Episodic/Focused SOAP Note

Episodic/Focused SOAP Note

Episodic/Focused SOAP Note

Patient Information:

Initials: E.S

Age: 46 years

Sex: Female

Race: White

Subjective

CC (chief complaint): “Pain in both ankles.”

HPI: E.S is a 46-year-old White female patient with a chief complaint of pain in both ankles. The ankle pain began four days ago when playing soccer when she heard a “pop” sound followed by an abrupt, intense pain. The pain has worsened gradually and is more intense on the right ankle. She states she can bear weight with both lower limbs, but it is uncomfortable, especially the right foot. The patient states that the right ankle is a bit swollen and tender. Besides, the pain is worsened by movement. She reports taking OTC Aspirin to relieve the pain and has relieved it to some extent. The severity of pain on the right ankle is 7/10 and on the left ankle is 3/10.

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Current Medications: OTC Aspirin.

Allergies: No drug/food allergies.

PMHx: No history of chronic illnesses or surgery; Immunization is up to date.

Soc Hx: E.S is a high school teacher and soccer coach. She is married and lives with her husband and two children, 22 and 15 year-olds. She takes alcohol on weekends (2-3 beers per sitting) but denies using tobacco or other drug substances. Her hobbies include playing soccer and hiking. She reports sleeping 7-9 hours a day.

Fam Hx: The maternal grandmother died from stroke. The paternal grandmother died from lung cancer. Her father has HTN. Siblings are alive and well.

ROS:

GENERAL:  Negative for fever, chills, weight changes, general body weakness, or fatigue.

SKIN: Positive for bruises on the right ankle. Denies discoloration, rashes, or itching.

CARDIOVASCULAR:  Negative for palpitations, chest pain/pressure, edema, or dyspnea on exertion.

RESPIRATORY:  Denies cough, shortness of breath, chest pain, or sputum production.

NEUROLOGICAL:  Negative for lightheadedness, headache, syncope, muscle weakness, numbness, or tingling sensations in the extremities.

MUSCULOSKELETAL:  Positive for right ankle pain, tenderness, and swelling. Positive for limitations in movement. Negative for joint stiffness, muscle pain, or enlarged joints.

Objective.      

Vital signs: BP- 116/70; HR- 90; RR-20; Temp-98.78 F

HT- 5’5 WT-147 lbs.

General: Female patient in her 40s, well-groomed and appropriately dressed. She is alert and in no acute distress. Her speech is clear and coherent. She maintains eye contact and exhibits positive mannerisms.

Respiratory: Uniform respiratory movements. Lungs clear on auscultation.

Cardiovascular:  No neck vein distension or edema. Regular heart rate and rhythm.

Musculoskeletal: Left Ankle- No bruises, erythema, edema, or loss of function noted. Mild tenderness on the anterior aspects. No bony point tenderness. No difficulties in bearing weight. Total ankle motion has decreased by 2 degrees.

Right ankle- Bruises noted; Moderate tenderness at the maximal points of the anterior aspect. Moderate loss of function. Decreased total ankle motion by 7 degrees. Pain noted with weight-bearing. No bony point tenderness.

Neurological: Muscle strength- 5/5; CNs are intact.

Diagnostic results:

X-ray of the right and left ankle: An X-ray will be required to identify the cause of pain and rule out fractures. The X-ray is guided by the Ottawa Ankle Rules, which state that an ankle X-ray series is needed if there is pain in the malleolar zone in addition to any of the following three findings:

1. Bone tenderness at the posterior edge or the lower 6 cm of the fibula.
2. Bone tenderness at the posterior edge or the lower 6 cm of the tibia.

• Difficulty bearing weight the moment after the injury and in the ED (Halabchi & Hassabi, 2020).

Assessment

Acute Right Ankle Sprain: Acute ankle sprain is an inversion-type foot twist. It is accompanied by pain, tenderness, swelling, bruising, and muscle spasm (Halabchi & Hassabi, 2020). Besides, there is loss of function and joint instability, which depends on the severity of the sprain. The patient’s symptoms consistent with the diagnosis include ankle bruising, pain, tenderness, swelling, difficulty bearing weight, moderate loss of function, and decreased total ankle motion.

Achilles tendon rupture: Positive patient findings supporting the differential diagnosis of Achilles tendon rupture include ankle pain, popping sensation during the time of ankle injury, and difficulties and pain with bearing weight (Park et al., 2020).

Achille Tendonitis: This is an inflammatory disorder that manifests with pain at tendinous insertions into bone (Achilles tendon at the heel). It causes pain, swelling, and impaired performance (Medina Pabón & Naqvi, 2021). Achille Tendonitis is a differential diagnosis based on the patient’s symptoms of ankle pain, swelling, and loss of function with difficulty bearing weight.

Ankle Dislocation: Clinical manifestations of ankle dislocation include significant ankle edema with deformity ranging from trace to evident. Tenting of the skin by the malleoli can be present. Joint palpation reveals tenderness along the joint line (Lawson et al., 2018). Ankle Dislocation is a differential diagnosis based on positive symptoms of right ankle swelling, bruises, and ankle tenderness.

Right Ankle Fracture: Signs and symptoms of a fractured ankle include swelling, severe pain, ecchymosis, soft tissue injury with abrasions and lacerations, loss of function, limited range of motion, cold foot, or paresthesia (Lawson et al., 2018). Right Ankle fracture is a differential diagnosis based on positive features of right ankle pain, tenderness, abrasions, loss of function, and decreased total ankle motion.

References

Halabchi, F., & Hassabi, M. (2020). Acute ankle sprain in athletes: Clinical aspects and algorithmic approach. World journal of orthopedics, 11(12), 534–558. https://doi.org/10.5312/wjo.v11.i12.534

Lawson, K. A., Ayala, A. E., Morin, M. L., Latt, L. D., & Wild, J. R. (2018). Ankle fracture-dislocations: a review. Foot & Ankle Orthopaedics, 3(3), 2473011418765122. https://doi.org/10.1177/2473011418765122

Medina Pabón, M. A., & Naqvi, U. (2021). Achilles Tendonitis. In StatPearls. StatPearls Publishing.

Park, S. H., Lee, H. S., Young, K. W., & Seo, S. G. (2020). Treatment of Acute Achilles Tendon Rupture. Clinics in orthopedic surgery, 12(1), 1–8. https://doi.org/10.4055/cios.2020.12.1.1

Episodic/Focused SOAP Note Template

 

Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).

PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

 

Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL:  Denies weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  Denies hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  Denies rash or itching.

CARDIOVASCULAR:  Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  Denies shortness of breath, cough or sputum.

GASTROINTESTINAL:  Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL:  Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  Denies muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  Denies anemia, bleeding or bruising.

LYMPHATICS:  Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  Denies history of depression or anxiety.

ENDOCRINOLOGIC:  Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  Denies history of asthma, hives, eczema or rhinitis.

O.

Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)

A.

Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

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