Acute Exacerbation SOAP Note #2

Acute Exacerbation

You will be required to write two SOAP notes during the course. Both should address the management of an acute problem in an adult or older adult individual who has a chronic disease. For example, an acute onset of respiratory symptoms in a patient with diabetes.

You could also address an acute exacerbation of a chronic problem. For example, a patient with chronic depression presents with an exacerbation or recurrence of depressive symptoms. Another example would be a patient with a history of chronic back pain s/p surgery presents with worsening pain and radicular symptoms. \\\”Thanks Again!\\\”

 

SOAP NOTE ADVICE:

 

Gathering data for the HPI (or subjective section) requires knowledge of underlying disease processes, presenting symptoms of disease and illness, age related risk factors, environmental risk factors, and relevant family and social histories. Remember, you should have a short list of differential diagnoses developed by the time you have finished interviewing the patient.

Your physical exam should help you rule in or out some of those diagnoses.  If needed, further focused diagnostic tests can also help you confirm or rule out a diagnosis.  It is necessary that you gather a very thorough patient history with every patient complaint as diagnoses are most often made by the history information.

 

The interview should be organized and led by you (re-direct the patient back to the questions at hand when they digress).  Consider yourself an “investigator.”  You start by asking more general questions; as the interview goes on your questions become more targeted as your mind goes through the process of ruling in/ruling out illness/disease processes based on the patient responses.  Although you are asking the questions and leading the interview, be sure to be a good listener.  Often times a patient may mention something relevant that you may have not thought to ask about.

 

When writing your soap notes, you want to stay organized so you need to record chief complaints and chronic conditions that are unrelated to the chief complaints in separate paragraphs.  In addition, if a patient has more than one chief complaint that are not related to one another you want to record these in separate paragraphs also. For example, if you have a patient who presents to the office for routine care of DM but who also has been having sinus symptoms, you may approach that note like this:

 

CC: 36 y.o. single white female with a hx of type I IDDM since the age of 16 presents to the office for her routine follow up of DM, and also reports a 2 week history of sinus pain, headache, and nasal congestion. Pt is a reliable historian. 

 

S: Pt reports a 2 week history of frontal headache; frontal sinus pain; ear congestion; clear rhinitis; nasal congestion; pharyngitis; waxing and waning fever with Tmax of 101.  Last temp noted yesterday morning.  She also admits to mild, occasional, dry cough which is worse at night.  Sx are not getting worse, but are also not improving.  Has taken various OTC meds with minimal effect.  Tylenol 650 mg qd to bid prn for fever. 

Has no history of frequent or recurrent URI or sinusitis.  No chronic respiratory illnesses.  NO hx of environmental allergies.  Non smoker/no smoke exposure.  No ill known ill contacts.  Appetite has been fair.  Drinking fluids.  Denies dizziness, SOB, wheezing, chest pain, NV.  LMP-1 week ago, normal.  Uses OCPs as directed.  Denies any chance of pregnancy.  Had 2013 flu vaccine last week at local pharmacy.

 

Pt has a hx of type I IDDM, diagnosed at age 16.  Follows here q4 months for care.  Also follows with endocrinology q3 months for insulin pump management.  Last saw them one month ago.  At that time A1c was stable at 6.4.  Labs in chart reviewed and are UTD-all of them last done in 1/13.

BP-at goal.

Lipids at goal with LDL of 70.  Tchol 136. Trigs 120. 

Urine microalbumin-wnl.  BP at goal.

BUN/CR 22/1.3  eGFR >60. Last ophthalmologyexam-2 months ago. Pt follows with Dr. Smith.  Reports normal exam.  Will call for results. 

Pt does own foot care.

UTD on pneumovax (1/12) and Hep B series (8/12). 

Meds for DM: she is on an ACE Iinhibitor for renal protection and uses Humalog in her insulin pump. 

Appetite has been good.  Following dietary guidelines.  Has seen dietician in past.  Reports morning FBS in low 120s.  Post prandials usually around 150. Denies any lightheadedness, dizziness, syncope, polydipsia/uria/phagia, CP, SOB, NVDC, impairment in skin of feet, numbness/tingling of fingers or toes, infections other than recent URI sx noted above.  NO ER visits or hospitalizations for her DM since last OV.  She is feeling well in terms of her DM, and does not have any questions or concerns about her DM today. 

 

This is just an example of how to set it up.

• Also, please remember this is not a complete H and P, so I think it is best to not do a SOAP note on a new patient (a new patient visit, even for a simple problem, still requires a lot more information than would generally go into a SOAP note).
• As mentioned in previous e mails, the SOAP note format should include the following:

CC: reason for the visit. For example: “ My stomach hurts” or “I am getting headaches”.

S: Subjective data only. A complete “investigation” of the chief complaint. Include any pertinent positives and negatives including relevant PMH, SOC hx, FMH.

The paragraph should start like this:  Mrs. P is a 57 yo female with a PMH of migraines, HTN, and DM, who presents to the office today with a 2 week hx of refractory headaches that are not responding to usual treatment with imitrex.

Note: With medications it is not possible to work through a CC and develop a plan unless you know what meds a patient is taking. In this section of te note you want to list all of the patients medications along with doses and administrations information.  For example: Levothyroxine .112mcg po X1 q day

O: Objective data only. No ROS or subjective information here.

A: A stands for “assessment” or “diagnosis” (not physical assessment, but rather, your assessment of the subjective and objective data you collected. Also known as the “impression” or your list of differential diagnoses).

This is your “assessment” of the data you have collected via the subjective and objective data.

P: This is the treatment plan and it should include pharmacologic and non-pharmacologic treatment, referrals, any patient education, and follow-up information.

 

Solution

 

 

Acute Exacerbation of a Chronic Problem

 

SOAP Note 2

Student name

Clarion/Edinboro University

Nursing 640 Clinical Decision Making III

Lecturer

Date

 

Acute Exacerbation of a Chronic Problem

 

SOAP Note

Patient Initials: A.L.               Age: 69 years old           Race: White       Gender: Female

SUBJECTIVE DATA:

Chief Complaint (CC): “I am getting unexplained headache and I wake up between sleep at night. I also have recurrent suicidal thoughts.”

History of Present Illness (HPI): A.L. is a 69-year-old white female patient who has visited the clinic for a follow-up visit. She was in the clinic for her first visit 2 weeks ago. Her reason for visiting the clinic today is that she needs help with problematic symptoms that started 48 hours ago. As reported by A.L., she has been getting unexplained intermittent headache in the past 2 days and is unable to sleep comfortably for the last two nights due to insomia. She reports feelings of worthlessness currently and has recurrent suicidal thoughts.

During her last visit to the clinic, A.L. was diagnosed with depression due to symptoms which had lasted for 6 months. At that time, she had multiple symptoms including a depressed mood, loss of interest in activities, excessive sleep, lack of energy, and reduced appetite. A.L. also reported anxiety and agitation, feelings of worthlessness, and a mild headache. These symptoms began six months ago as per her initial report and were the reasons for her initial finish. A.L. further states today that she thinks that she will not recover from her current status because she has started to develop other problems since her last visit to the clinic.

Following her diagnosis two weeks ago, the doctor prescribed 2.5 mg of Valium (Diazepam) which she has been taking twice a day for two weeks now. The doctor also prescribed Zoloft (Sertraline) at a dose of 25 mg orally daily. As reported by A.L., her anxiety has reduced significantly since she started to use the drug. However, she reports strange symptoms since she started to use the named medications. These include occasional seizures, vision changes, weakness, and poor memory. She reports that she ignored the symptoms thinking that they will disappear with time and denies drug non-adherence. These strange symptoms that started about 10 days ago, together with those that began 2 days ago, have negatively affected her quality of life.

Medications:

• 5 mg of Valium (Diazepam) twice a day
• Zoloft (Sertraline) at a dose of 25 mg orally daily

Allergies: Denies drug and food allergies.

Past Medical History (PMH): A.L. denies being diagnosed with a serious medical condition before. However, she reports several occasions of fever which were effectively managed using painkillers. The patient cannot recall whether she was hospitalized due to any medical conditions during her childhood.

Past Surgical History (PSH): Denies surgical history.

Sexual/Reproductive History: A.L. reports that she is happily married with two children, a girl and a boy. Her children are currently teenagers and they are in college. A.L. further states that she used Brevicom, an oral contraceptive pill, for 15 years. She is still sexually active.

Personal/Social History: A.L. is a retired accountant. She used to work as the finance manager in a nearby coffee factory. Her husband is a retired teacher who currently owns a private school. The two normally stay at home most of the time because their ability to move around is hampered by their reduced physical mobility. As reported by A.L., she consumes neither alcohol nor cigarettes.

She also denies using illicit drugs such as heroin and cocaine. She is a Christian of the Catholic faith who also acts as a leader in her church. A.L. reports eating a balanced diet full of fruits and vegetables. Before her current symptoms, A.L. used to perform house chores and complete activities of daily living comfortably without difficulties. Completing them has been quite a challenge since she started to fall ill.

Immunization History: A.L.’s medical records indicate that she received all her immunizations according to schedule.

Significant Family History: A.L. has lost both parents. Her mother died three year ago at the age of 82 due to cardiac complications. Her father who was an engineer died 10 years ago at the age 89 years. She has one brother who is still alive and has never been diagnosed with a serious medical condition. Their son and daughter are healthy without any significant medical problems.

Review of Systems:

General: No changes in body weight reported. Denies fever, chills, or constipation. Reports reduced appetite.

HEENT:

Head: No physical head injury reported. Denies a mild headache.

Eyes: Reports changes in vision characterized by blurriness. Visual acuity is good. Sclera is white, conjunctiva is moist and pink.

Ears: No hearing problems reported. Denies ear pain.

Nose: Denies nasal congestion. No runny nose reported. Denies nasal pain.

Throat: Denies pain while swallowing food. Denies soreness in the throat. Denies a cough.

Neck: No neck-related pain reported.

Respiratory: Denies breathing difficulties. Denies chest pain.

Cardiovascular/Peripheral Vascular: No tightness of the chest reported.

Gastrointestinal: Denies stomachache, constipation, or abdominal pain.

Genitourinary: Denies pain in the genitals. Denies vaginal itching. Denies pain during urination. Denies abnormal urination frequency.

Musculoskeletal: No joint pain reported.

Neurologic: Reports unexplained intermittent headache which has lasted for the past 2 days. Denies numbness on fingers and toes.

Psychiatric: Reports insomnia, feelings of worthlessness, and recurrent suicidal ideation. She further reports occasional seizures, vision changes, weakness, and poor memory which started after she began to use the prescribed medications.

Skin: No skin itchiness, rashes, or redness reported.

Hematologic: Denies a history of blood-related disorders such as hemophilia and sickle cell anemia.

Endocrine: Denies abnormal night sweats. Denies excessive thirst or frequent urination. Denies a history of thyroid disease. Reports weakness.

OBJECTIVE DATA:

Physical Exam:

Vital signs:

• Height: 55.8 inches
• Weight: 139 lb
• RR: 20
• HR: 70

. BP: 120/80

• Oxygen saturation: 99%
• Temperature: 95.6 F.

General: A.L. looks healthy and attentive. She is well-groomed and appropriately dressed for the weather. She described her problems clearly.

HEENT:

Head: Head is Normocephalic with no evidence of trauma. Hair is distributed normally throughout the scalp. The scalp has no masses. No evidence of frontal sinus and maxillary sinus tenderness. Lymphadenopathy is absent.

Eyes: Hair on lashes and eyebrows are perfectly distributed. No evidence of lesions on the eye lids, both eyes are without edema. The sclera is white, the conjunctiva is pink and without lesions. The pupil is reactive to light and responds to changes in light intensity. No hemorrhage on the fundus. No corrective lenses. Visual acuity at 20/20.

Ear: The tympanic membranes of both ears are pearly-grey in color and are intact. Both ears respond adequately to changes in sound.

Nose: The nasal mucosa is hairy, pink, and moist and pink. The septum located midline separating the two nostrils into equal halves.

Mouth & Jaws: Mouth mucosa is clear and without ulcers. The throat is not erythematous.

Neck: No evidence of goiter or swelling. No evidence of pain on touching. Neck strength: 5/5.

Chest/Lungs: Both lungs contract and relax properly during exhalation and inhalation respectively. No evidence of lesions or deformity on the chest walls. Absence of adventitious sounds. No wheezing.

Heart/Peripheral Vascular: No murmur. Complete capillary refill takes less than 3 seconds. No bruit in the arteries. Absence of edema in the legs.

Abdomen: The abdomen is soft, no evidence of tenderness, and no masses. No lesions are observed. Percussion of the spleen reveals no evidence of dullness.

Genital/Rectal: No evidence of masses or swelling.

Musculoskeletal: Absence of joint pain or deformity. No ridges on the nails. The patient has a normal gait and there is no evidence of imbalance.

Neurological: Good coordination on fingers and toes. Pain sensitivity is good on both upper and lower limbs.

Skin: A.L.’s skin is clear without rashes, lesions, or dryness. No evidence of erythema on the skin.

Lab tests and other procedures:

• A complete blood count (CBC) test is performed to assess thyroid function: There is normally a link between thyroid dysfunction and depressive symptoms. Excessive and insufficient production of thyroid hormones usually cause mood changes that can be confused to be depression (Mayo Clinic, 2021; Dains et al., 2016). Therefore, a CBC test will help to assess thyroid function to establish whether it might be associated with the current symptoms displayed by patient A.L.
• A psychiatric evaluation using the DSM-5 criteria is conducted to find the actual mental health problem that patient A.L. is suffering from: A patient’s symptoms must meet a number of criteria for the presence of depression to the confirmed (Mayo Clinic, 2021). Using the fifth edition of the diagnostic and statistical manual of mental disorder, the clinician should evaluate A.L.’s symptoms to determine whether they are attributed to depression or something else.
• The patient’s headache is evaluated on a pain scale to determine its severity: A.L. has complained of unexplained intermittent headache that began 2 days ago. It is important that the clinician evaluates her further to establish how severe the headache is before initiating treatment (Sullivan, 2019; Ball et al., 2017).

ASSESSMENT:

Differential diagnoses: 1. Chronic depression with acute exacerbation (Primary diagnosis).

2. Bipolar disorder
3. Drug intoxication

Rationale

1. Chronic Depression with Acute Exacerbation (Primary Diagnosis)

Although no clear evidence has been documented to describe the pathophysiology of depression, some researchers have explained the possible origin of symptoms that are normally displayed by patients with the disease. According to Lim et al. (2018), the pathophysiology of depression involves multiple neurotransmitters including norepinephrine, the central nervous system serotonin (CNS 5-HT), glutamate, and brain-derived neurotrophic factor (BDNF).

One reason that makes researchers ascertain the involvement of CNS 5-HT in depression is the ability of selective serotonin reuptake inhibitors (SSRIs) to improve symptoms of depression in the affected patients (Lim et al., 2018). The pathophysiology of depression has also been associated with vascular lesions in the brain in various regions of the cortex. This explains why a positron emission tomography (PET) scan of the brain is sometimes ordered for patients with depression, especially when severe symptoms are experienced (Lim et al., 2018).

The DSM-5 tool helps clinicians to evaluate a patient’s symptoms to either confirm or rule out the presence of depression. One of the criteria that must be met is the presence of at least five of the listed symptoms including; a depressed mood, lack of interest in activities, insomnia, agitation, fatigue, feelings of worthlessness, inability to concentrate, and recurrent symptoms of suicidal thoughts (Institute for Clinical Systems Improvement, 2021).

Additional criteria that are normally assessed during patient evaluation include; the absence of a mixed episode, lack medication or drug involvement in the patient’s symptoms, and the absence of schizophrenic and manic episodes (Institute for Clinical Systems Improvement, 2021). As reported by A.L., she had multiple symptoms including a depressed mood, loss of interest in activities, excessive sleep, lack of energy, and reduced appetite during her initial visit.

These symptoms confirms the presence of depression or a major depressive disorder. Just 2 days ago, A.L. started to experience acute recurrence of depressive symptoms characterized by insomnia, unexplained intermittent headache, and recurrent suicidal thoughts. Based on these symptoms, it is appropriate to conclude that A.L.’s primary diagnosis for today is chronic depression with acute exacerbation.

2. Thyroid Dysfunction

Symptoms of major depressive disorder can be confused with those of thyroid dysfunction. Thyroid dysfunction normally affect a person’s mood. During hyperthyroidism, a person may present with restlessness, anxiety, and irritability. Depression-like symptoms that are usually experienced during hypothyroidism include; mood swings, excessive fatigue, and abnormal weight loss.

To rule out the absence of thyroid dysfunction in a person who presents with depression-like symptoms, it is always recommended that the clinician conducts a mental status exam assessment to compare symptoms with the diagnostic criteria for the disease (Mayo Foundation for Medical Education and Research (MFMER), 2021). Although patient A.L. has reported depressed mood with overall body weakness, it is less likely that she has thyroid dysfunction. Besides, objective assessment did not reveal evidence of thyroid dysfunction.

3. Drug Intoxication

Depressive symptoms that occur due to medication use is known as drug-induced depressive disorder. It is easy to tell when a person is suffering from a drug-induce depression. The reason is that symptoms of depression that did not occur before medication are experienced a few days or weeks inside medication. Drugs that are commonly associated with drug-induced depression are corticosteroids, antiepileptic medications, and illicit substances such as heroin and cocaine.

Symptoms that meet the DSM-5 criteria for depression are normally experienced by people who are suffering from drug intoxication (Revadigar & Gupta, 2021). Patient A.L. is not using any of the named drugs and she began to experience symptoms of depression even before she started to use her current medications. This explains why drug intoxication has not been chosen as her primary diagnosis.

PLAN:

Diagnostics:

• The nine-item Patient Health Questionnaire (PHQs) was administered to determine the presence and severity of depression (Maurer et al., 2018).
• The patient’s symptoms were evaluated further using the DSM-5 instrument to confirm the presence of depression. To confirm the presence of depression, the patient’s symptoms must match the features outlines in the Diagnostic and Statistical Manual for Mental disorders (DSM-5) (Maurer et al., 2018).

Therapeutics:

Pharmacological treatment:

• A.L. was advised to continue using Valium for his anxiety. Valium is an evidence-based treatment for anxiety. The patient has reported an improvement in anxiety symptoms since she started to use the drug. Therefore, it is advisable that she continues its use to prevent the recurrence of anxiety symptoms (Mayo Clinic, 2020).
• Tylenol was prescribed to help relieve the patient’s headache.
• Wellbutrin extended release (XL) take in the morning was added to the patient’s regimen. The prescribed dose was 150 mg taken orally. The reason for adding Wellbutrin XL to the patient’s current drug list is to boost the efficacy of Zoloft and eliminate its side effects that have been reported by A.L. During her last visit, A.L. was given Zoloft that she was advised to use at a dose of 25 mg taken orally daily. Zoloft is an antidepressant that has been approved for the treatment of depression in adults and older adults.
• The initial dose of the drug in older adults is usually 25 mg (Gartlehner et al., 2017). Patient A.L. has reported a slight improvement in depressive symptoms. However, she has also reported anxiety and agitation, feelings of worthlessness, and a mild headache. These are common side effects of Zoloft. Therefore, augmenting it with 150 mg of Wellbutrin XL will help to address the acute exacerbation of depressive symptoms while at the same time eliminating the drug’s side effects, thereby enhancing recovery (Gartlehner et al., 2017).

Non-pharmacological intervention:

• Individual psychotherapy was implemented to speed up the recovery process. Specifically, cognitive behavioral therapy in an individual setting was implemented. Cognitive behavioral therapy is an evidence-based psychotherapy for depression. Besides, administering the intervention in an individual setting will allow one on one interaction with the patient, thereby enhancing recovery (Gartlehner et al., 2017).

Patient education, health promotion, referrals, and follow-ups:

• The patient was educated about the risk factors of depression and how to avoid them. She was also informed warning signs that should be observed and the need to report to the clinic as fast as possible when they occur.
• A.L. was educated about drug adherence and its benefits. She was informed to take her medications as prescribed as it is only by doing so that her symptoms will improve (Edelman et al., 2017).
• Family members were involved in the care of the patient. Family members are a good source of social support, especially for older adults. Therefore, connecting A.L. with her family and friends can enhance recovery and provide her with people who can help with activities of daily living at home (Edelman et al., 2017).
• The patient was referred to a physiotherapist to offer guidance on age-appropriate physical activities. A.L. reported that they normally stay at home with the husband most of the time because their ability to move around is hampered by their reduced physical mobility. Even with reduced physical mobility, the patient should be helped to understand the importance of engaging in exercise. With the guidance of a physiotherapist, A.L. will be helped to choose and implement light exercises that are appropriate for her age (Edelman et al., 2017).
• A.L. was asked to contact the clinic in case her symptoms persist and when strange ones occur. She was informed to visit the clinic in two weeks for follow-up and evaluation (Edelman et al., 2017).

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2017). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

Edelman, C., Mandle, C., & Kudzma, E. (2017). Health promotion throughout the life span. 9^th ed. Elsevier Health Sciences. ISBN: 0323416748, 9780323416740

Gartlehner, G., Wagner, G., Matyas, N., Titscher, V., Greimel, J., Lux, L., Gaynes, B. N., Viswanathan, M., Patel, S.,& Lohr, K. N. (2017). Pharmacological and non-pharmacological treatments for major depressive disorder: Review of systematic reviews. BMJ Open, 7:e014912. doi:10.1136/ bmjopen-2016-014912.

Institute for Clinical Systems Improvement. (2021). Guidelines: Diagnose and characterize major depression/persistent depressive disorder with clinical interview. https://www.icsi.org/guideline/depression/diagnose-and-characterize-major-depression-persistent-depressive-disorder-with-clinical-interview/

Lim, G. Y., Tam, W. W., Lu, Y., Ho, C. S., Zhang, M. W., & Ho, R. C. (2018). Prevalence of depression in the community from 30 countries between 1994 and 2014. . Scientific Reports, 8, 2861. doi: 10.1038/s41598-018-21243-x.

Maurer, D., Raymond, T. & Davis, V. (2018). Depression: Screening and diagnosis. American Family Physician, 98(8):508-515. https://www.aafp.org/afp/2018/1015/p508.html

Mayo Clinic. (2020). Diazepam (oral route). https://www.mayoclinic.org/drugs-supplements/diazepam-oral-route/proper-use/drg-20072333

Mayo Foundation for Medical Education and Research (MFMER). (2021). Thyroid disease: Can it affect a person’s mood? https://www.mayoclinic.org/diseases-conditions/hyperthyroidism/expert-answers/thyroid-disease/faq-20058228

Revadigar, N., & Gupta, V. (2021). Substance induced mood disorders. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK555887/

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia