Typing Template for SOAP notes: A Sample for NU664B and NU665B

Student A. Sample

Online Department of Nursing, Regis College

NU665: Primary Care of the Family II

Dr. Professor’s Name

Date:

Typing Template for SOAP notes: A Sample for NU664B and NU665B

Assessment

This is the differential diagnosis section. List FOUR differential / working diagnoses. One of these will be your final diagnosis. For EACH of your diagnoses, list a brief rationale indicating why this diagnosis should be considered or not considered as the final diagnosis. Include references used to guide your thinking.

 

 

 

 

Final Diagnosis:

Plan

All plans until you graduate contain the following elements. If an item does not apply to the particular situation, please indicate not applicable or not needed at this time. If it’s not indicated, it is assumed to not have been addressed.

Pharmacology

Medications—both prescription and OTC—go here. Write out your prescription meds just like a prescription.

Non-Pharmacology

What non-pharmacologic interventions do you recommend for your patient?

Diagnostics

Are there any lab tests, radiology, or other diagnostics you would like to order? Remember to think primary care. No troponins or bedside stat echos in the office.

Consults/Referrals

Would you like to phone a friend? Should they follow up with a specialist for additional or further care?

Patient Education

What important information do you need to make certain they know? Don’t forget about serious medication interactions or OCP.

Follow Up

Think about how much leeway you want to give this patient before someone lays eyes on them again? One week? Two? What should they do if they experience new or worsening symptoms?

Sample Plan

Here is how this needs to look on i-Human submissions: (This is a sample only—do not include in your submission.)

Pharmacology:

Ramipril 10mg 1 tablet PO QD

Norvasc 5mg 1 tablet PO QHS

HCTZ 12.5mg 1 tablet PO QAM

(more if needed)

Non-pharmacology

DASH diet

Lifestyle modifications: exercise, etc.

Avoid caffeine and other stimulants

(more if needed)

Labs

CBC (anemia, “paleness,” fatigue)

CMP (liver function, renal function, electrolytes, nutrition status)

BNP (cardiac dysfunction)

Microalbumin (kidney function—due annually for htn/dm patients)

(more if needed)

Diagnostics

EKG

ECHO

Stress test

Sleep study

(more if needed)

Patient education

Compression stockings may help with the edema as will reducing the calcium channel blocker. You need to check your blood pressure twice a day before you take your medications and keep a log. Please bring this log to your appointments.

Address the benefits and limitations to each medication. Address common side effects and the patient goals. Also, address common education topics.

(more if needed)

Referrals

Cardiology

(more if needed)

Follow up

Follow-up appointment in 1 week to address medication changes and review additional laboratory results (CITATIONsA, 2020; CITATIONsB, 2020)

References

American Psychological Association. (2020). Publication Manual of the American Psychological Association (7th ed.). American Psychological Association.

Daresh, J. C. (2004). Beginning the assistant principalship: A practical guide for new school administrators. Corwin.

Herbst-Damm, K. L., & Kulik, J. A. (2005). Volunteer support, marital status, and the survival times of terminally ill patients. Health Psychology, 24, 225–229. doi:10.1037/0278-6133.24.2.225

U.S. Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute. (2003). Managing asthma: A guide for schools (NIH Publication No. 02-2650). Retrieved from http://www.nhlbi.nih.gov/
health/prof/asthma/asth_sch.pdf

Reflective Post to Alicia Schlicher

Four differential diagnoses:

1.     Atopic dermatitis- Huang et al., (2018) discussed the incidence of atopic dermatitis in children reporting that this skin condition can progress to significant morbidity rates causing infectious complications. Research describes atopic dermatitis as a common and chronic skin disease within the childhood population; whereas itching and relapsing symptoms can re-occur at different stages of the disease process (Akan et al., 2020). The patient in this case demonstrated having chronic itching and reoccurrence of symptoms despite current interventions and medication use. Although the patient did not develop an infectious process, it is still likely to occur if the rash is not well controlled. Atopic dermatitis can present as an acute or chronic finding with symptoms consisting of a various distribution of the rash on the body with period of intense pruritis and severity especially occurring at night (Akan et al., 2020). Atopic dermatitis is likely the appropriate diagnosis for the patient.

2.     Psoriasis- Psoriasis is an inflammatory skin disease that can develop within the childhood and adolescent stage, with the tendency to progress to a severe form of psoriasis (Branisteanu et al., 2021). The presentation of this type of skin condition is associated with genetic and trigger risk factors such as increased stress, diet, obesity, and chemical irritants (Branisteanu et al., 2021). The physical appearance of psoriasis can exhibit as scaly small and thin plaques that can develop on the face, skinfolds, or any other area of the body; usually within a symmetric pattern (Murzina, 2020). The patient’s physical examination did not exhibit a rash that consisted of a plaque-like appearance on his body, nor was there mention of genetic or familiar history of psoriasis. Psoriasis is unlikely to be the diagnosis for the patient.

3.     Allergic contact dermatitis- Owen et al., (2018) reported that patients who have atopic dermatitis is at risk of developing allergic contact dermatitis due to the application of different topical medications. Allergic contact dermatitis is prominent in both children and adults and can include common allergens such as lanolin, neomycin and fragrances found in personal skin products (Owen et al., 2018). Allergic contact dermatitis is unlikely to be the correct diagnosis for Taumi because the parents’ response to the interviewing questions reported that they are using fragrance-free and sensitive skin products at home. The parents also confirmed that Taumi did not eat any new foods that could have triggered an allergic response.

4.     Drug-reaction rash- Elzagallaai et al., (2017) reported that drug related reactions are common amongst children because their body systems are more susceptible to the bioavailability of medications; thus, leading to a risk of developing a systemic reaction. The parents reported that the medications helped a little but did not report intolerance or an adverse effect to the medications. Considering that the patient has been taking these medications for quite some time and had not experienced an initial drug reaction would support the reasoning that this diagnosis is unlikely the appropriate diagnosis for the patient.

Diagnosis

Atopic dermatitis

Pharmacology

Continue Diphenhydramine 25mg, 1 tablet by mouth, however, increase the frequency to every 4 to 6 hours as needed at night– which would help to relieve the patient’s pruritus at night and improve sleep. Will plan to reassess the patient after 1 week of taking the medication to see if any resolution in symptoms. Medication should be stopped once there is resolution of symptoms and itch.

Discontinue Hydrocortisone 2% as it is not effective with controlling the skin rash

Discontinue Zyrtec 10mg as it is not effective with controlling the patient’s symptoms

Start Tacrolimus topical 0.03% ointment, apply twice a day to affected areas for 5 days

Start Crisaborole (Eucrisa) 2% ointment, apply to affected areas twice a day for 7 days

Start Children’s Allegra, 5ml oral suspension by mouth every 12 hours as needed for itch or allergic symptoms during the daytime hours

Start Mupirocin 2% ointment, apply to left elbow only, three times per day for 7 days

Non-pharmacology

·      Oatmeal baths to soothe skin irritation

·      Daily warm baths

·      Fragrance-free emollients such as Eucerin cream, Aveeno or Curel; applied to affected areas up to 3 to 4 times a day as needed for moisturizing

·      Use of cool humidification to decrease humidity and keep the environment cool

Labs/Diagnostics

Although there is no definite diagnostic testing for atopic dermatitis, the following lab tests could be useful for providing additional information:

·      Culture swab of skin if evidence of purulent drainage from rash or lesion to rule out possible bacterial skin infection

·      Allergen-specific IgE blood test to determine level of allergens within the body

·      Serum CRP -Research supports the decision of utilizing the CRP level as a diagnostic measure; the CRP level is identified as a systemic marker to determine the severity of atopic dermatitis (Vekaria et al., 2017).

Referrals

·      Referral to allergist for evaluation of possible allergens

·      Dermatology consult to ensure and confirm the appropriate medication skin regimen, as well as further assess the skin rash

Patient Education

1.     Using your fingertip, apply the topical medication to the affected areas of the body and use the palm of your hand to evenly distribute the ointment

2.     Avoid applying the topical medication to the face, including the eyes or mouth; to prevent accidental systemic absorption of the medication

3.     Avoid applying the topical medication to any open wounds or breaks in the skin

4.     Avoid scented skin products, use fragrance-free or sensitive skin products

5.     Apply the topical medication to the skin while it is still damp to aid in absorption and trap in the moisture

6.     Keep Taumi’s fingernails short and trimmed to prevent skin trauma or secondary skin infections

7.     Avoid preparing new foods for Taumi that may trigger an allergic response

8.     Encourage Taumi to wear loose fitting clothing, especially at night for comfort and to prevent perspiration

9.     Teach and encourage Taumi to practice proper hand hygiene to prevent secondary skin infections

10.  Teach and encourage Taumi to avoid scratching the skin as this can worsen the rash and cause skin scarring

11. Ensure adherence and completion of prescription instructions to prevent recurrence of symptoms or a poor response to treatment.

12. Monitor left elbow drainage for changes to amount or consistency of drainage. After applying the Mupirocin ointment, may use a gauze to cover the left elbow to help contain the drainage.

One Health Maintenance

The primary prevention intervention for a health maintenance example would involve Taumi’s parents using good skin care practices; maintaining appropriate daily hygiene practices and the application of fragrance-free or sensitive skin moisturizing products.

One Social Determinant

One social determinant would involve a lack of financial resources to purchase and adhere to the prescribed treatment regimen. Skin products can be expensive causing for a financial strain and delay of treatment and resolution of symptoms. As the nurse practitioner for this patient, I would inform the parents of cost-effective treatment options, and also provide manufacturer discount saving coupons that could be applied towards the prescription co-pay cost.

 References

Akan, A., Dibek-Misirlioglu, E.D., Civelek, E., Vezir, E., & Kocabas, C.N. (2020). Diagnosis of atopic dermatitis in children: Comparison of the Hanifin-Rajka and the United Kingdom working party criteria. Allergologia et Immunopathologia, 48(2), 175-181. https://doi.org/10.1016/j.aller.2019.07.008 

Branisteanu, D.E., Georgescu, S., Serban, I.L., Pinzariu, A.C., Boda, D., Maranduca, M.A., Glod, M.,..Branisteanu, D.C. (2021). Management of psoriasis in children. Experimental and Therapeutic Medicine, 22(6), 1429. https://doi.org/10.3892/etm.2021.10864

Elzagallaai, A., Greff, M.J., & Rieder, M.J. (2017). Adverse drug reactions in children: The double-edged sword of therapeutics. Clinical Pharmacology & Therapeutics, 101(6), 725-735. https://doi.org/10.1002/cpt.677

Huang, E., & Ong, P.Y. (2018). Severe atopic dermatitis in children. Current Allergy and Asthma Reports, 18(35). doi: https://doi.org/10.1007/s11882-018-0788-4

Murzina, E. (2020). Pediatric psoriasis: Clinical features and course. Journal of Biomedical Science, 2(1). https://biomedscis.com/fulltext/pediatric-psoriasis-clinical-features-and-course.ID.000147.php#article-info

Owen, J.L., Vakharia, P.P., & Silverberg, J.I. (2018). The role and diagnosis of allergic contact dermatitis in patients with atopic dermatitis. American Journal of Clinical Dermatology, 19, 293-302. Doi: https://doi.org/10.1007/s40257-017-0340-7

Vekaria, A.S., Brunner, P.M., Aleisa, A.I., Bonomo, L., Lebwohl, M.G., Israel, A., & Guttman-Yassky, E. (2017). Moderate to severe atopic dermatitis patients show increases in serum C-reactive protein levels, correlating with skin disease activity. F1000 Research, 6(2), 1712. doi: 10.12688/f1000research. 12422.2