The Assignment:
Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:
Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescriiption and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. Provide a review of systems.
Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results?
Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential in or out. Explain you critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.
Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. Follow APA 7th edition formatting.
Case Study:
A 76-year-old woman presents today with complaints of nasal drainage, clearing of throat, and occasional nasal congestion, especially upon waking in the morning. She has recently moved into an independent living center after living in her home for 40 years. She states that, although she has had these symptoms before, generally, the symptoms appeared in the spring, and she associated the nasal drainage with pollination. Because it is winter, she could not identify the trigger of her symptoms.
Chief complaint: Persistent “runny nose” for the 3-week duration, associated clearing of the throat and nasal congestion on awakening in the morning.
Objective data: Blood pressure (BP) 130/84, temperature 98.6, pulse 78, respiratory rate 20.
What further ROS questions will you want to ask her? List at least three.
What physical exam (PE) will you perform on this patient? List at least three.
What are the differential diagnoses that you are considering? Describe at least four.
What laboratory tests will help you rule out some of the differential diagnoses?
You have determined, by choosing your ROS, PE, and differential diagnosis, that this patient has allergic rhinitis (AR).
Describe the treatment options for your diagnosis, and what specific information about the prescription will you give to this patient?
List at least two treatment options: medications with dose, side effects, and/or cautions in the older adult.
When will you have the patient follow-up? Be specific.
Write a focused SOAP note for this case. Choose the ROS, PE, and medications you will use in your SOAP note.
