SOAP Note
SOAP Note
In this discussion, you consider case studies of abnormal findings from patients in a clinical setting. You determine what history should be collected from the patients, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions.
Your discussion post should be in the SOAP note format, rather than the traditional narrative-style discussion posting format. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in the Week 4 Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.
Case 1: Nose Focused Exam
Richard is a 50-year-old male with nasal congestion, sneezing, rhinorrhea, and postnasal drainage. Richard has struggled with an itchy nose, eyes, palate, and ears for 5 days. As you check his ears and throat for redness and inflammation, you notice him touch his fingers to the bridge of his nose to press and rub there. He says he has taken Mucinex OTC the past two nights to help him breathe while he sleeps. When you ask if the Mucinex has helped at all, he sneers slightly and gestures that the improvement is only minimal.
Richard is alert and oriented. He has pale, boggy nasal mucosa with clear thin secretions and enlarged nasal turbinates, which obstruct airway flow, but his lungs are clear. His tonsils are not enlarged but his throat is mildly erythematous.
(SOAP Note)
To prepare:
- With regard to the case study you were assigned:
- Review this week’s learning resources and consider the insights they provide.
- Consider what history would be necessary to collect from the patient.
- Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition.
- How would the results be used to make a diagnosis?
- Identify at least 10 possible conditions that may be considered in a differential diagnosis for the patient.
References
Sullivan, D. D. (2019). Guide to Clinical Documentation (3rd ed.). Philadelphia, PA: F.A. Davis Company. https://www.fadavis.com/product/nursing/sullivan-clinical-documentation-guide-3
National Institute of Allergy and Infectious Diseases. (2020). Allergic rhinitis. https://www.niaid.nih.gov/diseases-conditions/allergic-rhinitis
Mayo Clinic. (2022). Common cold: Symptoms and causes.https://www.mayoclinic.org/diseases-conditions/common-cold/symptoms-causes/syc-20351605
Centers for Disease Control and Prevention. (2021). Sinusitis: Causes, symptoms, and treatment. https://www.cdc.gov/nchs/fastats/sinusitis.htm
American Academy of Allergy, Asthma & Immunology. (2020). Non-allergic rhinitis. https://www.aaaai.org/conditions-and-treatments/related-conditions/non-allergic-rhinitis
