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Assignment: Evaluate and Critique a SOAP Note for Completeness and Thoroughness

Assignment: Evaluate and Critique a SOAP Note for Completeness and Thoroughness

 

Subjective History

  1. The HPI has not addressed the chief complaints, which are nausea, vomiting, and diarrhea. The ‘OLDCART’ has identified the onset of the chief complaints in the form of the exact time it happened. However, this should be written as how many hours, days, or weeks ago. The duration has been indicated as intermittent; this should, however, be written in hours or minutes the symptoms last such as 20 minutes or 1 hour (Pearce, Ferguson, George, & Langford, 2016).
  2. The ‘T’ in ‘OLDCART’ has stated the treatment currently being used by the patient. However, this should be improved by including the timing of the symptoms, for example, if they present after or before eating.
  3. The SOAP NOTE only reveals that the patient was diagnosed with Influenza Type A. Nonetheless, this should be improved to inform the exact time or how long ago the patient was diagnosed with the Influenza Type A.
  4. The medication the patient is taking was not indicated under the subjective component. Current medications should be listed to assist the health care providers in deciding which drugs should be stopped or continued in the treatment plan.
  5. Sexual history. The sexual history of the patient was not obtained. This should be included in the SOAP note to help in identifying whether the patient is sexually active and history of STIs (Pearce, Ferguson, George & Langford, 2016). Besides, it will facilitate patient education on safe sex education.
  6. Immunization history. Information on the immunization status of the patient was not obtained. The immunization history should be recorded to establish whether it is up to date as per the guidelines on immunization (Pearce, Ferguson, George & Langford, 2016). The history will further help to decide if the patient will require a booster vaccine or whether the presenting condition is as a result of lack of immunization.
  7. Information on known food and drug allergies has not been provided. This should be improved to include any food or drug allergies the patient has. Besides, it helps the care provider to decide which drugs to prescribe to the patient that will not result in an allergic reaction.
  8. Social history. The patient’s social history was included under demographics; however, this should be under the subjective history. Information on the history of cigarette smoking, alcohol consumption, and drug substance abuse should be included to help identify if the presenting symptoms are a result of substance or alcohol use (Pearce, Ferguson, George & Langford, 2016). The occupation of his parents should also be included to help establish the economic status of the family.
  9. In the review of the abdomen, the SOAP note indicates that the patient denies vomiting, yet the chief complaint is vomiting. The discrepancy in patient’s history should be avoided by improving the history taking technique.

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Objective History

  1. Vital Signs. The vital signs were recorded under the general condition, but the respiration rate was not included. To improve this, the vital signs should be recorded first in the SOAP note indicating the patient’s blood pressure, temperature, pulse, and respirations (Pearce, Ferguson, George & Langford, 2016). Recording of all vital signs helps in establishing the underlying condition and deciding the priority medical interventions that will stabilize the patient.
  2. Body Mass Index (BMI). The BMI was not indicated; however, it is essential that the BMI is indicated to help identify a case of overweight or underweight and offer appropriate nutrition support.
    Assignment Evaluate and Critique a SOAP Note for Completeness and Thoroughness

    Assignment Evaluate and Critique a SOAP Note for Completeness and Thoroughness

  3. Genito-urinary system. The system was not reviewed in objective history. This should be improved by performing a physical examination of the genitals to help identify the presence of any anomalies that could be the underlying problem.  
  4. Neurological system. An assessment of the neurological system functioning was not conducted. This can be improved by reviewing the nerve function of both the peripheral and central nervous system.
  5. Arterial Blood Gas Analysis (ABGs). ABGs analysis is missing in the SOAP note objective data. The patient was experiencing shortness of breath, vomiting, and diarrhea, which could cause an alteration in the carbonic acid and bicarbonate levels in the body (Castro & Keenaghan, 2019). An ABG analysis should be conducted to facilitate in establishing if the patient has alkalosis or acidosis, which are caused by an underlying disease.
  6. Laboratory tests. The tests conducted included Rapid Strep test, Rapid Flu test, and Mono Spot. However, a test stool for ova and cyst test should have been undertaken to help identify the causative factor for diarrhea in the patient (Panda, Chandrakar, Bawankar & Chandi, 2016).
  7. Radiology tests. A radiology test, such as a chest X-ray is essential in the case of this patient to establish the cause of respiratory difficulties. Besides, it will help in coming up with a definite medical diagnosis for the patient.

 

Differential Diagnosis

  1. Acute Maxillary Sinusitis with Viral Syndrome: According to the SOAP note, this was identified as the primary diagnosis based on the patient’s history of Influenza and physical findings of maxillary sinus pain on palpation. In addition, the diagnosis was made based on fever, cough that worsened at night, nasal congestion, headache, halitosis, eye pressure, and a sore throat. The physical findings are not accurate as per the subjective data since there is no report of a cough that worsens at night. However, the positive findings on the objective data are accurate and thorough as per the physical exam.
  2. Streptococcal pharyngitis. The differential diagnosis was made based on the patient’s history, physical examination findings, and the negative Rapid Strep test. The criteria used to identify streptococcal pharyngitis as a possible diagnosis was not thorough. This is because the diagnosis has to have the fever, anterior cervical lymphadenopathy, exudate from the tonsillar gland, and absence of cough. The patient, however, was negative for tonsillar exudate but positive for cough.
  3. Infectious Mononucleosis: This was made a possible diagnosis as per the history and physical findings of fatigue, sore throat, fever, weakness, swollen tender cervical nodes, erythematous and edematous tonsils, loss of appetite and headache. A negative Mono Spot test was also used as a basis to come up with the differential diagnosis. Majority of the findings are accurate; however, the patient did not report loss of appetite.
  4. Adenovirus infection. This was identified as a possible diagnosis as per the patient’s history. The physical examination findings revealed sinusitis, which could be a secondary infection of Adenovirus infection and the presence of fever, cough, rhinorrhea, sore throat, diarrhea, abdominal cramps, and fatigue. Nevertheless, the positive findings for the diagnosis are not thorough since the patient did not report abdominal cramps.
  5. Meningitis: According to the SOAP note, the positive findings of nausea, fatigue, chills, fever, diarrhea, and myalgia made Meningitis a differential diagnosis. The patient had negative findings for tachypnea, vomiting, rash, neck stiffness, photophobia, and altered mental status that identified Meningitis as an unlikely diagnosis. Nevertheless, the data is not accurate since the patient’s subjective data did not reveal any muscle pain. The patient also had a normal range of motion and good muscle strength and coordination, which could not be achieved with myalgia. Furthermore, the patient’s chief complaint was vomiting, and this makes the negative findings stated inaccurate.

Recommendations on Health Promotion

The United States Preventative Task Force (USPTF) recommends that health care providers conduct screening for obesity in adolescents and children older than six years. Besides, it suggests that health providers should provide or refer obese children and adolescents for comprehensive and rigorous behavioral therapies that facilitate improvement in weight (Grossman et al., 2018). The USPTF further states that certain risk factors contribute to obesity, such as genetics, poor nutrition, and inadequate physical activity (Grossman et al., 2018). Poor sleep hygiene, sedentary lifestyles, and families earning a low income also significantly contribute to adolescent and child obesity.

The USPSTF recommends comprehensive and intensive behavioral approaches for a total period of 26 hours, over 2 to 12 months to facilitate weight loss (Grossman et al., 2018). Additionally, behavioral strategies for a total period of 52 hours or more resulted in a higher degree of weight loss and the prevention of cardiovascular and metabolic diseases.

Review this sample SOAP note Click for more options . Explain what needs to be done to improve this note and why. Be sure and identify the following:
Eight (8) or more data points in the subjective history that need improvement
Seven (7) or more data points in the objective history that need improvement
For each diagnosis or differential diagnosis identified, is the pertinent positive and negative data thorough and accurate?
Your response should contain a discussion of National Guidelines and ARHQ Health Promotion recommendations (according to the United States Preventative Task Force [USPTF]) appropriate to the case.

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