Episodic/Focused SOAP Note Template
Patient Information:
S.
CC:
HPI: JD is a 33-year-old female with a past medical history of polycystic ovary syndrome, obesity, and asthma who present to the clinic with a chief complaint of right-side facial drooping associated with excessive tearing and drooling that started this morning. She denies pain, or discomfort on the right of her face. The patient states this is the first time she has experienced these symptoms. No chest pain or difficulty breathing.
Current Medications:
One A Day women’s vitamin once daily
Proventil inhaler as needed
Mircette once daily
Allergies:
Penicillin: Erythema, and itchy skin
Sulfa antibiotics: Hives
Shrimp: Swelling to lips
Latex: Hives
PMHx:
Tdap
Influenza vaccine
Pfizer-BioNTech COVID-19 vaccine 8/2/2021-8/31/2021
Tonsillectomy: 6 years-old
Appendectomy: 15 years-old
Soc Hx: JD is currently employed as a protection operation manager at Target. She attends a university to obtain her bachelor’s degree in social work. The patient is single with no children. Her hobbies include soapmaking and spending quality time with her friends and family. JD denies any history of tobacco abuse, or illicit drug use. She enjoys drinking wine occasionally during social gatherings. The patient denies being sexually active, or STDs.
Fam Hx:
Mother- 62 years-old, alive, hypertension, osteomyelitis, and hypothyroidism.
Father- 64 years-old, alive, CVA with left sided residual, and uncontrolled hypertension.
Sister- 28 years-old, alive, obesity, eczema, and hypertension.
Brother- 31 years-old, alive, prehypertension, and asthma.
Maternal grandmother- 85 years-old, deceased due to a heart attack, type 2 diabetes, hypertension, hyperlipidemia, congestive heart failure.
Maternal grandfather- 87 years-old, deceased due to COVID-19, hypertension, hypercholesterolemia, benign prostatic hyperplasia,
ROS:
GENERAL: The patient appears to be anxious and stressed. However, she is well groomed, and denies fatigue, weight loss, chills, or fever.
HEENT: Verbalized right sided facial drooping, with excessive tearing, and drooling. Denies blurred vision, hearing loss, runny nose, or sore throat.
SKIN: Denies rash or itching, verbalized acne, oily skin, and facial hair.
CARDIOVASCULAR: Denies chest pain, irregular heart rate, or edema in upper and lower extremities
RESPIRATORY: Denies shortness of breath, or cough.
GASTROINTESTINAL: Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Denies discomfort while voiding, and frequent urination. Denies pregnancy. Last menstrual period 09/04/2021.
NEUROLOGICAL: Verbalizing right side facial numbness with excessive tearing, and drooling. Denies dysphagia
MUSCULOSKELETAL: Denies joint pain or stiffness. No weakness
HEMATOLOGIC: Denies history of anemia or blood transfusion
LYMPHATICS: Denies enlarged lymph nodes.
PSYCHIATRIC: Denies mood disorder, depression, or anxiety.
ENDOCRINOLOGIC: Patient verbalized PCOS, denies cold or heat intolerance.
O.
Physical exam:
Vitals: BP- 129/82, HR- 86, RR- 18, Temp- 98.9, O2- 99% on room air
GENERAL: The patient appears to be anxious and stressed. However, she is well groomed, her last physical exam, pap smear, and lab work was on 1/4/2021.
HEENT: Positive for right sided facial ptosis, with excessive epiphora, and sialorrhea.
SKIN: Negative for exanthem or pruritus
CARDIOVASCULAR: Negative for angina, palpitations, or edema to bilateral upper and lower extremities.
RESPIRATORY: Negative for dyspnea. Respirations are even and unlabored, chest is symmetrical.
GASTROINTESTINAL: Negative nausea, vomiting or diarrhea. Abdomen is round symmetrical, and nontender.
GENITOURINARY: Negative for polyuria, or dysuria. Last menstrual period 09/10/2021.
NEUROLOGICAL: Positive for facial numbness and tingling.
MUSCULOSKELETAL: Neck is supple, negative for arthralgia, or kyphosis.
HEMATOLOGIC: Negative for anemia, positive for decreased sex hormone binding globulin (SHBG), and elevated Anti-Mullerian hormone (AMH).
LYMPHATICS: Negative for lymphadenopathy.
PSYCHIATRIC: Negative for bipolar disorder, depression, or anxiety.
ENDOCRINOLOGIC: Positive for PCOS.
START HERE
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)
A.
Differential Diagnoses: List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each with evidence literature
References
Episodic/Focused SOAP Note Template
Patient Information:
S.
CC:
HPI: JD is a 33-year-old female with a past medical history of polycystic ovary syndrome, obesity, and asthma who present to the clinic with a chief complaint of right-side facial drooping associated with excessive tearing and drooling that started this morning. She denies pain, or discomfort on the right of her face. The patient states this is the first time she has experienced these symptoms. No chest pain or difficulty breathing.
Current Medications:
One A Day women’s vitamin once daily
Proventil inhaler as needed
Mircette once daily
Allergies:
Penicillin: Erythema, and itchy skin
Sulfa antibiotics: Hives
Shrimp: Swelling to lips
Latex: Hives
PMHx:
Tdap
Influenza vaccine
Pfizer-BioNTech COVID-19 vaccine 8/2/2021-8/31/2021
Tonsillectomy: 6 years-old
Appendectomy: 15 years-old
Soc Hx: JD is currently employed as a protection operation manager at Target. She attends a university to obtain her bachelor’s degree in social work. The patient is single with no children. Her hobbies include soapmaking and spending quality time with her friends and family. JD denies any history of tobacco abuse, or illicit drug use. She enjoys drinking wine occasionally during social gatherings. The patient denies being sexually active, or STDs.
Fam Hx:
Mother- 62 years-old, alive, hypertension, osteomyelitis, and hypothyroidism.
Father- 64 years-old, alive, CVA with left sided residual, and uncontrolled hypertension.
Sister- 28 years-old, alive, obesity, eczema, and hypertension.
Brother- 31 years-old, alive, prehypertension, and asthma.
Maternal grandmother- 85 years-old, deceased due to a heart attack, type 2 diabetes, hypertension, hyperlipidemia, congestive heart failure.
Maternal grandfather- 87 years-old, deceased due to COVID-19, hypertension, hypercholesterolemia, benign prostatic hyperplasia,
ROS:
GENERAL: The patient appears to be anxious and stressed. However, she is well groomed, and denies fatigue, weight loss, chills, or fever.
HEENT: Verbalized right sided facial drooping, with excessive tearing, and drooling. Denies blurred vision, hearing loss, runny nose, or sore throat.
SKIN: Denies rash or itching, verbalized acne, oily skin, and facial hair.
CARDIOVASCULAR: Denies chest pain, irregular heart rate, or edema in upper and lower extremities
RESPIRATORY: Denies shortness of breath, or cough.
GASTROINTESTINAL: Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Denies discomfort while voiding, and frequent urination. Denies pregnancy. Last menstrual period 09/04/2021.
NEUROLOGICAL: Verbalizing right side facial numbness with excessive tearing, and drooling. Denies dysphagia
MUSCULOSKELETAL: Denies joint pain or stiffness. No weakness
HEMATOLOGIC: Denies history of anemia or blood transfusion
LYMPHATICS: Denies enlarged lymph nodes.
PSYCHIATRIC: Denies mood disorder, depression, or anxiety.
ENDOCRINOLOGIC: Patient verbalized PCOS, denies cold or heat intolerance.
O.
Physical exam:
Vitals: BP- 129/82, HR- 86, RR- 18, Temp- 98.9, O2- 99% on room air
GENERAL: The patient appears to be anxious and stressed. However, she is well groomed, her last physical exam, pap smear, and lab work was on 1/4/2021.
HEENT: Positive for right sided facial ptosis, with excessive epiphora, and sialorrhea.
SKIN: Negative for exanthem or pruritus
CARDIOVASCULAR: Negative for angina, palpitations, or edema to bilateral upper and lower extremities.
RESPIRATORY: Negative for dyspnea. Respirations are even and unlabored, chest is symmetrical.
GASTROINTESTINAL: Negative nausea, vomiting or diarrhea. Abdomen is round symmetrical, and nontender.
GENITOURINARY: Negative for polyuria, or dysuria. Last menstrual period 09/10/2021.
NEUROLOGICAL: Positive for facial numbness and tingling.
MUSCULOSKELETAL: Neck is supple, negative for arthralgia, or kyphosis.
HEMATOLOGIC: Negative for anemia, positive for decreased sex hormone binding globulin (SHBG), and elevated Anti-Mullerian hormone (AMH).
LYMPHATICS: Negative for lymphadenopathy.
PSYCHIATRIC: Negative for bipolar disorder, depression, or anxiety.
ENDOCRINOLOGIC: Positive for PCOS.
START HERE
Diagnostic results:
- Electromyography (EMG): EMG is the recommended test for measuring the degree of nerve damage and the nature of electrical conductivity in a nerve (The Johns Hopkins University, 2021; Mayo Clinic, 2021). Results indicate reduced speed of electrical conduction in the facial nerve.
- Computed tomography (CT) scan or Magnetic Resonance Imaging (MRI): These tests are conducted in order to assess whether nerve impairment is due to structural damage or some pressure on the facial nerve. It is performed to rule out the presence of tumors and fractures on the skull (Mayo Clinic, 2021). MRI and CT scan can also detect neurosarcoidosis (Bradshaw et al., 2021).
- Blood tests: Conditions such as diabetes are risk factors for facial palsy. Blood tests are conducted to establish whether the patient has diseases such as diabetes and to determine its severity (The Johns Hopkins University, 2021).
- Cincinnati Pre-hospital Stroke Scale: Facial drooping, drooling, and tearing may occur due to stroke attack. Cincinnati Prehospital Stroke Scale has been administered to establish whether the patient’s symptoms are due to stroke. This test normally require only a single positive symptom: facial drooping to confirm the presence of stroke. This explains why it must be use together with other tests before making a conclusion that the patient has stroke (Baugh et al., 2018).
- Viral cultures and vesicular scrapings: Viral cultures are necessary to detect Herpes zoster oticus, a virus that is sometimes associated with facial palsy. Vesicular scrapings are also subjected to direct immunofluorescence to detect the viral (Pitton & Fornari, 2018).
A.
Differential Diagnoses:
- Bell’s palsy (primary diagnosis): Bell’s palsy is a sudden episode of paralysis of the facial muscle. Symptoms usually worsen within a period of 48 hours from the initial diagnosis. Bell’s palsy usually results from the damage of the facial nerve, the 7th cranial nerve (The Johns Hopkins University, 2021). Symptoms of the disease that are normally used as the diagnostic criteria include; facial drooping on one side of the face, drooling, rapid onset, pain, discomfort around the eye, and tearing. These symptoms are present in the present. Objective findings that have confirmed the presence of Bell’s Palsy include; reduced speed of electrical conduction in the facial nerve and structural damage of the facial nerve (The Johns Hopkins University, 2021; Mayo Clinic, 2021).
- Stroke: Stroke attack on the facial nerves normally causes facial drooping that is also observed in patients with Bell’s Palsy. It normally has a sudden onset too. However, stroke patients do not normally present with drooling (Baugh et al., 2018).
- Ramsay-Hunt syndrome (RHS), also known as herpes zoster oticus: Facial palsy may occur as a results of a viral infection caused by herpes zoster oticus also known as Ramsay-Hunt syndrome. In addition to facial drooping and drooling, affected patients normally have rashes on the face and hearing problems. These symptoms are absent in the patient. Again, the viral cultures did not reveal any bacterial growth (Pitton & Fornari, 2018).
- Neurosarcoidosis: This is an immune-mediated disorder affecting nerves. Attack of the facial nerve causes affected individuals to display symptoms that resemble those of Bell’s Palsy. However, MRI and CT scan results of a person with neurosarcoidosis of the facial nerves normally indicate granulomatous inflammation of the nerves (Bradshaw et al., 2021). These are absent in the patient’s case.
- Cancer/tumor involving the facial nerve or parotid gland: Tumor/cancer affecting the facial nerves causes patients to present with drooling, facial drooping, and tearing (Mayo Clinic, 2021). CT and MRI scan have not revealed any form of pressure caused by tumor/cancer.
References
Baugh, R. F., Basura, G. J., Ishii, L. E., Schwartz, S. R., Drumheller, C. M., Burkholder, R., Deckard, N. A., Dawson, C., Driscoll, C., Gillespie, M. B., Gurgel, R. K., Halperin, J., Khalid, A. N., Kumar, K. A., Micco, A., Munsell, D., Rosenbaum, S., & Vaughan, W. (2018). clinical practice guideline: Bell’s palsy. Otolaryngology–Head and Neck Surgery, 149(3_suppl), S1–S27. https://doi.org/10.1177/0194599813505967
Bradshaw, M. J., Pawate, S., Koth, L. L., Cho, T. A., & Gelfand, J. M. (2021). Neurosarcoidosis: pathophysiology, diagnosis, and treatment. Neurology(R) Neuroimmunology & Neuroinflammation, 8(6), e1084. https://doi.org/10.1212/NXI.0000000000001084
Mayo Clinic. (2021). Bell’s palsy. https://www.mayoclinic.org/diseases-conditions/bells-palsy/diagnosis-treatment/drc-20370034
Pitton, R. J., & Fornari, C. A. L. (2018). Herpes zoster oticus, ophthalmicus, and cutaneous disseminated: case report and literature review. Neuro-ophthalmology (Aeolus Press), 43(6), 407–410. https://doi.org/10.1080/01658107.2018.1523932
The Johns Hopkins University. (2021). Bell’s palsy. https://www.hopkinsmedicine.org/health/conditions-and-diseases/bells-palsy