| SOAP Note Form | |||
| S/ Identifying Information: (initials, age/DOB, gender, reliability) | Family Hx:
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| Personal/Social Hx: | |||
| Chief Complaint/RFE: | |||
| Hx Present Illness: (7 Variables but do not list as such) | |||
| CURRENT HEALTH | |||
| Medications: | |||
| Allergies: | |||
| Last PE & Screenings: | |||
| Immunization Status: | |||
| LMP & Birth Control (if applicable) | |||
| PMH | |||
| Illnesses & Trauma: | |||
| Hospitalizations/Surgeries: | |||
| OB Hx/Sexual Hx: | |||
| Emotional/Psy Hx: | |||
| REVIEW OF SYSTEMS | |||
| General | |||
| Nutrition | |||
| Skin/Hair/Nails | |||
| HEENT | |||
| Breasts | |||
| Respiratory | |||
| CV/peripheral vascular
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| GI | |||
| GU | |||
| MSK | |||
| Psych | |||
| Neuro | |||
| Lymph/Heme/Endocrine | |||
| O/ Physical Exam: T: P: R: BP: HT: WT: BMI: | |||
| General | |||
| Skin | |||
| Head | |||
| EENT | |||
| Neck | |||
| Breasts/Chest | |||
| Lungs | |||
| Heart/ perip vascular | |||
| Abdomen | |||
| Genitalia/Rectum | |||
| Lymph | |||
| MSK | |||
| Neuro | |||
| Medical Dx: (2max) | Rule Outs (only if applicable): | ||
| Health Profile: | |||
| age/gender/racial risks: | |||
| Pertinent Positives:(1DX) | |||
| personal/family: | |||
| screening needs: | |||
| Pertinent Negatives: | counseling needs: | ||
| Immunization/chemo needs: | |||
| Differential DX:(3-5) | Alteration in Health Prevention R/T: | ||
| Screening deficits: | |||
| Counseling deficits: | |||
| Nursing Dx: | Immunization/chemo deficits: | ||
| I. PLAN: Do separate sections in the plan to include: Max 1-2 pages
Diagnostics:
Medications/Treatments:
Education:
Follow-up:
Referrals:
Prevention Plan:
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| II. Rationale: ( Max 2 pages) |
| III. Patho: (Max 2 pages) |
Mixed Up Soap Note
Name
Institution
- What type of history will you obtain for this visit?
- Presenting complain
- History of presenting complaint
- Past medical history (Sataloff, 2019)
- Drug history
- Family history
- Social history
- What additional history would you obtain from the family that is significant to A.J.’s situation
- Family history e.g. Cardiac and diabetes history
- Presence of genetic conditions in the family
- Practice using clinical reasoning and list possible diagnoses for A.J. based on the subjective information provided
- Muscle or tendon injury
- Medial tibial stress syndrome
- Stress fracture,
- Exertional compartment syndrome
- Nerve entrapment
- For each of the following:
- Medical Diagnosis: Muscle or tendon injury:
- Pathophysiology
- Muscle strain occurs from overstretched muscles and is common among sporting people. Symptoms include leg pain and mobility difficulties among others.
- Muscle strains cause excessive fiber stretching due to exertion of tensile force at the muscle. The pathophysiological process is characterized by destruction, repair and remodeling. Destruction involves tearing and myofibrils necrosis, creation of hematoma and division of inflammatory cells (Bengtsson, Ekstrand, Waldén & Hägglund, 2017). Repair and remodeling phases involve necrotic tissue phagocytosis, myofibrils regeneration and concomitant development of connective scar tissue, neoformation of vessels and growth of neurons also occur (Hamilton et al., 2020) MIXED UP SOAP NOTE – Nurs 5220 Advanced Health Assessment
- ICD 10 code: ICD-10-CM Code S86
- Diagnosis 2: Medial tibial stress syndrome
- Pathophysiology:
- Clinical exercise induced pain caused by repetitive loading stress during running and jumping and triggered on palpation over a length of ≥5consecutive centimeters. It occurs along the posteromedial tibial border.
- Foot inversion by dorsiflexes of the tibialis anterior is followed by extension of the great toe. Other toes extend causing pain and dysfuctions.
- ICD-10-CM Diagnosis Code S83.132A
- Differential diagnosis, 3-5 Differentials
- Stress fracture
- Tiny cracks in bones caused by repetitive force, often from overuse — such as repeatedly jumping up and down or running long distances. Stress fractures can also develop from normal use of a bone that’s weakened by a condition such as osteoporosis.
- ICD-10-CM Diagnosis Code M84.35
- Exertional compartment syndrome
- It is associated with pain and pressure on the leg due to failure of muscle expansion on the affected tissues. It causes inflammation, pain and disability of arms and legs. It is nerve condition or exercise induced.
- ICD-10-CM Diagnosis Code M79.A22 (ICD10data, 2018).
- Nerve entrapment
- It is characterized by pain, tingling, numbness and muscle weakness. It is a medical condition resulting from direct exertion of pressure on the nerves (Black, Brindle & Honaker, 2016). Localized structural changes and microvascular function interferences cause dysfunction of peripheral-nerves (Kastenschmidt, Mannaa, Muñoz & Villalta, 2019).
- ICD-10-CM Diagnosis Code S84.02XD
- Pertinent positives
- muscle injury;
- pain
- Pertinent negatives
- Broken bone
References
Kastenschmidt, J. M., Mannaa, A. H., Muñoz, K. J., & Villalta, S. A. (2019). Immune System Regulation of Muscle Injury and Disease. In Muscle Gene Therapy (pp. 121-139). Springer, Cham.
Hamilton, B., Pollock, N., Reurink, G., de Vos, R. J., Purdam, C., & Thorborg, K. (2020). Muscle Injury Classification and Grading Systems. In Prevention and Rehabilitation of Hamstring Injuries (pp. 189-198). Springer, Cham.
Bengtsson, H., Ekstrand, J., Waldén, M., & Hägglund, M. (2017). No difference in muscle injury rates during professional football matches preceded by three to five days of recovery. British Journal of Sports Medicine, 51(4), 294-294.
Black, J. M., Brindle, C. T., & Honaker, J. S. (2016). Differential diagnosis of suspected deep tissue injury. International wound journal, 13(4), 531-539.
ICD10data. (2018). The Web’s Free 2019/2020 ICD-10-CM/PCS Medical Coding Reference. Retrieved from https://www.icd10data.com/
Sataloff, R. T. (2019). Patient history. Obesity and Voice, 65. MIXED UP SOAP NOTE – Nurs 5220 Advanced Health Assessment