Complete all the requirements of the case scenario.
Use at least one scholarly source other than your textbook to connect your response to national guidelines and evidence-based research in support of your ideas.
Case Scenario 2
Table 1
Definition and
how does this
test work
Pelvic UltrasoundAbdominal
Ultrasound
Pelvic UltrasoundTransvaginal
Ultrasound
Saline infusion
Sonohysterography
Hysteroscopy
HSGhysterosalpingogram
Laparoscopy
Endometrial Biopsy
(EMB)
Colposcopy
Endocervical
Curettage (ECC)
Dilation and
curettage (D&C)
What medical
conditions or
diagnoses are
best suited for
this test
Any special
considerations or
instructions prior to
or during the test
Donna is 35-year-old African American female who comes to the clinic complaining of pelvic pain that started as intermittent, but now is almost constant. She also complains of irregular vaginal bleeding/spotting that has occurred in between her monthly menses for the last six months. She has no family history of breast or ovarian cancer. Her vital signs (VS) and BMI are all within normal limits (WNL), but upon physical examination, you palpate a firm, raised area on her uterus. You note no cervical motion tenderness (CMT), no adnexal tenderness (AT), and no other abnormalities. She is G2 P2 with both normal spontaneous vaginal deliveries (NSVD) 10 and 8 years ago.
Write a brief SOAP note regarding this patient. Make sure to include your answers to these questions in your SOAP note.
1. Subjective:
a. What other relevant questions should you ask regarding the HPI?
b. What other medical history questions should you ask?
c. What other social history questions should you ask?
d. What other family history questions should you ask?
2. Objective:
a. Write a detailed focused physical assessment on this patient.
b. Explain what test(s) you will order and perform, and discuss your
rationale for ordering and performing each test.
3. Assessment/ Diagnosis:
a. What is your presumptive diagnosis? Why? Which diagnostic test will
confirm your diagnosis?
b. Any other diagnosis or differential diagnosis you would like to add?
4. Plan:
a. How will you manage this patient? What treatment or medication
would you prescribe and why?
b. Explain treatment guidelines including any possible side effects
and/or considerations of the treatment.
c. What patient education is important to include for this patient?
(Consider including pharmacological, supplements, and non
pharmacological recommendations and education)
d. What is the follow-up plan of care?
e. Explain complications that can occur if patient does not comply with
treatment regimen.
Running head: PROBLEM FOCUSED SOAP NOTE WEEK 6
1
Problem-Focused SOAP Note Week 6
West Coast University
NURS 668L-A Advanced Health Care Residency
Professor Aileen M. Kizlinski, MSN, FNP-C
PROBLEM FOCUSED SOAP NOTE WEEK 6
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Demographic Data: 11 y/o Asian Female. Mother present with patient.
Subjective
Chief Complaint: “I have a sore throat x 2 days and fever x 1 day.”
HPI: 11 y/o female is brought to clinic by mother with complaints of sore throat x 2 days and a
fever x 1 day. Pain is to the back of the throat, continuous for the last 2 days, worse when trying
to swallow, 8/10 on pain scale. Describes pain as aching and feels like “something sharp is
hurting her” when she tries to swallow solid foods. Mother has given Children’s Tylenol 15mls q
4hours with some improvement in child’s pain, decreased to 4/10 after dosing and has helped
with her temp. Max temp 102F was last night. Last Tylenol was given 2 hours prior to coming
to clinic for temperature of 101F. Mother denies any ill contact at home or school and denies
anyone in the household with similar symptoms. *Went through OLD CART for this
complaint
Past Medical History:
• Past Medical History: Denies past medical history
• Surgeries: Denies past surgeries
• Hospitalization: Denies past hospitalizations
• OB/Gyn hx: this is a child so nothing to put here
• Sexual hx: again child so nothing to put here
• Medications: Children’s Tylenol Suspension 160mg/5mL 15 mL PO Q4H PRN
fever/pain
• Allergies: Denies any known drug, food, latex or environmental allergies
• Immunizations: DTaP #5- 11/2011, IPV #4- 11/2011, MMR #2- 11/2011, Varicella #211/2011 (Due for next immunizations in November 2018).
• Health Maintenance: Last well child physical- 11/2017, Last dental exam- 5/2018,
doesn’t wear glass. Last eye exam with physical and normal
Family History:
• Paternal grandfather, living, age 83, history of diabetes and high cholesterol
• Paternal grandmother, living, age 64, history of hypothyroidism and psoriasis
• Maternal grandfather, living, age 60, history of diabetes, hypertension and high
cholesterol
• Maternal grandmother, living, age 59, history of hypothyroidism
• Father, living, age 35, history of gout
• Mother, living, age 34, history of hypothyroidism and diabetes
• Older brother, living, age 13, no past medical history
Social History:
Patient is in 6th grade and living with her paternal grandparents, parents and her older brother in a
4-bedroom house. She loves to play the violin in her school band and also sings in her church.
Both her parents work full-time as registered nurses and her grandparents are both retired and
PROBLEM FOCUSED SOAP NOTE WEEK 6
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stay home to take care of her and her older brother. She has a regular diet, which consists of
Filipino food that her grandmother prepares but she usually buys lunch at school. Her favorite
subject is math but says she likes all her classes. She has many friends at school and at church.
She attends a Christian church with her parents and grandparents and sings in the children’s
praise and worship group. She is independent with her personal needs and schoolwork. She gets
along with her older brother.
Review of Symptoms:
• Constitutional: (+) fever, (+) fatigue, (-) weight loss/gain, night sweats, chills, and
changes in sleep.
• HEENT: (+) sore throat, difficulty swallowing, (-) headache, dizziness, vision changes,
hearing changes, nasal congestion, sinus pain or rhinorrhea.
• Lungs: (-) SOB, (-) pain, cough or wheezing.
• Heart: (-) chest pain, (-) dyspnea, edema, palpitations or syncope.
• Abdomen: (-) pain, (-) nausea/vomiting, (-) diarrhea or constipation
Objective
•
•
•
•
•
•
•
•
•
Height: 56” Weight: 82 lbs. BMI: 18.5 (Normal) LMP not started yet
Temperature: 99.0 F, Blood Pressure: 101/70, Pulse: 82, Respiration: 18
General: 11 y/o female, AAOx3, slightly fatigue, interactive and answers appropriately
HEENT: NC/AT, PERRL, EOMI, good conjugate gaze, TMs normal bilaterally; Nares
patent bilaterally, no sinus pain or pressure, MMM, oropharynx with erythema. (-)
exudate from throat, Tonsils 1+
Neck: Supple, Normal ROM, bilateral tenderness and lymphadenopathy to anterior
cervical nodes, no masses noted.
Lungs: Normal respiratory effort, even and unlabored, CTAB, no cough
Heart: RRR, normal s1/s2, no m/r/g, no edema
Abdomen: soft, non-distended, (+) normal BS x 4, (-) masses, hernia, rebound tenderness
or guarding.
Rapid Strep Antigen Test: (+) positive
Assessment
Differential Diagnosis:
1. Influenza- ICD-10: J11: Influenza is a highly contagious, acute viral illness of the
respiratory tract that involves the nasal mucosa, pharynx, respiratory tract and the
conjunctiva (Hollier, 2016). The clinical manifestations include high fever, sore throat,
cough, rhinorrhea, pharyngitis, headache, malaise, irritated mucous membranes, cervical
lymphadenopathy and GI complaints in children (Hollier, 2016). Pertinent positives are
fever, sore throat, and cervical lymphadenopathy. Pertinent negatives include no cough,
rhinorrhea, headache or malaise.
PROBLEM FOCUSED SOAP NOTE WEEK 6
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2. Acute upper respiratory infection- ICD-10: J06.9: Acute upper respiratory infection or
illness is an infection of the upper respiratory tract caused by a virus (Hollier, 2016).
Clinical manifestations include nasal stuffiness, sneezing, scratchy throat, irritated or sore
throat, hoarseness, red and irritated nasal mucosa, clear or yellow mucus discharge,
malaise, headache, cough, and occasional low-grade fever (Hollier, 2016). Pertinent
positives are fever and sore throat. Pertinent negatives include no nasal stuffiness,
sneezing, red or irritated nasal mucosa, clear or yellow mucus discharge, malaise,
headache or cough.
Final Diagnosis:
• Streptococcal Pharyngitis- ICD-10: J02.0
Due to the patient’s chief complaints, the presenting symptoms, physical
examination and in office rapid strep antigen test results being positive,
Streptococcal Pharyngitis is diagnosed. Pertinent positives include fever, sore
throat, difficulty swallowing, fatigue, oropharynx with erythema, bilateral
tenderness and lymphadenopathy to anterior cervical nodes.
Streptococcal pharyngitis is an infection of the oropharynx caused by S. pyogenes
(CDC, 2016). It is commonly spread through direct person-to-person
transmission, typically through saliva or nasal secretions from an infected person
(CDC, 2016). The incubation period for group A strep pharyngitis is
approximately two to five days (CDC, 2016). The clinical manifestations include
sudden onset of sore throat, odynophagia, fever, headache, abdominal pain,
nausea, vomiting, pharyngeal and tonsillar erythema, tonsillar hypertrophy with
or without exudates, palatal petechiae and anterior cervical lymphadenopathy
(CDC, 2016).
Plan
•
•
Diagnostics:
o Rapid Strep Antigen Test (Rapid antigen detection test-RADT) done in clinic.
? Swabbing the throat and testing for GAS pharyngitis by RADT or culture
should be performed because the clinical features alone do not reliably
discriminate between GAS and viral pharyngitis (Shulman, Bisno, Clegg,
Gerber, Kaplan, Lee, Martin & Van Beneden, 2012).
Pharmacological:
o Amoxicillin suspension 250mg/5mL 7.5mL PO TID x 10 days
? Patients with acute GAS pharyngitis should be treated with an appropriate
antibiotic for duration of usually 10 days, with the drug of choice being
penicillin or amoxicillin for those non-allergic to these agents (Ferri,
2018). o Children’s Tylenol Suspension 160mg/5mL 15 mL PO Q4H PRN
fever/pain
? Use an analgesic/antipyretic agent such as acetaminophen or an NSAID
for treatment of moderate to severe symptoms or control of high fever
PROBLEM FOCUSED SOAP NOTE WEEK 6
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(Shulman, Bisno, Clegg, Gerber, Kaplan, Lee, Martin & Van Beneden,
2012).
• Non-pharmacological:
o Encourage fluids to prevent dehydration (Ferri, 2018). o Encourage salt-water
gargles for cleansing and pain (Ferri, 2018).
o Encourage to change the patient’s toothbrush after treatment (Hollier, 2016)
• Education:
o Educate patient about diagnosis of acute pharyngitis, including the spread of
infection and that it may take 3-4 days after treatment is started for the symptoms
to subside (Weinstock, Neides & Chan, 2015). o Educate patient about
medications, including how to properly take the medications, the importance of
finishing the course of treatment even after the patient is feeling better, and
possible side effects, including nausea, vomiting, diarrhea, and stomach pain
(Hollier, 2016). o Educate patient about proper hand hygiene to prevent the
spread of infection (Hollier, 2016).
o Educate the patient not to share drinking glasses, eating utensils or anything else
that goes into the mouth (Hollier, 2016). o Educate patient about avoiding Aspirin
in children (Shulman, Bisno, Clegg, Gerber, Kaplan, Lee, Martin & Van Beneden,
2012).
• Follow Up:
o Follow up as needed/RTC if symptoms persist or worsen
o Go to ER if persistence of symptoms longer than 1 week without improvement,
respiratory difficulty, particularly stridor, difficulty in handling secretions,
difficulty swallowing, severe pain in the absence of erythema, a palpable mass, or
blood, even in small amounts in the pharynx or ear (Ferri, 2018).
• Health Maintenance:
o Well child exam due in November 2018. o Meningitis A #1, Tdap, HPV #1 and
Influenza vaccine to be given in November with next well child exam.
o Dental exam due in November 2018.
National Standards of Care/ National Guidelines
• For this patient with streptococcal pharyngitis, the standards of care and national guidelines
were followed according to the Centers for Disease Control and Prevention (2016) and
the reference of the clinical practice guidelines by using the Rapid Strep Antigen Test for
diagnosis in the clinic. The guidelines were also followed with the antibiotic treatment of
Amoxicillin dosage and use of Tylenol for fever (Shulman, Bisno, Clegg, Gerber, Kaplan,
Lee, Martin & Van Beneden, 2012).
PROBLEM FOCUSED SOAP NOTE WEEK 6
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References
Center for Disease Control and Prevention. (2016). Pharyngitis (Strep throat). Retrieved on
October 14, 2018 from https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html
Ferri, F. (2018). 2018 Ferri’s clinical advisor: 5 books in 1. Philadelphia: PA. Elsevier.
Hollier, A. (2016). Clinical guidelines in primary care (2nd ed). Scott, LA: Advanced Practice
Education Associates, Inc.
Shulman, S.T., Bisno, A.L., Clegg, H.W., Gerber, M.A., Kaplan, E.L., Lee, G., Martin, J.M. &
Van Beneden, C. (2012). Clinical practice guideline for diagnosis and management of
Group A Streptococcal Pharyngitis: 2012 Update by the infectious diseases society of
America. Clinical Infectious Diseases, 55(10) e86-e102.
https://doi.org/10.1093/cid/cis629. Retrieved on October 14, 2018 from
https://academic.oup.com/cid/article/55/10/e86/321183
Weinstock, M.B, Neides, D.M., & Chan, M. (2015). The resident’s guide to ambulatory care (7th
ed.). Columbus, OH: Anadem