ANSWER
The four elements of the SOAP acronym—Subjective, Objective, Assessment, and Plan—should be used to organize a SOAP note for an NP (Nurse Practitioner) scenario. This is a broad overview of the SOAP note’s structure:
Example of a SOAP Note
34-year-old Black woman patient
Visit Date: [Insert Date]
Presenting Problem: Leg cramps and chest pain
S: Personal
“I’ve been experiencing leg cramps and chest pain for a few days now,” is the Chief Complaint (CC).
Present Illness History (HPI):
For the past three days, the 34-year-old woman has been experiencing ongoing chest pain. describes the discomfort as confined to the middle of the chest, acute, and sporadic. The discomfort gets better when you move or sit up straight, but it gets worse when you lie down. The patient currently has a pain score of 2/10 and experiences occasional, unpleasant leg cramps. Since she started taking Remicade for Crohn’s illness three weeks ago, she has been smoking one pack of cigarettes every day since she was twenty.
Drugs:
30 minutes before breakfast, 40 mg of pantoprazole each day
50 mg of HCTZ each day
Three weeks ago, Remicade (infliximab) was prescribed for Crohn’s disease.
No medication allergies are known to exist.
History of Society (SH):
14 years of smoking one pack a day, which I stopped three weeks ago
Alcohol: Use on occasion
Work: An office worker
Family History (FH): At the age of 40, the mother died of MI.
Father alive, using hydrochlorothiazide to treat hypertension
No history of GI issues in the family
O: Goal
Vital Signs:
The reading is 148/94 mmHg.
99 beats per minute
20 breaths per minute is the respiratory rate.
99.4°F is the temperature.
95% O2 Saturation
Physical Examination:
In general: A healthy, well-developed woman
Cardiovascular: regular beat, no JVD, no murmurs
Respiratory: No crackles or wheeze, both sides are clear to auscultation.
Soft, non-tender, without rebound or guarding discomfort in the abdomen
Extremities: bilateral 2+ pulses, minimal cyanosis or edema, and mildly uncomfortable leg cramps
Neurological: Three times as alert and focused, with no focal impairments
Skin: No lesions or rashes were found.
A: Evaluation
Given her chest pain, which may be made worse by stress and Crohn’s illness, the primary diagnosis is most likely gastroesophageal reflux disease (GERD).
Secondary Points to Remember:
cramping in the legs caused by electrolyte imbalance or dehydration (after using HCTZ).
Chest pain may be exacerbated by hypertension (BP 148/94).
A history of smoking raises the risk of cardiovascular disease.
Recent drug use: Crohn’s disease remicade therapy, which may affect cardiovascular and immune system health.
P: Make a plan
Drugs:
To better control blood pressure, think about modifying antihypertensive medication.
To treat leg cramps, take a potassium supplement or suggest eating more foods high in potassium, such as oranges and bananas.
For 2-4 weeks, begin taking a proton pump inhibitor (PPI) for GERD, such as omeprazole 20 mg before breakfast.
Depending on effectiveness, modify Remicade dosage or look into other Crohn’s disease treatments.
Changes in Lifestyle:
Continue your attempts to quit smoking. If necessary, suggest medication or support groups for quitting smoking.
To improve gastrointestinal and cardiovascular health, increase physical exercise and use mindfulness or relaxation techniques to minimize stress.
A follow-up blood pressure check and evaluation of leg cramps are scheduled for one to two weeks later.
Diagnostics:
Given her family history of MI, an ECG is necessary to rule out any cardiac causes of chest pain.
electrolytes (potassium, sodium, and magnesium) to determine whether leg cramps are caused by any imbalances.
Troponin and BNP are cardiac biomarkers used to rule out myocardial infarction.
Given her history of Crohn’s disease, stool for occult blood is necessary to assess any potential GI hemorrhage.
Suggestions:
Referral to cardiology if chest pain doesn’t go away or if the ECG yields alarming findings.
follow-up with a GI expert to continue managing Crohn’s disease.
Patient Instruction:
Teach them how to take their medications as prescribed, particularly for GERD.
Stress the value of staying hydrated and keeping an eye out for leg cramps.
Talk about ways to lower your risk of cardiovascular disease, such as quitting smoking, changing your diet, and getting frequent follow-up care for high blood pressure.
[Insert three academic sources with APA citations]
QUESTION
NP
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.
create a soap note using the following template and follow the rubric attached