SOAP Note Case Study
Mr. D. is a 72 y.o. male who presents to your practice for a routine physical examination. During the review of systems, he reports getting up to urinate on average three times nightly. He comments that it is getting very annoying and he has cut back on his fluid intake after dinner, including his usual glass of wine, but the problem persists. He denies any burning with urination and has not noticed any blood in his urine. His bowels are regular and he has not made any changes in his diet.
Chronic health problems include hypertension, dyslipidemia, and osteoarthritis.
Medications: valsartan and hydrochlorothiazide 80/12.5, one tablet daily in a.m., acetaminophen arthritis, one to two tablets occasionally for arthritic pain, atorvastatin 10 mg PO daily in the evening.
Vital signs: Blood pressure 130/82, pulse 74 (regular), respiratory rate 16, temperature 98.6ºF orally, BMI 24.5
Chief Complaint: Urinating three times at night
Case Study Overview and Rubric
| Provided pertinent subjective (HPI, Medications/Allergies, PMH, PSH, social history, family history) data and rationale | |
| Provided pertinent objective data (vitals, physical exam) and rationale | |
| Discussed appropriate differential diagnoses and rationale | |
| Discussed the plan of care including any diagnostics, medications education, and follow-up/referral | |
| Discussion of national guidelines in plan of care | |
| Use of correct grammar, scholarly/professional vocabulary, cited all sources using APA format |
Overview:
The Case study is to be written as a formal paper in APA format. Make sure you include all areas included in the rubric. You may want to view this more as a research paper. You need to do a review of the literature and include at least 3 peer-reviewed journal articles and all pertinent evidenced based guidelines. The guidelines need to be from the original source. It is not satisfactory to simply site Up-to-date as a guideline. You must use the national guideline pertinent to the diagnosis. You need to include a thorough/comprehensive discussion of differential diagnoses and discuss for each of these differential diagnoses what subjective and objective data and diagnostics you would use to be able to determine your actual diagnosis. Then pick your top three likely diagnoses and discuss the plan of care for each of them. Make sure to include the rationale so that I can see your critical thinking process. Do not make any assumptions. Include the rationale.
Subjective:
The subjective section must include all of the following areas: HPI, PMH, Past surgical history, Family history, Social history, medications, allergies, and ROS. For each of these sections, you need to discuss what further information you would need to gather from the patient beyond what is given in the written case study in the book. Giving me the information from the book will not get you any points. You must think beyond what the book gives you in the case.
HPI (5 points): You must discuss all chief complaints presented if there is more than one. You must include a thorough discussion of each component of the HPI specific to the chief complaint. Do not just list out what PQRST means. You must think beyond asking those generic questions and make them meaningful to the case and include your rationale.
PMH (2 points): Discuss any past medical history given in the case (why it is pertinent) and what specifically you would ask the patient about their PMH during their visit. Include your rationale.
Past Surgical History (2 points): Discuss any past surgical history given in the case and why it is pertinent. Discuss what you would specifically ask the patient about their surgical history during their visit and include your rationale.
Family History (1 point): Discuss any family history given in the case and why it is pertinent. Discuss what you would specifically ask the patient about their family history during their visit and include your rationale.
Social History (1 point): Discuss any social history given in the case and why it is pertinent. Discuss what you would specifically ask the patient about their social history during their visit and include your rationale.
Medications (2 points): Discuss any medications given in the case and why it is pertinent. Discuss what you would specifically ask the patient about their medications during their visit and include your rationale.
Allergies (2 points): Discuss any allergies given in the case and why it is pertinent. Discuss what you would specifically ask the patient about their allergies during their visit and include your rationale.
Review of Systems (5 points): Include a thorough review of systems pertinent to the case with supporting rationale. ROS includes both general or constitutional complaints as well as a review by body system. DO NOT just include a comprehensive ROS. Include the pertinent aspects relative to the case with supporting rationale.
Objective: The objective section should include discussion of the vitals and the objective data given in the case and why it is pertinent in determining your differential and all areas you would assess in your physical exam of the patient pertinent to the case. It should be a discussion of a focused exam of the patient pertinent to the case with supporting rationale. Include any missing vitals that you would want to obtain and why.
Differential Diagnoses: A comprehensive list of differentials should be provided with rationale. Include at least 6 and no more than 10differentials. For each differential, include a discussion of what subjective and objective data and diagnostics you would use to be able to rule that diagnosis in or out. Then pick your top three diagnoses and include a rationale for why you chose them.
Treatment Plan: The treatment plan must include a thorough discussion of diagnostics, medications, education, and follow-up/referral for each of the top 3 differentials with supporting rationale. The diagnostics discussion should not be limited to the top 3 differentials. It should encompass diagnostics pertinent to the differentials discussed.
Guidelines: Guidelines specific to the top three differential diagnoses should be discussed related to each aspect of the plan of care (medications, diagnostics, education, referral/follow-up).
| 10 | 8 | 6 | 4 | 2 | |
| Guidelines | Complete and thorough discussion of all pertinent guidelines for all three top differential diagnoses | Missing 25% of pertinent discussion of guidelines | Missing 50% of pertinent discussion of guidelines | Missing 75% of pertinent discussion of guidelines | Missing 90% of pertinent discussion of guidelines |
Technical Aspects/Format/APA: The case study should be written as a formal paper in APA format. The paper should be written using proper grammar and scholarly/professional vocabulary. Plagiarism is prohibited. In order to help decrease the likelihood of plagiarism, a turn-it-in score in the green will be required. A turn-it-in score in the green does not mean that plagiarism has not occurred. If you take a sentence or phrase exactly as written from another source, you must cite accordingly with quotations and the page number (see APA guidelines). When you paraphrase, you must still cite your source (author, page number). Please review your APA guidelines so that you cite appropriately. A turn-it-in score not in the green will not be accepted. If you submit a paper with a turn-it-in score not in the green, you will be allowed up to 48 hours to resubmit. Papers not resubmitted within 48 hours will forfeit a score of 0.
| 10 | 8 | 6 | 4 | 2 | |
| Structure of paper/ grammar/ APA | Complete adherence to APA guidelines | Missing 25% of APA compliance | Missing 50% of APA compliance | Missing 75% of APA compliance | Missing 90% of APA compliance |
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