Soap Note 1 is based on the Case Study # 1 (10 Points)
You MUST use the Case Study #1 as the base of this SOAP NOTE #1
Must use the sample template for your soap note, keep this template for when you start clinicals.
Templates used from another classes will not be accepted. Student must use the template provided in this class which must clearly contain the progress note (in the Assessment section) of the encounter with the patient ( this section is clearly mark in bold, highlighted and underlined). No passing grade will be granted if this section is not completed properly.
Late Assignment Policy
Assignments turned in late will have 1 point taken off for everyday assignment is late, after 7 days assignment will get grade of 0 (zero). No exceptions
Follow the MRU Soap Note Rubric as a guide
Use APA format and must include minimum of 2 Scholarly Citations.
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C
Soap Note # ____ Main Diagnosis ______________
PATIENT INFORMATION
Name:
Age:
Gender at Birth:
Gender Identity:
Source:
Allergies:
Current Medications:
·
PMH:
Immunizations:
Preventive Care:
Surgical History:
Family History:
Social History:
Sexual Orientation:
Nutrition History:
Subjective Data:
Chief Complaint:
Symptom analysis/HPI:
The patient is …
Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )
CONSTITUTIONAL:
NEUROLOGIC:
HEENT:
RESPIRATORY:
CARDIOVASCULAR:
GASTROINTESTINAL:
GENITOURINARY:
MUSCULOSKELETAL:
SKIN:
Objective Data:
VITAL SIGNS:
GENERAL APPREARANCE:
NEUROLOGIC:
HEENT:
CARDIOVASCULAR:
RESPIRATORY:
GASTROINTESTINAL:
MUSKULOSKELETAL:
INTEGUMENTARY:
ASSESSMENT:
(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data)
Example : “Pt came in to our clinic c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and that etc.)
Main Diagnosis
(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 6th or 7th Edition.
Differential diagnosis (minimum 3)
–
–
–
PLAN:
Labs and Diagnostic Test to be ordered (if applicable)
· –
· –
Pharmacological treatment:
–
Non-Pharmacologic treatment:
Education (provide the most relevant ones tailored to your patient)
Follow-ups/Referrals
References (in APA Style)
Examples
Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).
ISBN 978-0-8261-3424-0
Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010
(25th ed.). Print (The 5-Minute Consult Series).
image1.png
,
Copyright © 2018 by Elsevier Inc. All rights reserved.
Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests, 6th Edition
Iron-Deficiency Anemia
Case Study
A 72-year-old man developed chest pain whenever he was physically active. The pain ceased on
stopping his activity. He has no history of heart or lung disease. His physical examination was
normal except for notable pallor.
Studies Result
Electrocardiogram (EKG), p. 485 Ischemia noted in anterior leads
Chest x-ray study, p. 956 No active disease
Complete blood count (CBC), p.
156
Red blood cell (RBC) count, p.
396
2.1 million/mm (normal: 4.7–6.1 million/mm)
RBC indices, p. 399
Mean corpuscular volume
(MCV)
72 mm 3 (normal: 80–95 mm
3 )
Mean corpuscular hemoglobin
(MCH)
22 pg (normal: 27–31 pg)
Mean corpuscular hemoglobin
concentration (MCHC)
21 pg (normal: 27–31 pg)
Red blood cell distribution width
(RDW)
9% (normal: 11%–14.5%)
Hemoglobin (Hgb), p. 251 5.4 g/dL (normal: 14–18 g/dL)
Hematocrit (Hct), p. 248 18% (normal: 42%–52%)
White blood cell (WBC) count, p.
466
7800/mm 3 (normal: 4,500–10,000/mcL)
WBC differential count, p. 466 Normal differential
Platelet count (thrombocyte
count), p. 362
Within normal limits (WNL) (normal: 150,000–
400,000/mm 3 )
Half-life of RBC 26–30 days (normal)
Liver/spleen ratio, p. 750 1:1 (normal)
Spleen/pericardium ratio <2:1 (normal)
Reticulocyte count, p. 407 3.0% (normal: 0.5%–2.0%)
Haptoglobin, p. 245 122 mg/dL (normal: 100–150 mg/dL)
Blood typing, p. 114 O+
Iron level studies, p. 287
Iron 42 (normal: 65–175 mcg/dL)
Total iron-binding capacity
(TIBC)
500 (normal: 250–420 mcg/dL)
Transferrin (siderophilin) 200 mg/dL (normal: 215–365 mg/dL)
Transferrin saturation 15% (normal: 20%–50%)
Case Studies
Copyright © 2018 by Elsevier Inc. All rights reserved.
2
Ferritin, p. 211 8 ng/mL (normal: 12–300 ng/mL)
Vitamin B12, p. 460 140 pg/mL (normal: 100–700 pg/mL)
Folic acid, p. 218 12 mg/mL (normal: 5–20 mg/mL or 14–34 mmol/L)
Diagnostic Analysis
The patient was found to be significantly anemic. His angina was related to his anemia. His
normal RBC survival studies and normal haptoglobin eliminated the possibility of hemolysis..
His RBCs were small and hypochromic. His iron studies were compatible with iron deficiency.
His marrow was inadequate for the degree of anemia because his iron level was reduced.
On transfusion of O-positive blood, his angina disappeared. While receiving his third unit of
packed RBCs, he developed an elevated temperature to 38.5°C, muscle aches, and back pain.
The transfusion was stopped, and the following studies were performed:
Studies Results
Hgb, p. 251 7.6 g/dL
Hct, p. 248 24%
Direct Coombs test, p. 157 Positive; agglutination (normal: negative)
Platelet count, p. 362 85,000/mm 3
Platelet antibody, p. 360 Positive (normal: negative)
Haptoglobin, p. 245 78 mg/dL
Diagnostic Analysis
The patient was experiencing a blood transfusion incompatibility reaction. His direct Coombs
test and haptoglobin studies indicated some hemolysis because of the reaction. His platelet count
dropped because of antiplatelet antibodies, probably the same ABO antibodies that caused the
RBC reaction.
He was given iron orally over the next 3 weeks, and his Hgb level improved. A rectal
examination indicated that his stool was positive for occult blood. Colonoscopy indicated a right-
side colon cancer, which was removed 4 weeks after his initial presentation. He tolerated the
surgery well.
Critical Thinking Questions
1. What was the cause of this patient's iron-deficiency anemia?
2. Explain the relationship between anemia and angina.
3. Would your recommend B12 and Folic Acid to this patient? Explain your rationale for
the answer
4. What other questions would you ask to this patient and what would be your rationale for
them?
