Abdominal Pain: Comprehensive SOAP Exemplar Purpose: To demonstrate what each section of the SOAP Note should include. Remember that nurse practitioners treat patients in a holistic manner, and your SOAP Note should reflect that premise. Patient Initials: _______ Age: _______ Gender: _______ SUBJECTIVE DATA: Chief Complaint (CC): Coughing up phlegm and fever, physical History of Present Illness (HPI): Sara Jones is a 65-year-old Caucasian female who presents today with a productive cough x 3 weeks and fever for the last 3 days. She reported that the “cold feels like it is descending into her chest.” The cough is nagging and productive. She brought in a few paper towels with expectorated phlegm – yellow/brown in color. She has associated symptoms of dyspnea of exertion and fever. Her Tmax was reported to be 102.4 last night. She has been taking Ibuprofen 400mg about every 6 hours and the fever breaks, but it returns after the medication wears off. She rated the severity of her symptom discomfort at 4/10. Medications: 1.) Lisinopril 10mg daily 2.) Combivent 2 puffs every 6 hours as needed 3.) Serovent daily 4.) Salmeterol daily 5.) Over-the-counter Ibuprofen 200mg -2 PO as needed 6.) Over-the-counter Benefiber 7.) Flonase 1 spray each night as needed for allergic rhinitis symptoms Allergies: Sulfa drugs – rash Past Medical History (PMH): 1.) Emphysema with recent exacerbation 1 month ago – deferred admission – RX’d with outpatient antibiotics and hand held nebulizer treatments. 2.) Hypertension – well controlled 3.) Gastroesophageal reflux (GERD) – quiet, on no medication 4.) Osteopenia 5.) Allergic rhinitis Past Surgical History (PSH): 1.) Cholecystectomy 1994 2.) Total abdominal hysterectomy (TAH) 1998 Sexual/Reproductive History: Heterosexual G1P1A0 Non-menstruating – TAH 1998 Personal/Social History: She has smoked 2 packs of cigarettes daily x 30 years; denied ETOH or illicit drug use. Immunization History: Her immunizations are up to date. She received the influenza vaccine last November and the Pneumococcal vaccine at the same time. Significant Family History: Two brothers – one with diabetes, dx at age 65, and the other with prostate CA, dx at age 62. She has one daughter in her 30s, healthy, living in nearby neighborhood. Lifestyle: She is retired, has been widowed x 8 years, and lives in the city in a moderate crime area with good public transportation. She is a college graduate, owns her home, and receives a pension of $50,000 annually – financially stable. She has a primary care nurse practitioner provider and goes for annual and routine care twice annually and as needed for episodic care. She has medical insurance but often asks for drug samples for cost savings. She has a healthy diet and eating pattern. There are resources and community groups in her area at the senior center that she attends regularly. She enjoys bingo. She has a good support system composed of family and friends. Review of Systems: General: + fatigue since the illness started; + fever, no chills or night sweats; no recent weight gains of losses of significance HEENT: No changes in vision or hearing; she does wear glasses, and her last eye exam was 1 ½ years ago. She reported no history of glaucoma, diplopia, floaters, excessive tearing, or photophobia. She does have bilateral small cataracts that are being followed by her ophthalmologist. She has had no recent ear infections, tinnitus, or discharge from the ears. She reported her sense of smell is intact. She has not had any episodes of epistaxis. She does not have a history of nasal polyps or recent sinus infection. She has a history of allergic rhinitis that is seasonal. Her last dental exam was 3/2014. She denied ulceration, lesions, gingivitis, gum bleeding, and has no dental appliances. She has had no difficulty chewing or swallowing. Neck: No pain, injury, or history of disc disease or compression. Her last Bone Mineral density (BMD) test was 2013 and showed mild osteopenia, she said. Breasts: No reports of breast changes. No history of lesions, masses, or rashes. No history of abnormal mammograms. Respiratory: + cough and sputum production (see HPI); denied hemoptysis, no difficulty breathing at rest; + dyspnea on exertion; she has history of COPD and community acquired pneumonia 2012. Last PPD was 2013. Last CXR – 1 month ago. CV: No chest discomfort, palpitations, history of murmur; no history of arrhythmias, orthopnea, paroxysmal nocturnal dyspnea, edema, or claudication. Date of last ECG/cardiac work up is unknown by patient. GI: No nausea or vomiting, reflux controlled. No abd pain, no changes in bowel/bladder pattern. She uses fiber as a daily laxative to prevent constipation. GU: No change in her urinary pattern, dysuria, or incontinence. She is heterosexual. She has had a total abd hysterectomy. No history of STDs or HPV. She has not been sexually active since the death of her husband. MS: She has no arthralgia/myalgia, no arthritis, gout or limitation in her range of motion by report. No history of trauma or fractures. Psych: No history of anxiety or depression. No sleep disturbance, delusions, or mental health history. She denied suicidal/homicidal history. Neuro: No syncopal episodes or dizziness, no paresthesia, headaches. No change in memory or thinking patterns; no twitches or abnormal movements; no history of gait disturbance or problems with coordination. No falls or seizure history. Integument/Heme/Lymph: No rashes, itching, or bruising. She uses lotion to prevent dry skin. She has no history of skin cancer or lesion removal. She has no bleeding disorders, clotting difficulties, or history of transfusions. Endocrine: No endocrine symptoms or hormone therapies. Allergic/Immunologic: Has hx of allergic rhinitis, but no known immune deficiencies. Her last HIV test was 10 years ago. OBJECTIVE DATA Physical Exam: Vital signs: B/P 110/72, left arm, sitting, regular cuff; P 70 and regular; T 98.3 orally; RR 16; non-labored, SPO2 98%; Wt: 115 lbs; Ht: 5’2; BMI 21 General: A&O x3, NAD, appears mildly uncomfortable HEENT: PERRLA, EOMI, oronasopharynx is clear Neck: Carotids no bruit, jvd or lymphadenopathy Chest/Lungs: CTA AP&L except crackles LLL Heart/Peripheral Vascular: RRR without murmur, rub, or gallop; pulses+2 bilat pedal and +2 radial ABD: benign, nabs x 4, no organomegaly; mild suprapubic tenderness – diffuse – no rebound Genital/Rectal: external genitalia intact, no cervical motion tenderness, no adnexal masses. Musculoskeletal: symmetric muscle development – some age-related atrophy; muscle strengths 5/5 all groups Neuro: CN II – XII grossly intact, DTR’s intact Skin/Lymph Nodes: No edema, clubbing, or cyanosis; no palpable nodes ASSESSMENT: Lab Tests and Results: Diagnostics: Lab: CBC – WBC 18,000 with left shift Radiology: Left lower lobe consolidation CXR – cardiomegaly with air trapping and increased AP diameter ECG – normal sinus rhythm Differential Diagnosis (DDx): 1.) Acute Viral Bronchitis – pt with cough and fever, history of smoking. Does have elevated WBC with left shift, so makes this diagnosis less likely. (Kinkade, S. & Long, N.A., 2016). 2.) Pulmonary Embolus – pt with cough, smoking history and chest pain with coughing. Because pt also has fever, and normal pulse ox, makes this diagnosis less likely. 3.) Lung Cancer – although this pt is at high risk for lung cancer due to lengthy history of smoking, the cxr does not reveal any nodules. Diagnoses/Client Problems: 1.) CAP Left lower lobe – Severity of illness score (CURB-65) less than 2 (Kaysin, A. & Viera, A.J., 2016). 2.) COPD 3.) HTN, controlled 4.) Tobacco abuse – 40-pack-a-year history 5.) Allergy to sulfa drugs – rash 6.) GERD – quiet, on no current medication PLAN: Start patient on Levoquin 750 mg daily for 10 days due to presence of comorbidities. To continue on regular medications and should return to clinic if symptoms persist. Smoking cessation education given. Pt is also due for mammogram and routine labs. Will order total cholesterol, TSH, CMP, CBC, fasting blood sugar, UA to be done at 2 week follow up visit. Pt needs to be fasting. Also will schedule routine mammogram and colonoscopy in the next 2 months. Reflection: I learned a lot from this patient this week. I was not familiar with the assessment tool CURB-65. I now realize how important this tool is to help decide whether or not the patient needs to be admitted to the hospital or not. Although this patient was sick at the time of her physical, we still addressed risk factors and reviewed medications. Since the patient is sick at this time, we decided to pursue other labs at her follow up visit. This particular patient does have a history of compliance, other than continuing to smoke, so we felt comfortable with her treatment. Also, the patient was not fasting. I agree with the preceptor’s plan of care, although I did find an article that supported antibiotics for only 5 days. My preceptor explained that she has seen better outcomes personally by giving the CAP patients antibiotics for a full 10 days. After this learning experience I would not do anything differently. __________________________________ _______________________ Student Signature Date __________________________________ _______________________ Preceptor Signature Date References Kaysin, A. and Viera, A.J. (2016). Community-Acquired Pneumonia in Adults: Diagnosis and Management. American Family Physician, 94(9), 698-706. Kindade, S. & Long, N.A. (2016) Acute Bronchitis. American Family Physician, 94 (7), 560-565.
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