Discussion Topic: Soap Note External otitis

Requirements

– The discussion must address the topic

– Rationale must be provided mainly in the differential diagnosis

– Use at least 600 words (no included 1st page or references in the 600 words)

– May use examples from your nursing practice

– Formatted and cited in current APA 7

– Use 3 academic sources, not older than 5 years. Not Websites are allowed.

– Plagiarism is NOT permitted

I have attached the SOAP note template, a SOAP note sample, and the rubric.

Discussion Topic:
Soap Note

Requirements

– The discussion must address the topic

– Rationale must be provided mainly in the differential diagnosis

– Use at least 600 words (no included 1st page or references in the 600 words)

– May use examples from your nursing practice

– Formatted and cited in current APA 7

– Use 3 academic sources, not older than 5 years. Not Websites are allowed.

– Plagiarism is NOT permitted

I have attached the SOAP note template, a SOAP note sample, and the rubric.

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 7th Edition.

Differential diagnosis (minimum 4)

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Student’s Name

Miami Regional University

Date of Encounter: Mo/day/year

Preceptor/Clinical Site: MSN5600L Class

Clinical Instructor: Patricio Bidart MSN, APRN-IP, FNP-C

Soap Note # _____ Main Diagnosis: Dx: Herpes Zoster

PATIENT INFORMATION

Name: Ms. GP

Age: 78

Gender at Birth: Female

Gender Identity: Female

Source: Patient

Allergies: Peanut. Iodine

Current Medications:

 Insulin Lantus 100 u/ml 15 unit in the morning and at bedtime

 Metformin 500 mg 1 tablet PO once a day

 Atorvastatin 20 mg 1 tablet PO at bedtime

PMH:

 Diabetes mellitus type II

 Hyperlipidemia

 Varicella (Chickenpox) at the age of 20 year-old

Immunizations: Flu vaccine in 2020, Covid -19 (Pfizer) in 2021

Preventive Care: Wellness exam on 03/2021

Surgical History: appendicectomy 20 years ago

Family History: daughter 48 years old / hyperlipidemia

Social History: Patient is widow, lives with her daughter. Catholic religion. No alcohol. No

smoker. No history of drug used, sedentary lifestyle. Does not work.

Sexual Orientation: Straight

Nutrition History: Regular diet, low in carbohydrates and fat.

Subjective Data:

Chief Complaint: I have been feeling itching and pain on my right lower back” started 3 day

ago.

Symptom analysis/HPI: The patient is Ms. GP is 78-year-old Hispanic woman, who is

complaining about itching, pain or tingling on her right lower back. Patient stated that 3 days ago

she started to feel an increase in burning sensation on the area taking all right lower back and

don’t relieve the pain with analgesic, she stated that wear any clothes that touch the area is very

uncomfortable. Denies any episodes of fever but she feels fatigue and chills and mild headache.

She stated that today in the morning she feel worse and noted some redness in the area and

decided to come to the clinic to PCP evaluation.

Review of Systems (ROS)

CONSTITUTIONAL: fatigue, chills, denies weakness, no thirsty, no loss of weight. No fever.

NEUROLOGIC: mild headache, no dizziness, no changes in LOC, no loss of strength or

weakness/paresis/paralysis on extremities, no Hx of tremors or seizures.

HEENT: denies any head injury, denies any pain

 Eyes: patient denies blurred vision, no diplopia, no wear glasses for reading

 Ears: patient denies tinnitus, ear pain, no ear drainage through ear canal.

 Nose: no presence of nasal obstruction, no nasal discharge, denies nasal bleeding. (No

epistaxis)

 Thr