Review the following case study. construct a subjective data set for the case from the information provided. ? Structure the subjective data set in the format provided in your
- Review the following case study.
- construct a subjective data set for the case from the information provided.
- Structure the subjective data set in the format provided in your lecture materials.
NU610 Unit 3 Case Study
A 36-year-old female with a medical history of Multiple Sclerosis (MS) complains of constantly feeling tired even after a period of rest or sleep. She was diagnosed with MS 3 years ago and has been on Interferon. As a wife and mother of 2 with a full-time job, she states that by the end of the day, she has no energy whatsoever. The patient explains that she began noticing her lack of energy and tiredness a few months back, but it has gotten progressively worse. She also mentions that she has missed several days at work over the last 4 weeks because after getting showered and dressed, she had no energy left to go to work. Reports occasional glass of wine on the weekends, denies tobacco or illicit drug use. She has tried some CBD oil to help with energy without relief. Reports sleeping more than eight hours a night while needing several naps throughout the day. She reports an uncomfortable buzzing sensation traveling from the neck to the spine with what sounds like a Lhermitte’s sign. She denies loss of bowel or bladder. She denies fever, chills, weight loss, or weight gain. She reports some nasal congestion but contributes to allergies which she takes cetirizine 10 mg PO daily. Reports she is up to date on her pap smear. She does a monthly self-breast exam, which she denies concerns about. She saw her dentist and eye doctor within the last year and has no issues or concerns. Reports her mother, who is alive, has diabetes and hypertension. Her father and siblings are also alive without any health issues. She has an aunt on her mother’s side who also had MS and currently uses a wheelchair. She is alert and oriented to person, place, time, and situation. Does not appear in acute distress, is well-developed, and is slightly obese in the abdominal section. Skin is dry, warm, and intact. Normocephalic, neck supple, no thyromegaly. PERRLA is about 4mm pupil size. Conjunctivae rim pale. Optic fundi examined revealed a uniform red to pink color; the disk is pale pink, vessels emanate from the optic cup, and the fovea was slightly darker. Retinal vessels are free from hemorrhages or exudates. Face symmetrical. No lymphadenopathy. The oral mucosa is pink and moist. Heart rate bradycardic at 56 beats per minute but regular without pauses or extra beats. Lungs diminished bilaterally but otherwise clear. Abdomen soft, non-distended, bowel sounds normoactive in all four quadrants. No suprapubic or CVA tenderness. Able to differentiate between light and deep tough, no dysmetria or ataxia, normal alternating hand movements, gait steady. Muscle tone inspected and palpated, free from fasciculation, tenderness, or atrophy. Strength 5/5 in all extremities.
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SOAP Note _______ NU___:_________ Herzing University |
Name:_________________________ Typhon Encounter #: _____________________ Comprehensive:____Focused:____ |
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S: SUBJECTIVE DATA |
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CC: |
What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased. |
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HPI: |
Use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary] |
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PMH: |
This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible. |
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ALLERGIES |
State the offending medication/food and the reactions. |
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MEDICATIONS |
Names, dosages, and routes of administration along with indication of use. |
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SH |
Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources. |
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FH |
Use terms like maternal, paternal, and the diseases along with the ages they were deceased or diagnosed if known. |
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HEALTH PROMOTION & MAINTENANCE |
Required for all SOAP notes: Immunizations, exercise, diet, etc. Remember to use the United States Clinical Preventative Services Task Force (USPSTF) for age-appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines. Other wellness visits including but not limited to dental and eye exams. |
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ROS (put N/A in sections not completed day of exam) |
Constitutional |
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Head |
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Eyes |
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Ears, Nose, Mouth, Throat |
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Neck |
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Cardiovascular/Peripheral Vascular |
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Respiratory |
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Breast |
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Gastrointestinal |
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Genitourinary |
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Musculoskeletal |
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Integumentary |
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Neurological |
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Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7) |
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Endocrine |
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Hematologic/Lymphatic |
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Allergic/Immunologic |
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Other |
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O: OBJECTIVE DATA |
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VITALS: |
HR: |
RR: |
BP: |
Temp: |
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SpO2%: |
Ht: |
Wt: |
BMI: |
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Age: |
LMP: |
PAIN: |
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PHYSICAL EXAM (Pertinent data related to presenting problem or visit type. Put N/A in sections not completed day of exam) |
General Appearance |
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Head |
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Eyes |
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ENT, Mouth |
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Neck |
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Cardiovascular/Peripheral Vascular |
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Respiratory |
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Breast |
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Gastrointestinal |
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Genitourinary Male |
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· External Exam |
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· Internal Exam |
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Genitourinary Female |
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· External Exam |
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· Internal Exam |
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Musculoskeletal |
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Integumentary |
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Neurological |
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Psychiatric |
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Endocrine |
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Hematologic/Lymphatic |
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Allergic/Immunologic |
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Other |
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A: ASSESSMENT AND DIAGNOSIS |
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DIAGNOSIS |
ICD-10 CODES |
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PRIORITIZE DIAGNOSIS |
1. |
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2. |
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3. |
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VISIT CODES |
CPT BILLING CODES |
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DIAGNOSTICS |
POC TESTING |
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TESTS REVIEWED |
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P: PLAN |
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ACTIONS |
1. |
Diagnosis: Diagnostics Order: labs, diagnostics testing (tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your work up for the patient’s chief complaint.) Therapeutic: changes in meds, skin care, counseling, include full prescribing information for any pharmacologic interventions including quantity and number of refills for any new or refilled medications. (Ex: Amoxicillin 500mg, PO, q12h, x 7 days, #14, no refills) Education: information clients need in order to address their health problems. Include follow-up care. Anticipatory guidance and counseling. Consultation/Collaboration: referrals or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning. |
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2. |
Diagnosis: Diagnostics Order: Therapeutic: Education: Consultation/Collaboration: |
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3. |
Diagnosis: Diagnostics Order: Therapeutic: Education: Consultation/Collaboration: |
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PREVENTITIVE (Used for comprehensive exams) |
Enter Guidance, Health Promotion, and/or Disease Prevention for patient, family, and/or caregiver. |
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FOLLOW UP |
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