Soap Hypertension And Depressive Disorder Essay
APA stile, no plagiarism. This is an example of SOAP notes:
Patient Information
Name: Mr. R.G.
Age: 58-year-old
Sex: Male
Source: Patient
Allergies: No known allergies. No seasonal allergies detected
Current Medications: No current medication mentioned by the patient. Soap Hypertension And Depressive Disorder Essay Paper
PMH: The patient has been abusing alcohol but quit two years back. He is suffering from obesity disorder and hypothyroidism.
Immunizations: Immunization is up to date.
History of the Family: Mother- deceased at 70 years, no information related to the cause of his death but was having obesity disorder.
Father still alive: History of Type II diabetes, Hypertension
Soap Notes
Subjective
Chief Complain (CC): the patient came to the facility complaining of heat intolerance, and sweating.
HPI: Mr. R.G he is having an increased nervousness, sweating, and hotness of the body.
ROS
General: Patient appears to be weak and fatigue. He has a loss in the body weight, poor sleep, thirst, nausea, and increased frequency of defection. He also states of losing appetite and shaking. Soap Hypertension And Depressive Disorder Essay Paper
Constitutional: The patient denies of having chest pain, palpitations, shortness of breath, and disorientation.
Respiratory: No shortness of breath with no asthma or seasonal allergies
Cardiovascular: no history of Dyslipidemia, no history of high blood pressure. He has no dyspnea on exertion, there is absent of cough, edema, or heart murmurs.
Gastrointestinal: the patient has nausea but no vomiting. The patient has lost appetite.
GU: He denies vaginal discharge, no irritation in his urinary tract. Soap Hypertension And Depressive Disorder Essay Paper
Objective
Mr. R.G appears to be little disturbed, maintains his eye contact, clearly gives a proper description of how he feels and his age, and the dressing as per the present weather.
Vital Signs: B/P: 105/95 mmHg, Regular pulse of 90 beats per min, Temprature: 96.5; Height: 70 inches; weight: 113 lb: BMI: 16.2.
Clear and normal breathing sounds with no adventitious breathing sounds. Goiter noted on palpation.
Cardiovascular: no apparent distress, fidgeting in the seat, no presence of murmurs and gallops.
Gastrointestinal: soft and non-tendered abdomen when touched.
GU: suprapubic regions are tender to touch
Assessment
Hyperthyroidism, a disease related to Graves’ illness Soap Hypertension And Depressive Disorder Essay Paper
Plan
To acquire the baseline thyroid stimulating hormone assay; prescription of the antithyroid medications such as Carbimazole and propylthiouracil; performing thyroid hormone level using thyroid stimulating hormone blood test.; monitoring the thyroid-stimulating hormone assay at first and the third months, performing radioactive iodine treatment when necessary. In case the thyroid hormone level is not improved, thyroid lobectomy will be performed
Expect intense feedback on your standardized patient SOAP (PEN) notes. The reasons for this include:
Notes improve dramatically if you work at developing this core clinical skill. We use formats very similar to those of USMLE so this experience should help significantly with that exam. Even better, an organized approach to notes REALLY helps in practice, especially when you are most rushed and/or perplexed by a case. The note helps to organize the data, illustrate what items are missing, and prompt clinical reasoning. Even if the case cannot be resolved immediately, a complete and reliable baseline facilitates diagnosis and/or management as the clinical picture evolves – it makes your future work (or that of any subsequent physician) much easier.Soap Hypertension And Depressive Disorder Essay Paper
Strong Hints: (based on feedback from students and faculty)
Specific Components of the SOAP (PEN) Note
History (Subjective):
Note the instructions ask for pertinent positives and negatives from HPI, PMH, RoS, FH, SH. Faculty strongly suggest you write these headings down the left margin of your note before starting as once you start to write the note, it is easy to miss a specific subheading.
HPI: Start with the age, sex, race using the formula of age, sex, race and chief complaint. e.g. “Patient is a 40 yr old white female complaining of (or presenting because of)” If using a patient quote, mark it appropriately.Soap Hypertension And Depressive Disorder Essay Paper
Completely, succinctly describe the presenting complaint. Memorize a template for common problems. (First Aid book p. 25-32) Use the mnemonics or whatever helps you to remember a “script” for common symptoms/conditions, especially pain. Address the pertinent positives and negatives for the specific system in the HPI for completeness (e.g. include shortness of breath, ankle swelling, etc in a presenting complaint of chest pain) Good practice is to end with what the patient thinks or fears as the cause of symptoms.
We suggest a “rule of 4″for each section but individualize to balance getting the data you need in the time available – you must leave plenty of time for PE and discussions with the patient.Soap Hypertension And Depressive Disorder Essay Paper
PMH: Consider 4 items + 1 in women
Shorthand example ~Soap Hypertension And Depressive Disorder Essay Paper
Patient denies past serious illnesses, hospitalizations, surgeries. Tylenol 1-4 /month for headache. Takes no prescription meds, supplements or vitamins. No known allergies. Up to date on immunizations. Cholesterol “low” at health fair 2 yrs ago. No other screening.
SH:
Shorthand example ~
Denies ever used tobacco, illicit drugs. Alcohol 1-4 beers/month. College graduate, schoolteacher, enjoys work. Lives with wife and son (6yrs) daughter (4 yrs). Monogamous, sexually active. No stressors at home/work. Plays basketball on weekends and runs 30 mins twice/week.Soap Hypertension And Depressive Disorder Essay Paper
FH:
Shorthand example (headache case) ~
F67, M64 alive & well. F hypertensive controlled with unknown medication. Sibs (38, 40) no health problems. PGF died aged 54 stroke, no other known heart disease, stroke, HBP, diabetes, cancer in family. No know headache, neurological conditions in family.
RoS: Brief scan of key symptoms in each system. Textbook list is probably too long. But don’t forget mood! Focus on the key items in the differential for each case. What else could explain the symptoms? What other conditions are common in a person of the age/type? RoS is not well addressed in the example notes given in either textbook.Soap Hypertension And Depressive Disorder Essay Paper
Physical Exam: (Objective)
SP sessions and examinations require focused physical examinations. You must select which systems to examine based on the data required to diagnose and/or manage the case. If you do too much PE, you are taking time away from history and negotiation with the patient. You also give the impression you did not know what to do so automatically did everything. The key issues are:
1. Vital Signs:Usually given in the chart but essential to document in the note. If one is abnormal, check for yourself and comment in the note. In specific cases, additional vitals may be required (e.g. orthostatic BPs and pulses in a fainting case).
2. General Impression of Patient: Lots of individual variation in how this is recorded. Keep this brief but comment on:Soap Hypertension And Depressive Disorder Essay Paper
3. Pertinent System(s) Exam: Systematically record the pertinent positive and negative findings for the systems(s) examined using subheadings to organize your findings. Both textbooks give the expected components for each body system (“First Aid” book p. 55, “USMLE” book p.23) and many examples of specific cases. In conditions like diabetes and hypertension that cause systemic damage, prioritize the target organs like fundi, heart size, peripheral nerves and circulation.Soap Hypertension And Depressive Disorder Essay Paper
4. Any Specific Exams: Special items may be appropriate to individual cases. If necessary, do not hesitate to ask the patient for permission to do a “sensitive” examination (breast, prostate, rectal, pelvic) and document the information you receive. If the patient does not consent but you still think the data from the exam is necessary, document “refused” or “declined” and put “arrange pelvic (or other sensitive) exam” in the diagnostic plan.Soap Hypertension And Depressive Disorder Essay Paper
The other specific exams are especially common in elderly patients (e.g. ADLs, IADLs, “get up and go” test) and in children (developmental screening) but include depression screening, MMSE, CAGE questions for alcohol, screens for domestic violence etc. In the exam situation, relevant screening instruments may be provided in the room. Specific items of physical exam include peak flows in asthmatics. Hint: Any unusual piece of equipment or paper in the room usually has a purpose!
Use your judgment about where to best record items such as CAGE, developmental, and domestic violence screening. They may be best in the HPI, RoS or their own heading in the history – but do remember to do and document them when appropriate.Soap Hypertension And Depressive Disorder Essay Paper
If only performing a focused physical makes you really nervous and you don’t want the reviewer to think you just forgot to do something, finish the PE section with a deferred statement e.g. “additional PE deferred” and consider putting items into the follow up plan e.g. “schedule for rectal /prostate examination”.
Differential Diagnosis (Assessment)
This section assesses how well you synthesize the data from the H&P into plausible medical explanations AND your sense of the most probable diagnoses for this presentation in the specific type of patient seen (e.g. severe RIQ abdominal pain could be caused by appendicitis in a child, ovarian or tubal conditions in a woman of reproductive age, diverticular disease in an elder, inguinal hernia in a young man).Soap Hypertension And Depressive Disorder Essay Paper
Follow the instructions noting:
Note: The focus is always on your patient communication and assessment skills, not your ability to guess “the right diagnosis”. Even in USMLE-CS, the scoring system is based on how you conduct the interview and propose a differential and plan. Focus on the most probable explanations for the case and don’t try to impress the examiners with “exotics”.
In the clerkship, a specific diagnosis may not be clear and the patient may have more than one condition to reflect the realities of primary care and geriatrics. Don’t forget to list important comorbidies like hypertension.Soap Hypertension And Depressive Disorder Essay Paper
Diagnostic Plan. (Note USMLE-CS asks only for diagnostic {work-up} plan. In the clerkship formative sessions, you are required to propose BOTH a diagnostic and a management plan). You are limited to the five priority items to obtain necessary diagnostic data for the case. Your ability to logically develop a diagnosis and to discriminate between all the possible tests is being assessed. The items listed above for differential diagnosis also apply to testing. Also see advice on page 54 of “First Aid” textbook.Soap Hypertension And Depressive Disorder Essay Paper
Diagnostic tests could include:
Consultations and referrals are part of management.Soap Hypertension And Depressive Disorder Essay Paper
Management Plan (not included in USMLE-CS)
As you will be residents within two years, we want you to practice proposing initial management of cases. All cases in the SP clerkship sessions are based on conditions/situations covered in the course and help faculty assess how well you use the classroom and didactic materials in working with patients. In primary care, a management plan can include: