).
· A peritonsillar abscess occurs mostly when tonsillitis is left untreated. Pus-filled pockets are formed around the tonsils. Symptoms are quite similar to tonsillitis, but they are more severe in the peritonsillar abscess. (Galioto, 2017).
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PLAN
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· Medications
· amoxicillin 50 mg TD Comment by Extra, Carmante: Prescription incomplete.
What are the side effects of these new medications?
· Ibuprofen to ease fever and pain. Comment by Extra, Carmante: How much ibuprofen and for how long? How does the patient take Ibuprofen?
· Fluid management and bed rest are prescribed.
· Comforting warm foods and beverages
· Patient Education:
· The patient should be taught that bacterial tonsillitis may be contiguous, so the patient should be conscious that he should not share his food, utensils, etc. with his family. To avoid reoccurrence, the patient should be taught infection controlling techniques, e.g., hand washing.
· Follow up
· After seven days of the antibiotic course, the patient will be re-examined for symptoms, enlarged tonsils. Also, a throat swab is recommended. Comment by Extra, Carmante: When does the patient seek emergent care?
|
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References
Comment by Extra, Carmante: Please review APA format for references
Perry.M, Whyte. A (1998). “Immunology of the tonsils.” Immunology Today (Review). 19 (9): 414–21. doi:10.1016/S0167-5699(98)01307-3. PMID 9745205. Comment by Extra, Carmante: Reference is outdated.
Galioto N.J. (2017). “Peritonsillar Abscess.” American Family Physician. Retrieved from:95 (8): 501–506. PMID 28409615.
Weber. R (2014). “Pharyngitis.” Primary Care. 41 (1): 91–8. DOI: 10.1016/j.pop.2013.10.010. PMC 7119355. PMID 24439883.
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Criteria
|
Points
|
Competent
|
Need Improvement
|
Not Acceptable
|
Score
|
|
Subjective (35 points)
|
Provides complete, concise, and accurate information which is well organized and easy to understand.
|
Provides most of the pertinent information but is not well organized and/or is slightly challenging to understand. May be missing pertinent negative information (e.g., patient denies…).
|
Limited or no summary of pertinent information, is organized poorly, contains inaccurate information, and/or is difficult to understand.
|
|
Chief complaint
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
5
|
5
|
|
|
|
|
|
|
|
|
|
|
3
|
|
|
|
|
|
|
|
1
|
5
|
HPI
|
|
|
|
|
|
|
|
|
|
|
10
|
10
|
|
|
|
8
|
|
|
|
6
|
10
|
Relevant PMH & FH
|
5
5
3
1
3
|
ROS
|
10
10
8
6
8
|
Currents: Allergies, Meds/OTCs, Tobacco, Immunizations, Diet, Exercise, Sleep
|
5
5
3
1
3
|
Objective (40 points)
|
Provides complete, concise, and accurate information which is well organized and easy to understand.
|
Provides most of the pertinent information but is not well organized and/or is slightly challenging to understand. May be missing pertinent negative information (e.g., patient denies)
|
Limited or no summary of pertinent information, is organized poorly, contains inaccurate information, and/or is difficult to understand.
|
|
General survey (Describe the state of the patient at the time of the examination)
|
10
10
8
6
10
|
Vital signs, wt., BMI
|
10
10
8
6
10
|
Physical exam-systematic, organized and thorough and related to the reason of the visit
|
|
20
|
20
|
18
|
16
|
18
|
Diagnosis/ Differentials Diagnosis (10 points)
|
Main diagnosis/ Differentials Diagnosis is supported by the objective and subjective assessment and rationale for choosing the diagnosis is supported by the evidence
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Main diagnosis/ Differentials Diagnosis is supported by the objective and subjective assessment but the rationale for choosing the diagnosis is not supported by the evidence
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Main diagnosis/ Differentials Diagnosis is not supported by the objective and subjective assessment and the rationale for choosing the diagnosis is not supported by the evidence
|
|
Diagnosis/ (Assessment)
|
5
5
3
1
5
|
List of differentials supported by S+O findings (5 points)
Must provide 3 differential diagnoses with one citation for each diagnosis.
|
5
5
3
1
5
|
Plan of care (10 Points)
|
Complete and appropriate plan for the main problem and other active problems. Includes pharmacologic and/or non-pharmacologic and/or complete sig components.
|
Mostly complete and appropriate plan for the main problem and other active problems. May be missing appropriate non-pharmacologic treatments and/or sig components.
|
Missing or inappropriate treatment plan for the main problem and other active problems.
|
|
Diagnostic tests/therapies/medications
|
5
5
3
1
3
|
Follow-up/Pt. Education and Health Promotion
|
5
5
3
1
3
|
References (5 Points)
|
Provides a complete and appropriate list of references that are in APA format.
|
References listed are appropriate (i.e. guidelines or primary), but not complete and some may be missing. Not APA formatted.
|
References missing or very limited. References listed are inappropriate (i.e. tertiary) and/or not relevant.
|
|
References
|
5
5
3
1
3
|
|
Total
|
100
|
86
|
Comment: Good start.
This is a good case. However, you missed important subjective and objective assessment. Please take feedback into consideration for next soap note.
