NURS 622: Advanced Health Assessment Soap note example -cough

NURS 622: Advanced Health Assessment Soap note example -cough

SOAP Note Example – Cough

To complete the “Cough” Objective Structured Clinical Examination (OSCE) on Bates’ Visual Guide to Physical Examination at batesvisualguide.com, please follow the instructions below:

Patient History:
Please note that unless specified in the case study, the patient’s Past Medical History (PMH), Past Surgical History (PSH), Family History (FH), Social History (SH), and Review of Systems (ROS) are considered “normal” or non-contributory. Your task is to create a set of “normal” findings for these categories and document them correctly in accordance with the SOAP format. This means you need to demonstrate your knowledge of what information belongs under each of these categories and how to document it appropriately. Examples can be found in your Bates’ text and pocketbook.

Physical Examination:
In the physical examination section, you should include any abnormalities discovered during the OSCE but also include so-called “normal” findings for each system. Your goal is to communicate both normal and abnormal findings effectively.

Assessment:
Under the “Assessment” section, you are required to choose the most likely diagnosis based on the presented data and assessment. You should also include the ICD 10 code that corresponds to that diagnosis. For instance, if your assessment for the encounter is “Acute Pharyngitis,” you should document it as “Assessment: Acute pharyngitis (ICD 10 Code J02.9).” You should also list the data that supports this diagnosis.

Differential Diagnoses:
Differential diagnoses are potential diagnoses based on the data available. They should be listed from the most probable to the least probable based on the data or diagnostic information. Ensure that each listed diagnosis has supporting data; if there is no data to support a diagnosis, it should not be considered.

Plan:
You do not need to document the full treatment plan in this SOAP note, except for diagnostics. Leave pharmacotherapeutics, surgeries, or therapies for future classes, as they are beyond the scope of our current course. After choosing your diagnostic tests, specify what specific findings/results from the test would either support or refute your diagnostic concerns.

Formatting:
Ensure your SOAP note includes a title page following standard APA format. An abstract is not required. You may single-space the document but maintain a double space between major sections. Use headings that correspond to the major sections of the SOAP format. Provide a reference page as well.

Low Birth Weight Babies Essay – NRS-434 Topic 1 DQ 1 GCU

Please refer to the “SOAP NOTE FORMAT” under “Course Resources and Information” for the specific format to use for your SOAP note.

Course Title: NURS 622 – Advanced Health Assessment

Module 2
Collection of Subjective Data
Demographic and Personal Information
Date: February 18, 2021, Time: 10:00 AM

Ms. Chen, a woman aged 45 of Asian heritage, is currently single and employed as a dispute mediator. Her present residence is located at 1532 Elizabeth Street, Joliet, Illinois 60431, and she can be reached at (815) 555-1645. She initiated contact for this assessment herself and appears reliable, as evidenced by her ability to recall events easily, maintain consistent memories, and exhibit an open and pleasant demeanor during the interview.

Primary Concern: “I have been coughing for a week and just can’t seem to stop. I can hardly sleep at night.” (Source: Bates, n.d.)

History of Present Illness:
Ms. Chen, a 45-year-old woman, has been smoking two packs of cigarettes daily for the past decade. She is presenting today with a persistent cough that has persisted for one week. Initially, she experienced symptoms starting just over a week ago, including a runny nose and the sensation of postnasal drip. Subsequently, her symptoms worsened, culminating in a cough. The cough is productive, yielding yellow-green sputum with intermittent pink streaks that resemble blood, though she only observes these streaks about 3-4 times daily. She denies chest pain but reports that the cough is particularly bothersome at night, disrupting her sleep. She has attempted to alleviate this by using two pillows, which helps her head but does not resolve the sleep disturbance. Despite the cough, she experiences no fatigue affecting her daily activities. She also endures wheezing and shortness of breath when exerting herself, such as ascending stairs or engaging in yard work, though she does not experience these symptoms at rest while working at her desk.

She has been using over-the-counter (OTC) decongestants and ibuprofen twice a day. She took her temperature at home yesterday, which registered at 101 degrees Fahrenheit, and her fever persists during the assessment. She has no history of these symptoms and acknowledges seasonal allergies to pollen and goldenrod, which are subsiding for the season. She also notes a history of mild childhood asthma without hospitalizations or complications. Although she recently traveled to Shanghai, she had no known exposure to sick individuals and exhibited no symptoms during her trip. She denies weight loss, night sweats, or a history of tuberculosis. Her grandmother experienced tuberculosis as a child, but Ms. Chen had no contact with her while she was symptomatic. She received a negative TB skin test ten years ago and denies experiencing acid reflux symptoms or an acid taste.

Medications: Ms. Chen is not currently taking any prescription medications but has been using OTC decongestants and ibuprofen at the recommended dosage for the past week.

Allergies: There are no known allergies to drugs or food. She does, however, acknowledge seasonal allergies to pollen and goldenrod.

Tobacco Use: Ms. Chen has been smoking two packs of cigarettes daily for the past ten years without any periods of successful cessation. She does not use chewing tobacco.

Alcohol and Drug Use: She consumes one glass of wine approximately three times per week and denies any use of illicit or prescription drugs.

Past Medical History

Childhood Illness: During her elementary school years, Ms. Chen had a history of mild asthma with no hospitalizations.

Adult Illnesses:
Medical: Seasonal allergies during the fall and spring seasons.

Surgical: She has no surgical history.

Obstetrical: There is no history of obstetrical issues.

Psychiatric: There is no history of psychiatric issues.

Health Maintenance: Ms. Chen had a TB skin test ten years ago and is up to date on all immunizations. She receives the influenza vaccine annually, with her most recent vaccination in September 2020. Her last pap smear, conducted in January 2020, yielded negative results for intraepithelial lesions or malignancy, and no HPV was detected. She had a mammogram in 2019, which showed no masses.

Family Medical History: Her maternal grandmother had tuberculosis in her twenties and is currently alive at the age of 85. Ms. Chen denies any other family history of cancer, respiratory disorders, cardiovascular disorders, kidney disease, diabetes, neurological disorders, musculoskeletal disorders, gastrointestinal disorders, genetic disorders, or mental illness.

Personal and Social History: Ms. Chen was born in Joliet, Illinois, into a family consisting of her mother, father, and one sister who is two years her senior. She has resided in Joliet, Illinois, her entire life. Presently, she lives alone with her two cats and has never been married nor does she have children.

Sexual Orientation and Gender Identity: She was born female and currently identifies as female. Her sexual orientation is heterosexual.

Significant Relationships and Support Systems: Ms. Chen has been in a monogamous relationship for approximately one year and meets with her partner a few times weekly. She feels safe and supported in this relationship, which has introduced her to many mutual friends through their church group, where they initially met. She is actively engaged in her Catholic church, attending church services and participating in activities several times weekly. After work, she frequently dines with friends at least twice a week and believes she has a supportive circle of friends, rarely experiencing loneliness.

Work History and Occupation: Ms. Chen currently works full-time as a dispute mediator, a position she has held for about 20 years. She characterizes her work as stressful but personally fulfilling, feeling secure in her job and supported by her colleagues. She maintains a daily work schedule from 9 AM to 5 PM, Monday through Friday. She denies being in proximity to any unwell coworkers or clients. She attributes her cigarette smoking to stress relief stemming from her job. Her salary provides her with a comfortable lifestyle, and she is not facing significant financial stress or crises.

Education: She completed high school and possesses a four-year college degree.

Lifestyle: Ms. Chen leads a social life with numerous scheduled events throughout the week after work. She rarely dines alone, usually meeting with friends, family, or her significant other. She reports no difficulty managing household chores, enjoys gardening and landscaping, and volunteers at her church on weekends. In her free time, she reads and engages in painting. She maintains sufficient energy levels to accommodate her weekly schedule and reports sound sleep, averaging 7-8 hours per night. Prior to the onset of her present illness, she did not experience any sleep issues. She shares her bedroom with her two cats.

Travel: A few months ago, she traveled to Shanghai with her family. She was fully vaccinated for the trip and had no known exposure to diseases or contact with sick individuals.

Nutrition and Exercise: Ms. Chen adheres to a well-balanced diet, striving to include all food groups in each meal. She consumes three meals daily and prepares her lunch meals for the week on Sundays. When dining out socially, she avoids fried or greasy foods. She incorporates an hour of treadmill walking into her morning routine before work.

Alcohol and Tobacco Use: In addition to her smoking habit of two packs of cigarettes daily, Ms. Chen occasionally consumes one glass of wine approximately three times per week.

Illicit Drug Use: She denies any use of illicit drugs.

Review of Systems: All other systems are negative except as noted in the History of Present Illness.

General: Reports low-grade fever. Otherwise, she feels well.

Skin: Denies rashes, itching, or changes in mole appearance.

HEENT:
Head: No head trauma or headaches.
Eyes: Seasonal allergies with itchy, watery eyes.
Ears: No earaches, hearing loss, or tinnitus.
Nose: Seasonal allergies with a runny nose.
Throat: Denies sore throat or hoarseness.

Respiratory: Occasional wheezing and shortness of breath with exertion.

Cardiovascular: Denies chest pain, palpitations, or peripheral edema.

Gastrointestinal: Denies heartburn, indigestion, or changes in bowel habits.

Genitourinary: Denies dysuria, hematuria, or frequency.

Musculoskeletal: No muscle or joint pain.

Neurological: No headaches, syncope, or seizures.

Psychiatric: No history of depression, anxiety, or other psychiatric conditions.

Endocrine: No polyuria, polydipsia, polyphagia, heat or cold intolerance.

Hematologic: No history of bleeding disorders.

Allergic/Immunologic: Seasonal allergies to pollen and goldenrod.

Posterior hip atrophy or bruising. There are no enlarged inguinal lymph nodes, bulges along the inguinal ligament, tenderness of the groin, or sacroiliac joint tenderness. Ischiogluteal bursae are not palpable, and there is no tenderness over the trochanter. Full range of motion (ROM) of the hips is achieved through flexion, extension, abduction, adduction, external rotation, and internal rotation. There is no atrophy of quadriceps muscles, no genu varum or genu valgum. There is no swelling of the patella, no knee pain or tenderness. There are no irregular bony ridges along the ribiofemoral joints. There is no medial or lateral collateral ligament tenderness. The patellar tendon is intact without tenderness, and the patella moves in a smooth sliding motion. There is no thickening, tenderness, bogginess, or warmth noted over the suprapatellar pouch, prepatellar bursa, or anserine bursa. The bulge, balloon, and balloting of the patella tests are negative.

There is no tenderness or swelling of the gastrocnemius or soleus muscles. There is no tenderness or thickening of Achilles tendon bilaterally. Full ROM of knees is achieved through flexion, extension, internal rotation, and external rotation. The McMurray test is negative bilaterally, as are the abduction and adduction tests, the anterior and posterior drawer sign, and the Lachman test. There are no deformities, swelling, nodules, calluses, or corns of the ankles or feet. There is no ankle joint swelling, bogginess, or tenderness bilaterally. There are no nodules or tenderness of the Achilles tendons. The posterior and inferior calcaneus and plantar fascia are nontender. The medial and lateral malleolus is nontender. There is no tenderness on compression of metatarsophalangeal joints bilaterally. There is no metatarsalgia. There are no forefoot abnormalities. Full ROM of tibiotalar joints is achieved through flexion and extension without pain. Full ROM of subtalar and transverse tarsal joints is achieved through inversion and eversion without pain.

Neurologic:

Mental Status: The patient is alert, relaxed, and cooperative. Her thought process is coherent, and she is oriented to person, place, and time. She responds to questions appropriately.

Cranial Nerves: Cranial nerve I is not tested. Cranial nerve II and III show visual acuity of 20/20 in the right eye, 2/20 in the left eye, and 20/20 in both eyes without correction. Visual fields are full, and pupils are round, 4mm in size, reactive to light and accommodation, constricting to 2mm. Cranial nerves III, IV, and VI exhibit intact extraocular movements with no nystagmus, ptosis, diplopia, or amblyopia. Cranial nerve V motor function is intact with temporal and masseter strength rated at 5/5 bilaterally, and there is no sensory facial loss noted to sharp or dull sensation. Corneal reflexes are present. Cranial nerve VII motor function reveals intact bilateral facial movements with no asymmetry or abnormal movements. Sensory function for taste is not tested. Cranial nerve VIII shows intact hearing bilaterally to whispered voice. Cranial nerves IX and X indicate modulated voice without hoarseness or nasality. There is no difficulty swallowing, and the rise and fall of the soft palate is symmetric, with the uvula midline. The posterior pharynx moves medially, and the gag reflex is intact. Cranial nerve XI exhibits strength of sternomastoid and trapezius muscles at 5/5. Cranial nerve XII shows clear articulation with no dysarthria, and the tongue is midline with no atrophy or fasciculation, asymmetry, or deviation.

Motor: Muscle bulk is symmetric and proportionate to the body with no atrophy noted. Muscle tone is intact with no evidence of decreased or increased resistance, and it is equal bilaterally with no marked floppiness or spasticity. Muscle strength is 5/5 in the upper and lower extremities bilaterally, including flexion and extension, adduction, and abduction. Cerebellar function exhibits intact rapid alternating movements, coordinated bilaterally. Finger-to-nose and heel-to-shin maneuvers are performed with smoothness and accuracy of movements noted bilaterally. The gait is steady, coordinated, balanced with a steady base, and coordination with rhythmic movement and steady posture is observed. The Romberg test shows maintained balance with eyes closed, and there is no pronator drift.

Sensory: Sensation to pinprick and light touch is intact over the right and left face, arms, and legs bilaterally. Position sense of bilateral big toes is intact, with no loss of position sense. Vibration sensation is demonstrated over the distal interphalangeal joint of bilateral fingers bilaterally without any loss or impairment, and vibration is intact over the interphalangeal joint of big toes bilaterally without any loss or impairment.

Reflexes: Biceps, triceps, brachioradialis, patellar, ankle, and abdominal reflexes are 2+ and symmetric, with plantar reflexes being downgoing.

ASSESSMENT:

Working diagnosis: Community Acquired Pneumonia (CAP). (ICD 10 Code J18.9). The acute onset of symptoms such as a productive cough with yellow-green and blood-tinged sputum, fever, shortness of breath upon exertion, and an increased respiratory rate could indicate community-acquired pneumonia (Kaysin & Viera, 2016). The presence of fever also suggests an infectious cause. Physical assessment findings, such as decreased tactile fremitus, dullness, egophony, and adventitious sounds in the lower left lobe, indicate consolidation, which is a consistent finding in CAP (Kaysin & Viera, 2016). Ms. Chen’s history of smoking puts her at a greater risk for contracting CAP.

PLAN:

Differential Diagnosis:

1. Atypical CAP: (ICD 10 Code J18.9). While patients with this condition commonly present with a dry “hacking cough,” this symptom is not exclusive, and many patients have an absence of pleuritic chest pain, as in Ms. Chen’s case (Centers for Disease Control and Prevention [CDC], 2018). Patients with atypical CAP are also less likely to have severe fatigue or symptoms affecting their daily activities, resembling symptoms of a common chest cold more closely (CDC, 2018). Atypical CAP often has a prodrome of viral symptoms similar to influenza, such as rhinitis, sore throat, or headache (Oda et al., 2018).

2. Acute Bronchitis: (ICD 10 Code J20.9). Patients with acute bronchitis usually present with the predominant symptom of a productive or nonproductive cough, which is usually self-limiting and lasts less than three weeks but longer than five days (Smith et al., 2020). While it is unlikely that a fever will persist for more than a few days after onset, bronchitis symptoms usually follow an upper respiratory infection (Kinkade & Long, 2016). Since Ms. Chen reported some symptoms consistent with an upper respiratory infection last week, it is still within a reasonable time frame to suspect that a fever could persist, which is consistent with acute bronchitis. While physical examination findings of lung consolidation typically indicate pneumonia over acute bronchitis, if pneumonia is eliminated as a diagnosis, these symptoms could be consistent with bronchitis as well (Kinkade & Long, 2016).

3. Influenza: (ICD 10 Code A15.0). Influenza symptoms have an acute onset, including cough, nasal congestion, sore throat, and myalgia. These symptoms are usually self-limiting but can develop respiratory complications such as bronchitis or pneumonia if a patient presents with positive respiratory physical examination findings (Ghebrehewet et al., 2016). With Ms. Chen initially reporting mild symptoms that then progressed to the productive cough, influenza needs to be determined or ruled out as a causative agent for her illness in order to progress treatment.

4. Pulmonary Tuberculosis: Ms. Chen’s symptoms of blood-tinged sputum, fever, persistent cough, and travel outside of the country within the past six months raise suspicion for pulmonary tuberculosis from Mycobacterium bacterium. While hemoptysis is usually a late symptom in the disease, showing cavitation, blood-tinged sputum accompanied by fever, cough, night sweats, weight loss, or chills may be early symptoms (Loddenkemper et al., 2016). While some patients may present as asymptomatic, those experiencing respiratory symptoms may have positive examination findings consistent with consolidation in the lungs (Loddenkemper et al., 2016).

Diagnostic Plan:

1. Oxygen Saturation: To determine the presence of hypoxia if oxygen saturation is less than 90%, which can guide the decision for outpatient treatment (Bates, n.d.).

2. Chest X-ray: This is the gold standard for diagnosing pneumonia. A chest X-ray can distinguish pneumonia from other possible diagnoses such as tuberculosis, bronchitis, or cardiovascular causes. While a chest X-ray cannot identify specific pathogens causing pneumonia, it may show focal infiltrates with pleural effusion suggesting bacterial infection or interstitial infiltrates suggesting viral infection. Tuberculosis may be seen on a chest X-ray with cavities but without air-fluid levels (Bates, n.d.).

3. Complete Blood Count with Differential and Metabolic Profile: This can indicate elevated white blood cell (WBC), neutrophil, and lymphocyte counts. These levels can guide pharmacologic interventions by indicating viral or bacterial origin. Additionally, a metabolic profile will show carbon dioxide levels, renal and liver function, which can influence antibiotic therapies (Kaysin & Viara, 2016).

4. Sputum Culture and Gram Stain: May be helpful in determining bacterial pathogens in severely ill patients (Bates, n.d.).

5. Influenza Test: Can determine if symptoms are attributed to influenza A or B.

6. Blood Cultures and Urine Antigen Tests: These are recommended for patients with severe pneumonia to determine the presence of legionella and pneumococcal antigens (Bates, n.d.).

References

Bates’ Visual Guide to Physical Examination (Producer). (n.d.). Objective structured clinical examinations (OSCE): Cough. Wolters Kluwer. https://batesvisualguide.com/multimediaplayer.aspx?multimediaid=6130478

Centers for Disease Control and Prevention (CDC). (2018). Mycoplasma pneumoniae infections. https://www.cdc.gov/pneumonia/atypical/mycoplasma/index.html

Ghebrehewet, S., MacPherson, P., & Ho, A. (2016). Influenza. BMJ, 355, i6258. https://doi.org/10.1136/bmj.i6258

Kaysin, A. & Viera, A. J. (2016). Community-acquired pneumonia in adults: diagnosis and management. American Family Physician, 94(9), 698-706. https://www.aafp.org/afp/2016/1101/p698.html

Kinkade, S. & Long, N.A. (2016). Acute Bronchitis. American Family Physician, 94(7), 560- 565. https://www.aafp.org/afp/2016/1001/p560.html

Loddenkemper, R., Lipman, M., & Zumla, A. (2016). Clinical Aspects of Adult Tuberculosis. Cold Spring Harbor perspectives in medicine, 6(1), a017848. https://doi.org/10.1101/cshperspect.a017848

Ota, K., Iida, R., Ota, K., Sakaue, M., Taniguchi, K., Tomioka, M., Nitta, M., & Takasu, A. (2018). An atypical case of atypical pneumonia. Journal of general and family medicine, 19(4), 133–135. https://doi.org/10.1002/jgf2.179

Smith, M.P., Lown, M., Singh, S., Ireland, B., Hill, A. T., Linder, J.A., & Irwin, R. S. (2020). Acute cough due to acute bronchitis in immunocompetent adult outpatients. Chest Journal, 157(5), 1256- 1265. https://doi.org/10.1016/j.chest.2020.01.044