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SOAP NOTE   Hordeolum .

Grading Rubric

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Student______________________________________

This sheet is to help you understand what we are looking for, and what our margin remarks might be about on your write ups of patients. Since at all of the white-ups that you hand in are uniform, this represents what MUST be included in every write-up.

1) Identifying Data (___5pts): The opening list of the note. It contains age, sex, race, marital status, etc. The patient complaint should be given in quotes. If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number.

2) Subjective Data (___30pts.): This is the historical part of the note. It contains the following:

a) Symptom analysis/HPI(Location, quality , quantity or severity, timing, setting, factors that make it better or worse, and associate manifestations.(10pts).

b) Review of systems of associated systems, reporting all pertinent positives and negatives (10pts).

c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem (10pts). If more than one chief complaint, each should be written u in this manner.

3) Objective Data(__25pt.): Vital signs need to be present. Height and Weight should be included where appropriate.

a) Appropriate systems are examined, listed in the note and consistent with those identified in 2b.(10pts).

b) Pertinent positives and negatives must be documented for each relevant system.

c) Any abnormalities must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe things. (5pts).

4) Assessment (___10pts.): Encounter paragraph and diagnoses should be clearly listed and worded appropriately including ICD10 codes.

5) Plan (___15pts.): Be sure to include any teaching, health maintenance and counseling along with the pharmacological and non-pharmacological measures. If you have more than one diagnosis, it is helpful to have this section divided into separate numbered sections.

6) Subjective/ Objective, Assessment and Management and Consistent (___10pts.): Does the note support the appropriate differential diagnosis process? Is there evidence that you know what systems and what symptoms go with which complaints? The assessment/diagnoses should be consistent with the subjective section and then the assessment and plan. The management should be consistent with the assessment/ diagnoses identified.

7) Clarity of the Write-up(___5pts.): Is it literate, organized and complete?

Comments:

Total Score: ____________ Instructor: __________________________________

Guidelines for Focused SOAP Notes

· Label each section of the SOAP note (each body part and system).

· Do not use unnecessary words or complete sentences.

· Use Standard Abbreviations

S: SUBJECTIVE DATA (information the patient/caregiver tells you).

Chief Complaint (CC): a statement describing the patient’s symptoms, problems, condition, diagnosis, physician-recommended return(s) for this patient visit. The patient’s own words should be in quotes.

History of present illness (HPI): a chronological description of the development of the patient’s chief complaint from the first symptom or from the previous encounter to the present. Include the eight variables (Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Treatment, Severity-OLDCARTS), or an update on health status since the last patient encounter.

Past Medical History (PMH): Update current medications, allergies, prior illnesses and injuries, operations and hospitalizations allergies, age-appropriate immunization status.

Family History (FH): Update significant medical information about the patient’s family (parents, siblings, and children). Include specific diseases related to problems identified in CC, HPI or ROS.

Social History(SH): An age-appropriate review of significant activities that may include information such as marital status, living arrangements, occupation, history of use of drugs, alcohol or tobacco, extent of education and sexual history.

Review of Systems (ROS). There are 14 systems for review. List positive findings and pertinent negatives in systems directly related to the systems identified in the CC and symptoms which have occurred since last visit; (1) constitutional symptoms (e.g., fever, weight loss), (2) eyes, (3) ears, nose, mouth and throat, (4) cardiovascular, (5) respiratory, (6) gastrointestinal, (7) genitourinary, (8) musculoskeletal, (9-}.integument (skin and/or breast), (10) neurological, (11) psychiatric, (12) endocrine, (13) hematological/lymphatic, {14) allergic/immunologic. The ROS should mirror the PE findings section.

0: OBJECTIVE DATA (information you observe, assessment findings, lab results).

Sufficient physical exam should be performed to evaluate areas suggested by the history and patient’s progress since last visit. Document specific abnormal and relevant negative findings. Abnormal or unexpected findings should be described. You should include only the information which was provided in the case study, do not include additional data.

Record observations for the following systems if applicable to this patient encounter (there are 12 possible systems for examination): Constitutional (e.g. vita! signs, general appearance), Eyes, ENT/mouth, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin, Neurological, Psychiatric, Hematological/lymphatic/immunologic/lab testing. The focused PE should only include systems for which you have been given data.

NOTE: Cardiovascular and Respiratory systems should be assessed on every patient regardless of the chief complaint.

Testing Results: Results of any diagnostic or lab testing ordered during that patient visit.

A: ASSESSMENT: (this is your diagnosis (es) with the appropriate ICD 10 code)

List and number the possible diagnoses (problems) you have identified. These diagnoses are the conclusions you have drawn from the subjective and objective data.

Remember: Your subjective and objective data should support your diagnoses and your therapeutic plan.

Do not write that a diagnosis is to be “ruled out” rather state the working definitions of each differential or primary diagnosis (es).

For each diagnoses provide a cited rationale for choosing this diagnosis. This rationale includes a one sentence cited definition of the diagnosis (es) the pathophysiology, the common signs and symptoms, the patients presenting signs and symptoms and the focused PE findings and tests results that support the dx. Include the interpretation of all lab data given in the case study and explain how those results support your chosen diagnosis.

P: PLAN (this is your treatment plan specific to this patient). Each step of your plan must include an EBP citation.

1. Medications write out the prescription including dispensing information and provide EBP to support ordering each medication. Be sure to include both prescription and OTC medications.

2. Additional diagnostic tests include EBP citations to support ordering additional tests

3. Education this is part of the chart and should be brief, this is not a patient education sheet and needs to have a reference.

4. Referrals include citations to support a referral

5. Follow up. Patient follow-up should be specified with time or circumstances of return. You must provide a reference for your decision on when to follow up.

SOAP NOTE: SCABIES 1

SOAP Note: SCABIES 2

SCABIES

Miami Regional University

Patient: F.D.

Age: 48 years old

Race: Hispanic

Gender: Male

Insurance: Private insurance.

SUBJECTIVE

Chief complaint: ” My skin itches a lot at night”

History of present illness (HPI): Patient is a Hispanic white male 48 year old who is coming to consultation today reporting that for a week he is having a lot of itching in the internal fold of elbows and legs that makes it difficult for him to sleep properly. He also says he lived for two months with his mother in a shelter. Patient denies a history of dermatitis or atopy and states that he is not using any OTC cream or lotion and the skin lesion has increased as well as itchy.

Past Medical History(PMH)

Last annual physical exam was made in January of current year.

Chronic Condition: Essential Hypertension Controlled with current treatment

Current Medication: Enalapril 20 mg 1 tab PO QD

Hospitalization: Patient denies hospitalizations or invasive procedures.

No history of mental illness or personality disorders.

No physical trauma or falls reported during the last twelve months.

Surgeries: Cholecystectomy 7 years ago

Exposure: Patient lived in a shelter for two months due to economic problems that were already solved. No knows HIV exposure during the last year. No blood transfusions or received other blood components or tissues.

Environmental exposure was negative to asbestos, radiations or other chemical substances. No exposure to the sunlight during day activities for long periods of time.

Immunizations: Immunizations up to date (Flu Vaccine: 01/23/2019)

Exercise: Patient refers frequently daily exercises.

Diet: Patient refers a “healthy diet” rich in whole grains, vegetables, fruits and proteins.

Social History: Patient is single, and lives with his mother in an apartment. The relationships between family members is good. Client denies using drugs, alcohol or cigarettes.

Educational level: Middle School.

Sexual Behavior: Patient is heterosexual and he reported one sex partner during the past year. Client said that he always uses condom. No risk behavior for STDs.

Allergies: NKDA, No Food/Seasonal Allergy

Family Medical History: Mother (75 y/o) Alive : HTN, Diabetes mellitus and Father: Unknown.

Review of systems:

Systemic: The systemic symptoms presented at this time is skin itchy. No chills, no neck rigidity. No weight loss.

Head: No headache. No sinus pain reported, no mass, no trauma.

Neck: No pain or stiffness reported in this area. No swollen glands in the neck.

Eyes: No redness, pruritus or secretion. Denies blurred vision, double vision or other conditions.

Oto-laryngeal: No change in hearing, ringing in ears, neither ear pain. Not presence of sinus/nasal congestion or bleeding gums.

Breasts: No symptoms such as pain, fulness sensation or discharge.

Cardiovascular: Denies chest pain, palpitations, discomfort neither occasional episodes of irregular rhythm.

Pulmonary: Denies chest congestion, wheezing, coughing, frequent infections or shortness of breath.

Gastrointestinal: Normal appetite. No dysphagia or heartburn. No nausea, vomiting or abdominal pain. No hematochezia. No diarrhea or constipation.

Genitourinary: No pain, hematuria or changes in urinary habits. No cloudy urine or bad smell. No penile discharge.

Endocrine: No symptoms. No polyuria, no polyphagia.

Hematologic: Denies easy bruising, loss of hair, heat/cold intolerance, change in nails, enlarged glands, prolonged bleeding, increased thirst, or hunger.

Musculoskeletal: Denies limited range of mobility, joint pain or limited ROM. Denies difficulty walking or trouble reaching above head.

Neurological: Denies migraine, balance problems, seizures or fainting lightheadedness, tremors or balance problems. Denies muscle weakness, numbness or tingling.

Psychological: Mood was euthymic, not feeling restless or anxiety. No feeling hopelessness or depressed. No sleep disturbances, trouble falling or staying asleep. Normal enjoyment of activities. Not easily distracted and no change in thought patterns.

Skin: The patient denies presence of white or brown spots, ulcer, ecchymosis, new nevus. During the interview he reports a lot of itchy during night for the las weeks localized in internal fold of elbows and legs.

OBJECTIVE

Physical Exam

Vitals Sign:

BP-sitting L: 120/80 mmHg

BP cuff size: Regular

Pulse Rate-Sitting: 78 bpm

Pulse Rhythm: Regular

Respiration Rate: 15 per min

Temp-Tympanic: 98.1 F0

Height 70 in

Weight:188 lbs.

Body Mass Index: 29.1 Kg/m2

Body Surface Area: 1.97 m2

Oxygen Saturation: 98 %

Pain Scale/Rate: 0/10

General appearance: Patient alert and oriented. Speech fluently. Currently; he no reflects discomfort in his face and posture. He is hydrated without increase of temperature.

Head: Normocephalic / no trauma. Scalp pink and dry. No tenderness noted over frontal or maxillary sinuses.

Neck: No visible mass and skin with normal coloration. No palpable masses or tenderness, trachea is midline, thyroid without nodules, no JVD, no lymph nodes.

Eyes: Extraocular movement in both eyes are symmetric. PERRLA, sclera is white, conjunctiva pink, no noted discharge. Normal visual acuity.

Ears: External auditory canal and meatus are normal. No swollen or reddened. Bilateral tympanic membranes were intact and pearly gray with light reflex. No erythematous, scarred or hemorrhage. No pus or serous exudate. No hearing loss.

Nose: No external deformities of the nose. Nasal mucosa moist and pink with clear drainage, septum midline. Nasal turbinate no erythematous, no swollen. No sinus tenderness.

Oral Cavity: Oral mucosa moist and pink. Gums with normal appearance without swollen, bleeding or hypertrophy. Teeth, the dentition are complete and good hygiene.

Pharynx: Moist and pink with tonsillar enlargement without lesions, plaques or exudate. No petechias, no strawberry tongue.

Lymph Nodes: No adenomegaly on observation on palpation in any of the ganglion’s chains.

Chest: Thorax symmetric, follow up the breading movement.

Lungs: Respirations are regular, equal, and unlabored with symmetrical chest expansion. Lung sounds clear to all lung fields. No wheezing, stridor, crackles, or rhonchi noted. No increased tactile fremitus noted.

Cardiovascular: Regular rate and rhythm, heart sounds of S1 and S2, no extra heart sounds, murmurs or bruits noted. PMI at 5th intercostal space, midclavicular line. No pericardial friction rub heard. No gallops, murmurs, or opening snaps.

All pulses 4+ palpable and equal. No clubbing, cyanosis or edema noted. Bilateral carotid arteries without bruits. Capillary refill test was normal.

Abdomen:

Inspection: Symmetric, no distended no visible masses. The skin is normal, no scars

Auscultation: Bowel sound active in all 4 quadrants. No bruits.

Palpation: Abdomen soft, no mass, non-tender or guarding. No hepatomegaly or splenomegaly.

Percussion: Normal.

Genitalia: Patient refused genital exam at this time.

Rectal: Patient refused rectal exam at this time.

Musculoskeletal: Normal gait, no limited range of mobility (joints). Normal inspection, palpation, muscle strength. Fingers, feet and toes are normal.

Neurological: Level of consciousness was normal. Patient oriented in person, time and space. Speech clear and fluent. Normal sensory/motor exam. Deep tendon reflexes symmetrical and equal bilaterally. Proprioception was normal. Balance, gain and stance were normal. No peripheral neuropathy was noted.

Psychiatric: Patient is euthymic, with normal level of anxiety and depression. The affect was normal.

Skin: Clean, warm and dry without sores or bruises. No suspicious nevi, no bruises or ecchymoses. On observation is noted the presence of burrows and vesicles in internal fold of elbows, knee and inner part of both thighs. Also, it was observed excoriated papules.

Hair: Normal distribution according to the gender. No hair loss in the lower extremities was observed.

Nails: Pink with normal appearance. No clubbing of the finger nails. No onychomycosis.

ASSESSMENT

Primary Diagnosis: B86 Scabies

It is an infestation of the skin by the mite Sarcoptes scabiei that results in an intensely pruritic eruption with a characteristic distribution pattern. The incidence of scabies undergoes cyclical fluctuations on a worldwide basis, although all parts of the globe are not necessarily in the same phase of the cycle at the same time. Transmission of scabies is usually from person to person by direct contact. In adults, areas most likely to yield mites are between the fingers, sides of hands, wrists, elbows, axillae, groin, breasts, and feet. Scabies usually presents with severe itching, often worse at night, and nondescript erythematous papules.

Differential Diagnosis:

Atopic Dermatitis: is a chronic inflammatory skin condition that appears to involve a genetic defect in the proteins supporting the epidermal barrier.  Exacerbating factors in atopic dermatitis that disrupt an abnormal epidermal barrier include excessive bathing, low humidity environments, emotional stress, xerosis or dry skin, overheating of skin, and exposure to solvents and detergents.

Impetigo: is a contagious superficial bacterial infection observed most frequently in children. It may be classified as primary impetigo direct bacterial invasion of previously normal skin or secondary impetigo infection at sites of minor skin trauma such as abrasions, minor trauma, and insect bites, or underlying conditions such as eczema. Variants of impetigo include non-bullous impetigo, bullous impetigo, and ecthyma.

Folliculitis: Multiple follicular-based erythematous papules or pustules on chest and back.

No burrows seen on physical exam.

Other Diagnosis

Essential Hypertension (Controlled) I10

Overweight E66.3

PLAN

Therapeutic

Permethrin 5% cream, massage thoroughly into the skin from the neck to the soles of the feet x 1 time, cream should be removed by washing after 8 to 14 hours. Apply a second time after two weeks.

Hydroxyzine tab 25 mg BID for 5 days.

Non-Therapeutic

Patient was instructed regarding general measures:

1. Treatment for those who were sexual and household contacts within the preceding 1 month is recommended at the same time that the patient is treated to prevent re-infestation.

2. Immediately following any treatment, all bedding and clothing should be washed in water that is 140°F or higher (≥60°C) and dried the day after the first treatment to decrease the chance of re-infestation.

3. Clothing or objects that cannot be washed should be placed in a sealed bag for a week.

No Test ordered/No needed to this diagnosis

Follow-ups/Referrals:

Follow-up in 3 weeks. Also, the patient was instrumented to return if the symptoms get worse.

Bibliographic References:

Chosidow O. Clinical practices. Scabies. N Engl J Med. 2006;354:1718-1727.[Abstract

Chouela E, Abeldano A, Pellerano G, et al. Diagnosis and treatment of scabies: a practical guide. Am J Clin Dermatol. 2002;3:9-18.[Abstract]

Hengge UR, Currie BJ, Jager G, et al. Scabies: a ubiquitous neglected skin disease. Lancet Infect Dis. 2006;6:769-779.[Abstract]

Heukelbach J, Feldmeier H. Scabies. Lancet. 2006;367:1767-1774.[Abstract]

Johnston G, Sladden M. Scabies: diagnosis and treatment. BMJ. 2005;331:619-622.[Abstract]

Johnstone P, Strong M. Scabies. Clin Evid. 2006:2284-2290.[Abstract]

Strong M, Johnstone PW. Interventions for treating scabies. Cochrane Database Syst Rev. 2007;3:CD000320.[Abstract]

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