Benchmark clinical soap note
I graduated 
SOAPExample.docxRunning Head: SOAP NOTE 1 1
PROGRESS NOTE 5 4
SOAP Note I
Students Name
Grand Canyon University
ANP XXX
Date
SOAP Note Example
Brief HPI: This is a 79 year old female, B.G., whom was admitted two days ago from the ER with complaints of lower extremity weakness and difficulty breathing. Admitting diagnoses were LE weakness and non-small carcinoma. B.G. has a medical history significant for COPD in which she requires home oxygen as needed for shortness of breath. She is very familiar to the pulmonary group and was seen at a sister campus last month for healthcare associated pneumonia.
If the patient has been hospitalized for a period of time, include a brief summary of the hospital course.
Subjective
Patient reports, “My breathing feels better today but I am still very weak” (This is your chief complaint. It is the answer to the question, “How are you doing today?” If patient unable to state, ask the nurse or the family member “How is the patient doing?) She reports constipation, last BM was three days ago, but denies any pain and started taking Miralax yesterday. Her leg weakness is slightly improved, and she states she has been able to get back and forth to the restroom with minimal assistance.
Inpatient Medications (Include dosage, route, and frequency)
Review of Systems (You must review at least 5 systems and include at least two pertinent positives or negatives per system)
Gen: Denies fever, chills
PULM: C/o shortness of breath. Increased with exertion. Improved over yesterday.
CV: Denies CP, palpitations
GU: Denies difficulty with urination. Clear yellow urine per patient.
GI: No change in bowel habits. No BM X3 days.
Ext: C/o lower extremity weakness. Denies pain.
Objective
Physical Exam
VS: Tmax 37.4- HR 60- RR 24- BP 147/70- 98% 3L via NC (Include if the are on RA, O2, Vent)
Constitutional: In respiratory distress, nontoxic.
Neuro: AAOx4, speech clear, PERRL, EOMI, no focal deficits.
HEENT: Normocepahlic, MM dry and pink, neck supple, trachea midline.
Cardiac: S1 S2, RRR at this time.
Resp: Labored, tachypneic, clear, equal rise and fall.
GI: Semi-firm, round, nontender, BS are present.
Derm: Skin warm, dry, and pale. No lesions.
Ext: Pulses easily palpable x4, no edema present, strength 4/5 all extremities.
Diagnostic Tests (Include any diagnostic tests from the last 24-48 hours. Include your interpretation of the test. Identify abnormal findings by bolding or underlining the results)
9.8
8.2 253.0
29.2
133 94 16
81
4.6 30 0.71
Phosphorus: 3.5
Magnesium 2.2
Cosyntropin stimulation test: mild response with 0.25mg ACTH tested 30 and 60 minutes post injection. She has been on chronic steroid therapy which would alter from a normal response.
Assesment (Include all pertinent acute and chronic diagnosis listed in order of acuity. Include appropriate ICD10 codes. Give supporting details. Why did you choses this diagnosis? Is this Acute? Chronic? Improving? Worsening?)
1) TOXIC MYOPATHY 359.4- acute, stable, most likely and leading: Acute type of corticiosteroid induced myopathy occurs less frequently than chronic and is associated with sudden more generalized weakness after high-dosed steroids for a short period of time (Foye, 2014). B.G. has been taking moderate to high dosed corticosteroids for years due to her advancing COPD. Her weakness is localized to her upper legs though she does report shortness of breath and even with her history of COPD, respiratory weakness from myopathy cannot be excluded. Classic steroid myopathy is more chronic with progressive proximal extremity weakness from prolonged high-dose steroid usage. Though nonfluorinated steroids such as prednisone are less commonly associated with steroid myopathy than fluorinated steroids such a dexamethasone, but it is not uncommon with higher doses. Women are twice as likely to have steroid-induced myopathy than men (Foye, 2014). B.G. does report only proximal extremity weakness including her legs having difficulty to stand and walk but she denies any symptoms of upper extremity weakness at home but physical examination does demonstrate moderate and bilateral weakness of all extremities.
2) POLYMYOSITIS 710.4 -(associated with malignancy)- acute, stable, also possible and second leading: Class III idiopathic inflammatory myopathies are associated with malignancy. Polymyositis causes bilaterally symmetrical proximal muscle weakness along with elevated muscle enzyme levels, characteristic electromyography, and muscle biopsy findings “showing endomysial mononuclear inflammatory infiltrate and muscle fiber necrosis” (Pappu, 2014, figure 2). G.B.’s CK was low at 43 U/L. Patients with polymyositis and related dermatomyositis are commonly associated with malignancy which is true in G.B.’s case. Men are also more commonly effected than women (Pappu, 2014).
3) MALIGNANT NEOPLASM OF LOWER LOBE BRONCHUS OR LUNG 162.5- acute, stable: Confirmed by fine-needle biopsy to be non-small cell lung cancer. She had a nodule that had grown since her last CXR in February.
4) HYPOSMOLALITY AND/OR HYPONATREMIA 276.1- acute, stable: Confirmed by laboratory.
5) OTHER DISORDERS OF NEUROHYPOPHYSIS 253.6- acute, stable, possible: Syndrome of inappropriate antidiuretic hormone (SIADH) should always be considered when a patient has a known or suspected malignant or metastatic tumor and the serum sodium is low. The tumors most commonly associated with SIADH include lung cancers but are most often small cell, not large cell lung tumors (Onitilo, Kio, & Doi, 2007).
6) OBSTRUCTIVE CHRONIC BRONCHITIS WITH (ACUTE) EXACERBATION 491.21- stable, confirmed: B.G. reports dyspnea and is tachypneic but has clear lung sounds. She is maintaining her oxygen saturations with three liters of oxygen at 98%; she normally uses two liters at home.
7) ANEMIA UNSPECIFIED 285.9- acute and chronic, stable, confirmed: B.G. has a history of chronic anemia that has not been tested to specify the cause or treated at this point. It has remained stable and she has never had a blood transfusion.
8) ANEMIA IN NEOPLASTIC DISEASE 285.22- acute, stable, possible: Malignancy itself can cause anemia which is more commonly true with patients that have lung or ovarian cancer as well as chronic anemia (American Cancer Society [ACS], 2014). This is true in B.G.’s case as her last discharge hemoglobin was 10.9 g/dL.
9) OTHER AND UNSPECIFIED HYPERLIPIDEMIA 272.4- likely chronic, stable, confirmed: Total cholesterol is 261 mg/dL. Triglycerides, HDL, and VLDL were all within normal ranges; LDL was elevated. She is not on a statin or other anti-dyslipidemic. This is good to note as statins have been known to cause myalgias.
Differential Diagnoses
Include three potential alternate differentials for the symptoms. Include pertinent positives and negatives for the alternate differential. Why did you rule out other diagnosis for the same symptoms? This must be included in order to get full points for impression/assessment.
Plan (This should be based on current clinical guidelines and heavily referenced. You should be looking up current clinical guidelines to help to guide your plan. Know why you are doing what you are doing.)
1) Muscle biopsy of her vastus lateralis tomorrow to help confirm diagnosis by histological examination.
2) Decrease Prednisone to 10mg to maintain control of her COPD which has improved her weakness so far as she has been able to ambulate with greater strength to and from the restroom. If it is discovered that she has polymyopathy, we will again increase her steroids to treat the inflammatory response in her muscles. Further testing is dependent on muscle biopsy results. We will continue with the 10mg of Prednisone for now and do a PT/OT consult to evaluate and treat (Foye, 2014).
3) PET/CT scan to assess for possible metastatis as she has neuromuscular weakness which may be associated with spinal cord involvement. We will obtain a CT at that time to have more immediate results if her PET scan shows areas suspicious for metastasis. B.G. does not currently have bone pain or hypercalcemia (calcium is 8.5) so we will only consider a bone scan if her PET/CT shows possible bone involvement, if she begins to complain about bone pain, or her calcium rises unexpectedly (American Cancer Society [ACS], 2014).
4) We will continue IVF hydration of NS with 20meq K @100ml/hr as ordered to maintain hydration.
5) Follow up serum and urine osmolality, urine sodium concentration, TSH w/reflex to T4 if indicated, and repeat BMP in the morning to assess kidney function, glucose, and electrolytes. We will do this to see if she meets SIADH criteria (Onitilo et al., 2007).
6) Continue oxygen to keep her oxygen saturations above 93% and for her respiratory comfort. We will continue her usual Symbicort and montelukast medications and provide albuterol SVNs as needed for dyspnea or wheezing.
7) We will not initiate statin or other anti-dyslipidemic therapy at this time due to her muscle weakness.
8) CBC daily due to anemia and to ensure her platelets are within normal limits.
9) Diet: Continue regular diet. NPO after midnight for muscle biopsy tomorrow. Continue IVF while NPO.
10) DVT prophy: Lovenox 40mg SQ BID for DVT prophy. Continue this as she is limited in her activity and needing VTE prophylaxis. Hold tomorrow morning dose for muscle biopsy. Platelets were WNL today. Padau score of 4 due to her age greater than 70, having cancer, BMI greater than 30, and not mobile (Jobin et al., 2011)
11) Pain: Continue acetaminophen 650mg Q6 hours as needed for pain. Has been well controlled and has not used any PRN pain medication over the last 24 hours. There is no need for escalation of pain medication.
12) Continue to work with PT/OT. They are currently recommending inpatient SNF for discharge.
13) Dispo: Continue inpatient MS status until workup complete. Likely will be ready for discharge to SNF in next 1-2 days. Case management working to facilitate placement.
(All plans should address all acute and chronic diagnosis listed in your impression or assessment and should always include Diet, DVT prophy, pain, therapies if indicated, and Dispo plan)
Geriatric/ethical/legal consideration:
40% of all non-small cell lung cancers (NSCLC) are discovered after age 70 and 50% are discovered after age 65. Age is a strong risk factor for cancer as the body is exposed to more carcinogens and has more difficulty eradicating damaged cells. Cancer treatments are also more complex due to the elderly often having more comorbidities that makes the cancer and treatment of cancer more complex. Most of the research on chemotherapy has not been on populations older than age 65. This makes providing the best EBP more difficult for B.G. and other elderly oncology patients. For the older population, more often than not, diagnosis is first made in advanced stages of cancer which makes treatment more obsolete with palliative care a viable option for most (Maione et al., 2010).
References (If a reference is listed here, it must be cited in your note.)
American Cancer Society. (2014). Anemia in people with cancer. Retrieved from http://www.cancer.org/treatment/treatmentsandsideeffects/physicalsideeffects/anemia/anemia-in-people-with-cancer
American Cancer Society. (2014). Bone metastasis. Retrieved from http://www.cancer.org/acs/groups/cid/documents/webcontent/003087-pdf.pdf
Foye, P. M. (2014). Corticosteroid-induced myopathy. Retrieved from http://emedicine.medscape.com/article/313842-clinical
Jobin, S., Kalliainen, L., Adebayo, L., Agarwal, Z., Card, R., Christie, B., ... Morton, C. (2011, September). Venous thromboembolism prophylaxis. Institute for Clinical Systems Improvement (ICSI). Retrieved from
Maione, P., Rossi, A., Sacco, P. C., Bareschino, M. A., Schettino, C., Ferrara, M. L., ... Gridelli, C. (2010, July). Treating advanced non-small cell lung cancer in the elderly. Therapeutic Advances in Medical Oncology, 2, 251-260. http://dx.doi.org/10.1177/1758834010366707
Onitilo, A. A., Kio, E., & Doi, S. A. (2007, December). Tumor-related hyponatremia. Clinical Medicine and Research, 5, 228-237. http://dx.doi.org/10.3121/cmr.2007.762
Pappu, R. (2014). Polymyositis. Retrieved from http://emedicine.medscape.com/article/335925-overview#a0101
