MIXED UP SOAP NOTE – Nurs 5220 Advanced Health Assessment

MIXED UP SOAP NOTE – Nurs 5220 Advanced Health Assessment

Mixed Up Soap Note (20%, CO 1, 3/ MO 2)
The goal of this assignment is to introduce to the SOAP note format. A SOAP template has been provided below for your use. You will read the Mixed-up Soap Note Scenario. You will identify the Subjective components in the narrative. You will take that data that you’ve been given, and you will enter the data in the appropriate area on the Soap note, you will want to abbreviate the content and complete a Review of Systems. There is limited objective data. You will then contemplate the information that you’ve been given, and from this information, you will create a diagnosis and a plan. You will complete the SOAP note, and you can utilize the second document to present your rationales and research. What you will see is that you can do the majority of your Diagnosis with an excellent history. Focus your diagnoses on what you “see.” Often as a provider, you start your diagnoses based on a physical finding or a complaint and then you will fine tune it based on your examination or other tests. For example, a patient presents with a cough based on history; you may then determine the patient is having respiratory distress through observation, you will then continue to fine tune your diagnosis to Wheezing with your examination and then once you have finished you have narrowed it down to Mild intermittent Asthma with exacerbation. This process will start with a vague diagnosis and become more specific as you gather more specific data. MIXED UP SOAP NOTE – Nurs 5220 Advanced Health Assessment

Subtitle or Section:

Read the rest of the case study below and then complete the blank Soap Note attached to the scenario.
Use only the information provided.
Decide what is pertinent and then place the components in the correct sections of subjective and objective components
Use appropriate abbreviations and concise terminology if appropriate
If you are lacking pertinent information supply the questions that you would ask the patient (pretend you are completing the visit, how would you phrase the questions)
Provide a second Word document answering the following questions
What type of history will you obtain for this visit?
What additional history would you obtain from the family that is significant to A.J.’s situation
Practice using clinical reasoning and list possible diagnoses for A.J. based on the subjective information provided
Provided the following:
· Medical Diagnosis (2)
o ICD 10 code

o Provide pathophysiology

o Pertinent positives

o Pertinent negatives

· Differential diagnosis (3-5)

· ICD 10 code

o Provide pathophysiology (brief for each)

o Pertinent positives

o Pertinent negatives

· Health maintenance/risk profile

· Reference List

APA format

Subtitle or Section:

Mixed Up Soap Note Scenario

Grading Rubric

SOAP Template Actions

 

5220 Advanced Health Assessment

Mixed up Subjective and Objective Data Work Sheet

A.J. is a 15-year-old female who is presenting to your primary clinic setting with her mother.  A.J. is a new patient, and this is her initial visit.  Her complaint is “left leg pain.” MIXED UP SOAP NOTE – Nurs 5220 Advanced Health Assessment

Vitals:    Temp:  37.0 C

HR: 88

RR: 16

BP: 110/72

Height: 5’ 6.”

Weight: 70.5 kg

1. Read the rest of the case study below and then complete the blank Soap Note attached to the scenario.  Use only the information provided.
   1. Decide what is pertinent and then place the components in the correct sections of subjective and objective components
   2. Use appropriate abbreviations and concise terminology if appropriate
2. Provide a second Word document answering the following questions
   1. What type of history will you obtain for this visit? MIXED UP SOAP NOTE – Nurs 5220 Advanced Health Assessment
   2. What additional history would you obtain from the family that is significant to A.J.’s situation
   3. Practice using clinical reasoning and list possible diagnoses for A.J. based on the subjective information provided
   4. For each of the following
      1. Medical Diagnosis, 2 primary
         1. Provide pathophysiology/Rationale/Plan
         2. ICD 10 code
      2. Differential diagnosis, 3-5 Differentials
         1. Provide pathophysiology/Rationale/plan
         2. ICD 10 code

• Health maintenance/risk profile

1. Pertinent positives
2. Pertinent negatives

1. Reference list
2. APA format

 

A.J. is a 15-year-old female, student.   A.J. participates competitively in Gymnastics.  She recently (3 days ago) had an injury to her left leg when she landed in an awkward position with a dismount from the uneven bars.  She has previously had an injury to her left knee, so the family put a brace on and started crutch use, but has not sought medical care.  The family knew that they had this upcoming appointment, so they chose to wait to seek care.  The left leg pain is isolated to the front lateral aspect of the left knee; It is not improved with their interventions, the mother states that she has given A.J. Motrin 600 mg 3-4 times a day since the injury. The injury is painful at night and worse when she is up at night with pain.  A.J. states that she is having trouble bending her knee when the brace is off.  She is frustrated with the injury and wants it better so that she can go back to practice; she has an important meet in 2 weeks.  A.J is currently a freshman in school (has just started back to school), previously her grades are A’s and B’s and struggles a bit in her algebra class but has utilized a tutor for help and is making progress in that class. MIXED UP SOAP NOTE – Nurs 5220 Advanced Health Assessment

 

A.J. states that most of her friends are in the gym, she has a few friends at school, but since the gym takes so much of her time, it is hard to have time for friends in other settings.  A lot of her friends from middle school do not seem to have similar interests, 9^th grade was a new school for her and mom is hinting that it has been a hard transition.  Including this injury is making it hard for her to get around the campus between classes.

 

A.J. has no allergies

 

A.J. takes no medications

 

A.J. denies changes in her weight

 

A.J. eats a healthy diet, she has recently talked about becoming a vegetarian, no one in the family has food allergies, and they do not maintain a vegetarian diet.  Mom is concerned that she is not getting enough protein.  A.J. has not mentioned concerns with her weight but often notes that she is taller than other gymnasts and gets frustrated that she is not as limber or agile as her other competitors. MIXED UP SOAP NOTE – Nurs 5220 Advanced Health Assessment

 

A.J. Denies drugs, alcohol or use of illegal substance, no sports enhancing drugs

 

A.J. denies sexual encounters, she likes boys, denies a boyfriend

 

A.J. participated in gymnastics five days a week for 1 to ½ hours a session, she likes to run as well but is recreational, no other clubs or interests

 

Previous left knee injury one year ago, no other broken bones to injuries

 

Birth history, term female, two other sibs (older) who are healthy.  Parents are married, and state that they are happy and financially comfortable.  She lives in a two story house, and her bedroom is upstairs, she is having challenges with navigating the steps with the crutches, one inside dog, no other animals.  Denies mental health concerns, but has been sadder the last couple of days and mom states short tempered with a recent injury.  No surgeries, hospitalizations or significant illness, trauma, or disabilities.  +yearly flu shots, and last got immunizations around age 11 and had one HPV and one Hepatitis A immunization at age 11; mom states that immunizations were up to date.  Denies use of glasses or hearing aid, had her vision and hearing checked at PCP visit at age 11, has not sought primary care since that visit MIXED UP SOAP NOTE – Nurs 5220 Advanced Health Assessment.  A.J. denies eye or vision issues, denies issues with her hearing or ear pain, denies a headache, denies nasal drainage, nose bleeds, or problems with smell or taste.  No sore throat or voice changes, no mouth or teeth issues, and routinely sees a dentist, last visit in the past six months.

 

A.J. Denies issues with her heart, no palpitations or chest pain, no syncope, no abdominal pain or problems with voiding or stooling, denies constipation or diarrhea and no blood in her stool.  No other concerns in her musculature other than her left knee.

 

A.J. is currently having issues sleeping relating to pain, she is sleeping in her bed and has tried to elevate her left leg, denies problems with concentration at school or any memory issues.

 

Family denies any previous blood transfusions or use of chronic medications.

 

A.J. started her periods at age 12 years and had them monthly, used pads and had a period in the past month, no concerns verbalized with length or intensity of bleeding, no birth control and has never seen a GYN.

 

A.J. does not work outside the home

 

Parents: Dad has a high-stress job and hyper tension, on medications, Mom is a stay at home mom, +weight issues but overall no meds and healthy.  Siblings (one in college, girl, +weight issues and overall healthy), brother (senior in high school, is looking at going away to school, healthy).  Mom states no mental health concerns in the family, denies diabetes, exposure to communicable diseases, no recent travel outside of the US, no smokers, no stroke, lung disease, or asthma, no blood disorders, seizures, headache.  Paternal grandfather with hypertension MIXED UP SOAP NOTE – Nurs 5220 Advanced Health Assessment

 

 

The concept with permission granted and appreciation per Dr. J Michaels.

 

• Name

mixed up soap rubric

• Description
• Rubric Detail

	Levels of Achievement
Criteria	Excellent	Competent	Novice	Needs Improvement
Case Study Completion Weight 5.00%	100 % Student is at ease with the information and appropriately understands and displays ability to process the information from the scenario	75 % unable to process the information from exam finding, displays lack of synthesis of case study information, student is unable to elaborate or provide additional details	50 % Student understands the information but is unable to provide basic details	0 % Student does not display ability to provide basic information
Formating/use of soap note template Weight 5.00%	100 % Appropriate Use of the Form	75 % Competent use of the form	50 % Basic use of the form	0 % Inadequate use of the form
Subjective Weight 30.00%	100 % Appropriately documents the Subjective components from the case study material, Review of systems (ROS)is completed appropriately, 3 HPI, 3 or greater ROS, 2+ Past/Social/Family History item	75 % one error in completion of the form, subjective components are missing, or mixing of subjective/objective components, lack of Review of system components or Review of system components are inappropriate or mixing of physical 2 HPI, 2 ROS, 1 Past/Social/Family History	50 % greater than one error or Inappropriate completion of the form, subjective components are missing, or mixing of subjective/objective components, lack of Review of system components or Review of system components are inappropriate or mixing of physical	0 % Incomplete or missing components
Medical Diagnosis/Rule Outs/Health Profile/Pertinent positives/Pertinent negatives/Diffenentials/Alteration in health prevention Weight 30.00%	100 % Appropriately completes the components and displays synthesis of information in the appropriate sections	75 % on error or inappropriately labeled/mixed or general lack of synthesis of information provided	50 % greater than one error, Components are missing or inappropriately labeled/mixed or overall lack of synthesis of information provided	0 % Incomplete or missing components
Plan/Rationale/Patho Weight 30.00%	100 % Appropriately completes the components and displays synthesis of information in the appropriate sections	75 % One error or Components are missing or inappropriately labeled/mixed or General lack of synthesis of information provided	50 % Greater than one error, Components are missing or inappropriately labeled/mixed or overall lack of synthesis of information provided	0 % Incomplete or Missing Components

 

 

 

SOAP Note Form
S/ Identifying Information:   (initials, age/DOB, gender, reliability)		Family Hx:
		Personal/Social Hx:
Chief Complaint/RFE:
Hx Present Illness: (7 Variables but do not list as such)
CURRENT HEALTH
Medications:
Allergies:
Last PE & Screenings:
Immunization Status:
LMP & Birth Control (if applicable)
PMH
Illnesses & Trauma:
Hospitalizations/Surgeries:
OB Hx/Sexual Hx:
Emotional/Psy Hx:
REVIEW OF SYSTEMS
General
Nutrition
Skin/Hair/Nails
HEENT
Breasts
Respiratory
CV/peripheral vascular
GI
GU
MSK
Psych
Neuro
Lymph/Heme/Endocrine
O/ Physical Exam: T:        P:        R:        BP:          HT:         WT:         BMI:
General
Skin
Head
EENT
Neck
Breasts/Chest
Lungs
Heart/ perip vascular
Abdomen
Genitalia/Rectum
Lymph
MSK
Neuro
Medical Dx: (2max)	Rule Outs (only if applicable):
	Health Profile:
	age/gender/racial  risks:
Pertinent Positives:(1DX)
	personal/family:
	screening needs:
Pertinent Negatives:	counseling needs:
	Immunization/chemo needs:
Differential DX:(3-5)	Alteration in Health Prevention R/T:
	Screening deficits:
	Counseling deficits:
Nursing Dx:	Immunization/chemo deficits:

 

I. PLAN:  Do separate sections in the plan  to include: Max 1-2 pages   Diagnostics:   Medications/Treatments:   Education:   Follow-up:   Referrals:   Prevention Plan:

II. Rationale: ( Max 2 pages)

III. Patho: (Max 2 pages)

 

 

 

 

 

 

 

Mixed Up Soap Note

Name

Institution

 

 

1. What type of history will you obtain for this visit?

• Presenting complain
• History of presenting complaint
• Past medical history (Sataloff, 2019)
• Drug history
• Family history
• Social history

1. What additional history would you obtain from the family that is significant to A.J.’s situation

• Family history e.g. Cardiac and diabetes history
• Presence of genetic conditions in the family

1. Practice using clinical reasoning and list possible diagnoses for A.J. based on the subjective information provided

• Muscle or tendon injury
• Medial tibial stress syndrome
• Stress fracture,
• Exertional compartment syndrome
• Nerve entrapment

1. For each of the following:
2. Medical Diagnosis: Muscle or tendon injury:
3. Pathophysiology

• Muscle strain occurs from overstretched muscles and is common among sporting people. Symptoms include leg pain and mobility difficulties among others.
• Muscle strains cause excessive fiber stretching due to exertion of tensile force at the muscle. The pathophysiological process is characterized by destruction, repair and remodeling. Destruction involves tearing and myofibrils necrosis, creation of hematoma and division of inflammatory cells (Bengtsson, Ekstrand, Waldén & Hägglund, 2017). Repair and remodeling phases involve necrotic tissue phagocytosis, myofibrils regeneration and concomitant development of connective scar tissue, neoformation of vessels and growth of neurons also occur (Hamilton et al., 2020) MIXED UP SOAP NOTE – Nurs 5220 Advanced Health Assessment

2. ICD 10 code: ICD-10-CM Code S86
3. Diagnosis 2: Medial tibial stress syndrome

• Pathophysiology:
• Clinical exercise induced pain caused by repetitive loading stress during running and jumping and triggered on palpation over a length of ≥5consecutive centimeters. It occurs along the posteromedial tibial border.
• Foot inversion by dorsiflexes of the tibialis anterior is followed by extension of the great toe. Other toes extend causing pain and dysfuctions.
• ICD-10-CM Diagnosis Code S83.132A
• Differential diagnosis, 3-5 Differentials
• Stress fracture
  • Tiny cracks in bones caused by repetitive force, often from overuse — such as repeatedly jumping up and down or running long distances. Stress fractures can also develop from normal use of a bone that’s weakened by a condition such as osteoporosis.
  • ICD-10-CM Diagnosis Code M84.35

 

• Exertional compartment syndrome
• It is associated with pain and pressure on the leg due to failure of muscle expansion on the affected tissues. It causes inflammation, pain and disability of arms and legs. It is nerve condition or exercise induced.
• ICD-10-CM Diagnosis Code M79.A22 (ICD10data, 2018).
• Nerve entrapment
• It is characterized by pain, tingling, numbness and muscle weakness. It is a medical condition resulting from direct exertion of pressure on the nerves (Black, Brindle & Honaker, 2016). Localized structural changes and microvascular function interferences cause dysfunction of peripheral-nerves (Kastenschmidt, Mannaa, Muñoz & Villalta, 2019).
• ICD-10-CM Diagnosis Code S84.02XD

 

• Pertinent positives
  • muscle injury;
  • pain
• Pertinent negatives
  • Broken bone

 

 

References

 

Kastenschmidt, J. M., Mannaa, A. H., Muñoz, K. J., & Villalta, S. A. (2019). Immune System Regulation of Muscle Injury and Disease. In Muscle Gene Therapy (pp. 121-139). Springer, Cham.

Hamilton, B., Pollock, N., Reurink, G., de Vos, R. J., Purdam, C., & Thorborg, K. (2020). Muscle Injury Classification and Grading Systems. In Prevention and Rehabilitation of Hamstring Injuries (pp. 189-198). Springer, Cham.

Bengtsson, H., Ekstrand, J., Waldén, M., & Hägglund, M. (2017). No difference in muscle injury rates during professional football matches preceded by three to five days of recovery. British Journal of Sports Medicine, 51(4), 294-294.

Black, J. M., Brindle, C. T., & Honaker, J. S. (2016). Differential diagnosis of suspected deep tissue injury. International wound journal, 13(4), 531-539.

ICD10data. (2018). The Web’s Free 2019/2020 ICD-10-CM/PCS Medical Coding Reference. Retrieved from https://www.icd10data.com/

Sataloff, R. T. (2019). Patient history. Obesity and Voice, 65. MIXED UP SOAP NOTE – Nurs 5220 Advanced Health Assessment

 

 

SOAP Note Form
S/ Identifying Information:   A.J, 15, F   MIXED UP SOAP NOTE – Nurs 5220 Advanced Health Assessment		Family Hx: Parents: Dad has a high-stress job and hyper tension, on medications, Mom is a stay at home mom, +weight issues but overall no meds and healthy.  Siblings (one in college, girl, +weight issues and overall healthy), brother (senior in high school, is looking at going away to school, healthy).  Mom states no mental health concerns in the family, denies diabetes, exposure to communicable diseases, no recent travel outside of the US, no smokers, no stroke, lung disease, or asthma, no blood disorders, seizures, headache.  Paternal grandfather with hypertension
		Personal/Social Hx: Has few school friends. Denies drugs, alcohol or use of illegal substance, no sports enhancing drugs; denies sexual encounters, she likes boys, denies a boyfriend
Chief Complaint/RFE: Left leg pain
Hx Present Illness: (7 Variables but do not list as such)she had  left leg injury 3 days ago; previous left knee injury;
CURRENT HEALTH
Medications:  Motrin 600 mg 3-4 times a day
Allergies: NKA
Last PE & Screenings:  Previous left knee injury one year ago, no other broken bones to injuries
Immunization Status: yearly flu shots, and last got immunizations around age 11 and had one HPV and one Hepatitis A immunization at age 11
LMP & Birth Control (if applicable):  N/a
PMH
Illnesses & Trauma:  none
Hospitalizations/Surgeries: never been hospitalized;
OB Hx/Sexual Hx: regular period; began at 12 years
Emotional/Psy Hx: concerns with height; often notes that she is taller than other gymnasts and gets frustrated that she is not as limber or agile as her other competitors.no major mental health concerns; short tempered and sad due to the injury
REVIEW OF SYSTEMS
General : Negative for fevers, chills, fatigue; weight loss
Nutrition : eats a healthy diet; wants to become vegetarian; not obese
Skin/Hair/Nails : negative for itching, burning, rashes; red and sore at the site of injury
HEENT: denies vision or hearing problems; does not wear glasses or hearing aids; denies nasal drainage, nose bleeds and problems with smell and taste; No sore throat or voice changes, no mouth or teeth issues, and routinely sees a dentist, last visit in the past six months. MIXED UP SOAP NOTE – Nurs 5220 Advanced Health Assessment
Breasts : no lumps or masses
Respiratory : negative for cough; dyspnea on exertion; denies chest pain
CV/peripheral vascular : Denies issues with her heart, no palpitations
GI : Normal bowel sounds, soft, non tender, non distended. No guarding or rebound; no abdominal pain or problems with voiding or stooling, denies constipation or diarrhea and no blood in her stool
GU: Negative for pain; urine normal in frequency and quality
MSK  : positive for painful on the left leg
Psych :  negative for mental issues or trauma
Neuro  : denies syncope
Lymph/Heme/Endocrine  : negative for enlarged nodes in the groin. No history of splenectomy
O/ Physical Exam: T: 37.0C  HR: 88      RR: 16       BP: 110/72        HT: 5.6”     WT: 70.5Kg        BMI: 24.2
General : appears sad and in pain
Skin  : no rashes and lesions
Head  : no head injuries; headache
EENT  no eye or vision issues, hearing or ear pain; nasal drainage, nose bleeds, or problems with smell or taste.  No sore throat or voice changes, no mouth or teeth issues, and routinely sees a dentist, last visit in the past six months.
Neck: no lumps; pain ; no sore throat
Breasts/Chest  : no palpitations or chest pain
Lungs  : clear to auscultation and percussion bilaterally
Heart/ perip vascular : . pulses+2 bilat pedal and +2 radia
Abdomen  : symmetrical without distention; bowel sounds are normal in quality and intensity; No masses or splenomegaly noted; negative for tenderness with deep palpation
Genitalia/Rectum  : no itching or reddening MIXED UP SOAP NOTE – Nurs 5220 Advanced Health Assessment
Lymph  : no inflamed lymph nodes
MSK  : left leg pain
Neuro : no problems with concentration at school or any memory issues.
Medical Dx: (2max)  : X-ray Physical examination Symptom history	Rule Outs (only if applicable):
	Health Profile:
	age/gender/racial  risks:
Pertinent Positives:(1DX) muscle injury; pain
	personal/family:
	screening needs:
Pertinent Negatives: Broken bone	counseling needs:
	Immunization/chemo needs:
Differential DX:(3-5) ·         Muscle or tendon injury ·         Medial tibial stress syndrome ·         Stress fracture, ·         Exertional compartment syndrome ·         Nerve entrapment,	Alteration in Health Prevention R/T:
	Screening deficits:
	Counseling deficits:
Nursing Dx:  •      Muscle or tendon injury	Immunization/chemo deficits:

 

I. PLAN:  Do separate sections in the plan  to include: Max 1-2 pages   Diagnostics: ·         Grade 2 Muscle or tendon injury   Medications/Treatments: ·         Over-the-counter (OTC) nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen; for pain relieving   Education: ·         Recovery exercise; massage Therapy; appropriate muscle resting   Follow-up: ·         Visit clinic every two weeks   Referrals: ·         Physical therapist   Prevention Plan:  ·         Patient will walk at a moderate pace for 3 to 5 minutes before doing any sports or other physical activities. ·         Wear shoes that provide stability and ensure that any other protective equipment fits appropriately and is in good condition. MIXED UP SOAP NOTE – Nurs 5220 Advanced Health Assessment. ·         Lift heavy objects or items with care and always use the correct technique.

II. Rationale: ( Max 2 pages) Muscle strain occurs from overstretched muscles and is common among sporting people. Symptoms include leg pain and mobility difficulties among others.

III. Patho: (Max 2 pages) Muscle strains cause excessive fiber stretching due to exertion of tensile force at the muscle. The pathophysiological process is characterized by destruction, repair and remodeling. Destruction involves tearing and myofibrils necrosis, creation of hematoma and division of inflammatory cells. Repair and remodeling phases involve necrotic tissue phagocytosis, myofibrils regeneration and concomitant development of connective scar tissue, neoformation of vessels and growth of neurons also occur MIXED UP SOAP NOTE – Nurs 5220 Advanced Health Assessment