Students must post one interesting case that he/she has seen in the clinical The case
Students must post one interesting case that he/she has seen in the clinical The case should be an unusual diagnosis, or a complex case that required in-depth evaluation 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.
In order to receive grade points for SOAP notes, the notes must be approved by the deadlines specified on the course assignments page. 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.
Students must post one interesting case that he/she has seen in the clinical The case should be an unusual diagnosis, or a complex case that required in-depth evaluation on the student’s part.
The focus of the presentation must reflect the learning objectives of the course and drawn from the current clinical setting of the student practice site. The evaluation of the presentation is based on the following: Criteria Points Chief Complaint & pertinent history 10 Pertinent exam and diagnostics
10 Working diagnosis with supporting criteria 5 Management plan 5 Epidemiological data -cited from literature 10 Evidenced based rationale for treatment (literature based) 10 Analysis of self-care and family issues r/t diagnosis and treatment plan 20 Evaluation parameters to be used (or were used) to determine outcomes 10 Identify major “lessons learned” and how it may affect your future practice 20 Total100
Expert Answer and Explanation
Episodic/Focused SOAP Note
Patient Information:
Mrs. B is a 67-years-old Caucasian female.
S.
CC: “I feel like my throat is sore; I have a headache and persistent dry cough.”
HPI: Mrs. B is a 67-years old Caucasian female to come to the medical facility complaining of a headache, sore throat, and dry cough that is persistent. The patient mentions that the signs stared by a flue with a running nose two weeks ago. However, the signs became severe three days ago. She rates the pain she feels on a scale of 7/10.
Onset: Two weeks ago.
Location: Respiratory region.
Duration: The pain has been increasing since two weeks ago.
Characteristics: The patient coughs a lot and complains of headaches and high fever.
Aggravating Factors: The disease is aggravated by cold weather.
Relieving Factors: Drinking a lot of water and resting.
Treatment: Plenty of fluids and bed rest.
Current Medications: OTC Motrin and Aspirin
Allergies: No allergy
PMH:
Medication Intolerances: She has not medical intolerance.
Chronic Illnesses/Major traumas: She does not have any chronic or major condition.
Screening Hx/Immunizations Hx: The patient received pneumonia and malaria immunizations seven months ago. Since then, she has not been vaccinated again.
Hospitalizations/Surgeries: She underwent C-section surgery two years ago.
Fam Hx: The patient lives in a family of three siblings. Both her parents are alive. However, her father is suffering from well-controlled diabetes, and her mother has well-controlled arthritis. Her younger brother has asthma. Her maternal grandmother died of cancer.
Soc Hx: The patient is a nurse working in a nursing home. Her work is to care for older patients who cannot conduct ADLs by themselves. She is married with one child about two years old. She is also a strong catholic follower. She does not smoke, use alcohol, or take drugs. She likes working out, especially on the weekends.
ROS:
GENERAL: The patient has a fever, dry, persistent cough, weakness, and fatigue.
HEENT: Head: She has a headache. Eyes: No vision problems. Ears, Nose, Throat: No ear infections. She has a sore throat and a stuffy nose.
SKIN: No skin diseases.
CARDIOVASCULAR: No chest pain or any other cardiovascular condition.
RESPIRATORY: She has difficulty breathing.
GASTROINTESTINAL: She does not have any gastrointestinal disease
GENITOURINARY: She sees her period regularly. The last time she saw her period was last month.
NEUROLOGICAL: No neurological disorder.
MUSCULOSKELETAL: Reports of body and muscle pains.
HEMATOLOGIC: No amenia.
LYMPHATICS: No history of lymphatic conditions.
ENDOCRINOLOGIC: No endocrinologic conditions.
PSYCHIATRIC: No psychiatric condition.
BREAST: No breast diseases.
ALLERGIES: No report of any form of allergy.
O.
Vitals: Her height is 154 cm, weight 79 kg, RR 18, HR 65, BT 38.7 degrees centigrade, and BP 127/90.
Physical exam: Observation and palpation were the main strategies used to conduct the physical exam (Abraham, Perkins, Vilke & Coyne, 2016). The patient was seen coughing persistently, and her nose was also stuffy. She was so fatigued that he could no sit. When touched, it was found that the patient’s body was hot.
Diagnostic results: The diagnostic test that might be ordered in this situation is the Polymerase reaction test (PRT). According to Li et l. (2017), this test is the most sensitive way of testing influenzas compared to any other test. It can be done when the patient is in the doctor’s office. The laboratory tests that can be done to detect the disease include Serology viral culture and rapid molecular assays.
Differential Diagnosis
- Influenza Virus
- Acute Respiratory Distress Syndrome (ARDS)
- Covid-19 Virus
- HIV/AIDS
- Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-Cov-2)
Primary diagnosis
Influenza is the primary diagnosis for this case. Li et l. (2017) note that Influenza is a virus that attacks a patient’s breathing system. The parts that can be most affected by the disease include the throat, nose, and lungs. The disease can also be called flu. However, it should not be mistaken by the flu and causes stomach diseases. Some of the symptoms of the disease include aching muscles, weakness and fatigue, chills, and sweats, fever over 100.2 F, sore throat, headache, persistent cough, and nasal congestion.
This disease has been selected as the primary diagnosis because the patient has shown more than 99% of the symptoms highlighted above. The difference between this condition and the other diagnoses is that a patient with Influenza mostly experiences dry cough and is persistent (Wu et al., 2020).
P
Rapid antigen testing is another testing that can be done to fast-track the disease and what causes it. Wu et al. (2020) argue that on many occasions, Influenza can be treated by quality rest and drinking a lot of fluids. However, if the condition worsens, the patient should be prescribed antiviral medications, such as Rapivab, Tamiflu, and Relenza (Vanderbeke et al., 2018).
These medications will focus on suppressing the virus in the body. If the patient has difficulty breathing, she can be prescribed Zanamivir or put on a ventilator. Education should be focused on helping the patient fight the disease and minimize the rate of infection. Observing a balanced diet is a form of non-medication treatment.
References
Abraham, M. K., Perkins, J., Vilke, G. M., & Coyne, C. J. (2016). Influenza in the emergency department: vaccination, diagnosis, and treatment: clinical practice paper approved by American Academy of Emergency Medicine Clinical Guidelines Committee. The Journal of emergency medicine, 50(3), 536-542. https://doi.org/10.1016/j.jemermed.2015.10.013
Li, H., Yang, S. G., Gu, L., Zhang, Y., Yan, X. X., Liang, Z. A., … & Yu, K. J. (2017). Effect of low‐to‐moderate‐dose corticosteroids on mortality of hospitalized adolescents and adults with influenza A (H1N1) pdm09 viral pneumonia. Influenza and other respiratory viruses, 11(4), 345-354. https://doi.org/10.1111/irv.12456
Vanderbeke, L., Spriet, I., Breynaert, C., Rijnders, B. J., Verweij, P. E., & Wauters, J. (2018). Invasive pulmonary aspergillosis complicating severe influenza: epidemiology, diagnosis and treatment. Current opinion in infectious diseases, 31(6), 471-480. doi: 10.1097/QCO.0000000000000504
Wu, X., Cai, Y., Huang, X., Yu, X., Zhao, L., Wang, F., … & Lu, B. (2020). Co-infection with SARS-CoV-2 and influenza A virus in patient with pneumonia, China. Emerging infectious diseases, 26(6), 1324. doi: 10.3201/eid2606.200299
| Criteria | Points | Competent | Need Improvement | Not Acceptable | Score |
| Subjective (35 points) | Provides complete, concise, and accurate information which is well organized and easy to understand. | Provides most of the pertinent information but is not well organized and/or is slightly challenging to understand. May be missing pertinent negative information (e.g., patient denies…). | Limited or no summary of pertinent information, is organized poorly, contains inaccurate information, and/or is difficult to understand. | ||
| Chief complaint | 5 | 5 | 3 | 1 | |
| HPI | 10 | 10 | 8 | 6 | |
| Relevant PMH & FH | 5 | 5 | 3 | 1 | |
| ROS | 10 | 10 | 8 | 6 | |
| Currents: Allergies, Meds/OTCs, Tobacco, Immunizations, Diet, Exercise, Sleep | 5 | 5 | 3 | 1 |
| Objective (40 points) | Provides complete, concise, and accurate information which is well organized and easy to understand. | Provides most of the pertinent information but is not well organized and/or is slightly challenging to understand. May be missing pertinent negative information | Limited or no summary of pertinent information, is organized poorly, contains inaccurate information, and/or is difficult to understand. |
| (e.g., patient denies) | |||||
| General survey (Describe the state of the patient at the time of the examination) | 10 | 10 | 8 | 6 | |
| Vital signs, wt., BMI | 10 | 10 | 8 | 6 | |
| Physical exam-systematic, organized and thorough and related to the reason of the visit | 20 | 20 | 18 | 16 | |
| Diagnosis/ Differentials Diagnosis (10 points) | Main diagnosis/ Differentials Diagnosis is supported by the objective and subjective assessment and rationale for choosing the diagnosis is supported by the evidence | Main diagnosis/ Differentials Diagnosis is supported by the objective and subjective assessment but the rationale for choosing the diagnosis is not supported by the evidence | Main diagnosis/ Differentials Diagnosis is not supported by the objective and subjective assessment and the rationale for choosing the diagnosis is not supported by the evidence |
| Diagnosis/ (Assessment) | 5 | 5 | 3 | 1 | |
| List of differentials supported by S+O findings (5 points) Must provide 3 differential diagnoses with one citation for each diagnosis. | 5 | 5 | 3 | 1 | |
| Plan of care (10 Points) | Complete and appropriate plan for the main problem and other active problems. Includes pharmacologic | Mostly complete and appropriate plan for the main problem and other active problems. May be missing | Missing or inappropriate treatment plan for the main problem and other active problems. | ||
| and/or nonpharmacologic and/or complete sig components. | appropriate nonpharmacologic treatments and/or sig components. | ||||
| Diagnostic tests/therapies/medications | 5 | 5 | 3 | 1 | |
| Follow-up/Pt. Education and Health Promotion | 5 | 5 | 3 | 1 | |
| References (5 Points) | Provides a complete and appropriate list of references that are in APA format. | References listed are appropriate (i.e. guidelines or primary), but not complete and some may be missing. Not APA formatted. | References missing or very limited. References listed are inappropriate (i.e. tertiary) and/or not relevant. | ||
| References | 5 | 5 | 3 | 1 | |
| Total | 100 |
