Posted: December 20th, 2022

TOPIC: SOAP NOTE

The case should be an unusual diagnosis, or a complex case that required in-depth Assessment on the student’s part. The case should be posted in the SOAP format, with references for the patient diagnosis, differential diagnoses (there should be at least 3), and the treatment plan. Notes will be graded as “pass/fail”. In order to receive grade points for SOAP notes, the notes must be approved by the deadlines specified on the course assignments page. The student will lose the opportunity for points on any SOAP notes not approved by the specified deadlines. The posting does not have to be written in APA format, but should be written with correct spelling and grammar. References should be in APA format. The selected references should reflect current evidence – dated within the past 5 years.
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SAMPLE ASSIGNMENT GUIDE:
in Week 3, you completed a focused SOAP note. This week, you will complete a comprehensive SOAP note. Both types of SOAP note provide a cognitive framework for diagnostic reasoning and treatment planning.

To prepare:

Review the Comprehensive SOAP Note Template.
Select a patient who you saw at your practicum site during the last 5 weeks. With this patient in mind, consider the following:
Subjective: What details did the patient provide regarding the personal and medical history?
Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities and psychosocial issues.
Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their CPT and ICD-10 codes for the diagnosis. What was your primary diagnosis and why?
Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
Reflection notes: What was your “aha” moment? What would you do differently in a similar patient Assessment?
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Patient to use 67 years black male with High blood pressure, Diabetes Type 2 on insulin. Live alone and has home health

Weight 258 Height 5’4
Diagnosis :
Type 2 diabetes mellitus with diabetic polyneuropathy
Hypertensive heart disease with heart failure

Chronic diastolic (congestive) heart failure

Bilateral primary osteoarthritis of knee

Type 2 diabetes mellitus with hyperglycemia

Type 2 diabetes mellitus with other specified complication

Other hyperlipidemia

Morbid (severe) obesity due to excess calories

Body mass index [BMI] 45.0-49.9, adult

Long term (current) use of insulin

Long term (current) use of aspirin

Medications
Tresiba FlexTouch Subcutaneous 100 UNIT/ML 40u Tresiba FlexTouch Subcutaneous 100 UNIT/ML 40 units
daily. Take AM subcutaneous(SQ)if > 200mg/dl consistently,
If you have a piece of Chess Pie with a meal give patient 15 units of Novolog (C)
NovoLOG FlexPen Subcutaneous 100 UNIT/ML 15 units Decrease Novolog (orange pen) to 15 units before
meals…If you are having a small meal take only 10 units daily. (C)
Meloxicam Oral 7.5 MG 1 Tab(s) Daily/By mouth
Farxiga Oral 10 MG 1 Tab(s) Daily/By mouth
Ozempic (0.25 or 0.5 MG/DOSE) Subcutaneous 2 MG/1.5ML 2 once weekly till sample pen completed then
start ozempic 1mg sub q weekly
Cholecalciferol Oral 1.25 MG (50000 UT) 1 Tab(s) Daily/By mouth
amLODIPine Besylate Oral 10 MG 1 Tab(s) Daily By mouth
Aspirin Oral 81 MG 1 Tab(s) Daily By mouth
Carvedilol Oral 12.5 MG 1 Tab(s) Twice daily. By mouth
Furosemide Oral 40 MG 1 Tab(s) Twice daily. By mouth
Losartan Potassium-HCTZ Oral 100-25 MG 1 Tab(s) Daily By mouth
Potassium 20MG/By mouth/1(tab) Twice daily
Celecoxib Oral 200 MG 1 Cap(s) Daily By mouth
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SAMPLE ANSWER GUIDE:
Subjective: Patient is a 67-year-old black male with a history of high blood pressure, diabetes type 2 on insulin. He lives alone and has home health. He reported experiencing symptoms of fatigue, weakness, and numbness in his feet. He also reported difficulty with mobility due to bilateral knee pain.

Objective: During the physical assessment, the patient was found to have a weight of 258 lbs and a height of 5’4”. Vital signs were within normal limits. Examination of the lower extremities revealed decreased sensation in the feet and bilateral knee effusions. Cardiovascular examination revealed a regular rhythm with a gallop and crackles in the lung bases.

Assessment:

Type 2 diabetes mellitus with diabetic polyneuropathy (CPT: 250.60, ICD-10: E11.40)
Hypertensive heart disease with heart failure (CPT: 402.01, ICD-10: I11.0)
Chronic diastolic (congestive) heart failure (CPT: 428.0, ICD-10: I50.9)
The primary diagnosis is Type 2 diabetes mellitus with diabetic polyneuropathy, as this is the most pressing concern causing the patient’s symptoms of weakness, fatigue and numbness in the feet.

Plan:

For diagnostics, the patient will undergo A1C testing and nerve conduction studies to confirm the diagnosis of diabetic polyneuropathy.
For treatment and management, the patient will continue with their current medications, including insulin, oral diabetes medications, and blood pressure medications. The patient will also be started on Meloxicam for knee pain and Celecoxib for pain management.
The patient will also be referred to physical therapy for knee pain and instructed on exercises to improve strength and mobility.
Follow-up will be scheduled in 2 weeks to monitor blood sugar levels, assess the effectiveness of current medications and treatment, and adjust treatment plan as needed.
Reflection notes: My “aha” moment during this Assessment was realizing the importance of considering all of the patient’s comorbidities and how they may impact one another. In a similar patient Assessment, I would make sure to review the patient’s full medical history and medications to ensure that all potential contributing factors are taken into account in the diagnosis and treatment plan.

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Tags: TOPIC: SOAP NOTE