Benchmark – Academic Clinical SOAP Note Essay
Benchmark – Academic Clinical SOAP Note Essay
Benchmark – Academic Clinical SOAP Note Essay
Academic SOAP Note Template
Reason for Follow-Up: Clinical follow-up for a patient seen in neurology on May 23rd, 2023, diagnosed with hypertensive encephalopathy after presenting with a BP-208/108, slight dizziness, and a slightly altered level of consciousness.
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Clinical Course Summary: T.M. is a 57-year-old AA male patient on his third day of admission after he was diagnosed with hypertensive encephalopathy in the neurology clinic. The neurologist recommended admission to the critical care unit for BP management and monitoring of BP. The patient had an initial BP of 208/108 and presented with dizziness and an altered level of consciousness. T.M. is a known hypertsensive patient diagnosed at 54 years. His BP has been uncontrolled in the past four months, and he admitted to being inconsistent with medications. The patient was initiated on Labetalol 2 mg/min by continuous IV infusion. Labetalol was prescribed to promote a consistent drop in BP without compromising cerebral blood flow. During the administration of Labetalol, BP was monitored every 10 minutes. For the past two days in the CCU, the patient has undergone arterial blood pressure monitoring for adequate titration of medications. The CCU nurses have routinely conducted neurologic reassessment to monitor signs of deterioration. The patient’s BP has progressively reduced and is currently at 168/92.
Review of systems:
General: Denies fever, chills, malaise, or weight changes.
Cardiovascular: Reports palpitations. Denies dyspnea on exertion or edema.
Respiratory: Reports wheezing. Denies cough, shortness of breath, sputum, or breathing difficulties.
Neurological: Positive for dizziness, altered level of consciousness, confusion, and headache. Denies tingling sensations or muscle weakness.
GI: Reports nausea. Denies abdominal pain, bowel changes, or rectal bleeding.
Physical Exam:
Vital signs: BP-168/92.; HR- 102; RR-20; Temp-98.4; SPO2-97%
General: The patient is an African American male in his late 50’s. He is lying on the examination bed. The patient is well-groomed and appropriately dressed. He is confused and has an altered level of consciousness.
Cardiovascular: Distended neck veins and diminished pulses. S1 and S2 are audible. No gallop sound or heart murmurs.
Respiratory: Chest expands uniformly. Smooth respirations with no use of accessory muscles. Rales and wheezes were heard bilaterally on auscultation.
Neurological: The patient is in a confused mental state. Repetitive and uncontrolled eye movements.
GI: Soft abdomen, Normoactive bowel sounds, no abdominal tenderness or guarding.
Laboratory and Radiology Results:
Head CT Scan No abnormal findings were noted.
Chest X-ray- Bilateral symmetric ground-glass opacities indicating pulmonary edema.
Assessment:
• Differential diagnoses:
Hypertensive Encephalopathy (ICD10- I67. 4): Hypertensive encephalopathy is characterized by transient migratory neurologic symptoms associated with a malignant hypertensive state in a hypertensive emergency (Balahura et al., 2022). The patient presented with deterioration in neurological status and a severely elevated BP, indicating Hypertensive encephalopathy.
Intracerebral hemorrhage (ICH) (ICD 10- I61. 9): This is a sub-type stroke. Hypertension is a common risk factor. Common symptoms include nausea, vomiting, headache, and sudden change in level of consciousness (McGurgan et al., 2020). The patient’s history of hypertension and neurological clinical features like headache, dizziness, and altered level of consciousness makes ICH a differential.
Acute thrombotic stroke (ICD 10- I63. 30): This is characterized by an abrupt loss of blood circulation to an area of the brain, contributing to a corresponding loss of neurologic function (Kuriakose & Xiao, 2020). The patient presented with a sudden decrease in consciousness and nystagmus, leading to the differential diagnosis of acute thrombotic stroke.
• Acute and chronic medical conditions:
Hypertensive Encephalopathy (ICD10- I67. 4)
Hypertension (ICD 10- I10)
Treatment Plan:
Admission Type: ICU admission.
Diagnostics: ECG, cardiac enzymes, urinalysis, and a metabolic panel with electrolytes and creatinine will be ordered to assess for end-organ damage (Balahura et al., 2022).
Medications: Continue Labetalol continuous infusion at 2 mg/min till BP is below 140/90 (Balahura et al., 2022).
After controlling BP, maintain the patient on Labetalol 200 mg orally BD.
Consultations: Consult a cardiologist and neurologist to assess the patient’s cardiovascular and neurological status and recommend a management plan if there is no improvement (Balahura et al., 2022).
Health education: The patient will be recommended lifestyle modifications. This includes weight management through a healthy diet and increased physical activity. He will be advised on moderating alcohol and sodium intake and quitting smoking to control BP. In addition, he will be educated on the importance of medication adherence to control BP (Balahura et al., 2022).
Discharge Plan: The patient will be discharged on Labetalol since it effectively maintained an adequate BP range during admission. Medication adherence will be emphasized, and adhering to clinic follow-ups to monitor his progress. The patient will be scheduled for a follow-up visit after two weeks.
Geriatric Considerations:
Management of hypertensive encephalopathy in elderly patients should incorporate a comprehensive set of pharmacological interventions, depending on the primary pathophysiological changes related to aging, coexistent comorbidities, preexisting risk factors, rate of progression of the condition, and the degree of organ involvement.
Alshami et al. (2018) explain that clevidipine, Labetalol, nicardipine, esmolol, and fenoldopam are the preferred medications in hypertensive crises in geriatrics owing to their efficacy and tolerability. Nitroprusside, hydralazine, and nifedipine should be avoided unless there are no other options because of the high risk of complications and unpredictable responses. Thus, if the patient were older, he would not be administered Nitroprusside, hydralazine, and Nifedipine to lower the elevated BP. Nitroprusside would be safe for this patient.
References:
Alshami, A., Romero, C., Avila, A., & Varon, J. (2018). Management of hypertensive crises in the elderly. Journal of geriatric cardiology: JGC, 15(7), 504–512. https://doi.org/10.11909/j.issn.1671-5411.2018.07.007
Balahura, A. M., Moroi, Ș. I., Scafa-Udrişte, A., Weiss, E., Japie, C., Bartoş, D., & Bădilă, E. (2022). The Management of Hypertensive Emergencies-Is There a “Magical” Prescription for All? Journal of clinical medicine, 11(11), 3138. https://doi.org/10.3390/jcm11113138
Kuriakose, D., & Xiao, Z. (2020). Pathophysiology and Treatment of Stroke: Present Status and Future Perspectives. International journal of molecular sciences, 21(20), 7609. https://doi.org/10.3390/ijms21207609
McGurgan, I. J., Ziai, W. C., Werring, D. J., Al-Shahi Salman, R., & Parry-Jones, A. R. (2020). Acute intracerebral hemorrhage: diagnosis and management. Practical neurology, 21(2), 128–136. Advance online publication. https://doi.org/10.1136/practneurol-2020-002763
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please follow directions below :
Academic clinical SOAP notes provide a unique opportunity to practice and demonstrate advanced practice documentation skills, develop and demonstrate critical thinking and clinical reasoning skills, and practice identifying acute and chronic problems and formulating evidence-based plans of care.
This assignment uses a template. Refer to the “Academic SOAP Note Template,” located on the college page of the Student Success Center under the AGACNP tab.
Develop a hospital follow-up progress SOAP note based on a clinical patient from your clinical/practicum setting. In your assessment, provide the following:
A one-sentence description of the primary working diagnosis, pending differential diagnoses, and the context or service in which the patient is being seen.
A one- or two-paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures. Include how many days the patient has been hospitalized, if applicable.
List of at least five systems affected by the working diagnosis. Provide two positive or negative effects that the working diagnosis has on each system.
List of at least five systems examined within the past 24 hours. Provide at least two pertinent positive or negative findings relevant to each system examined and include a full set of vital signs.
List of all admission diagnostics conducted for this visit or conducted within the past 24 hours.
List of all pertinent acute and chronic diagnoses in order of priority using ICD-10. Identify any differential diagnoses being eliminated.
Treatment plan that corresponds with the diagnosis. Provide information on admission type, types of diagnostics, any prescribed medications and dosages, and any relevant consults or follow-up procedures needed.
Discussion of any relevant ethical, legal, or geriatric-specific considerations.
Incorporate at least three peer-reviewed articles in the assessment or plan.
While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are required to submit this assignment to LopesWrite. A link to the LopesWrite Technical Support Articles is located in Class Resources if you need assistance.
Please write this note on a patient who came into the hospital and seen by neurology noted to have hypertensive encephalopathy, pt had initial BP 208/108, dizzy slighty altered loc
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Benchmark – Academic Clinical SOAP Note – Rubric
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Primary or Working Diagnosis (B) 6 points
Criteria Description
Primary or Working Diagnosis (C6.2)
Target 6 points
A one-sentence description of the primary working diagnosis, pending differential diagnoses, and context or service in which the patient is being seen is provided and includes supporting details.
- Acceptable 5.4 points
A one-sentence description of the primary working diagnosis, pending differential diagnoses, and context or service in which the patient is being seen is provided accurately.
- Approaching 4.8 points
A one-sentence description of the primary working diagnosis, pending differential diagnoses, and context or service in which the patient is being seen, is provided.
- Insufficient 3 points
A one-sentence description of the primary working diagnosis, pending differential diagnoses, and context or service in which the patient is being seen, is incomplete or incorrect.
- Unsatisfactory 0 points
A one-sentence description of the primary working diagnosis, pending differential diagnoses, and context or service in which the patient is being seen, is not provided.
Brief Clinical Course (B) 6 points
Criteria Description
Brief Clinical Course (C7.4)
- Target 6 points
A one-to-two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures and the number of days since the
Review Of Systems 6 points
Criteria Description Review Of Systems
Exam 6 points
Criteria Description Exam
Diagnostics 6 points
Criteria Description Diagnostics
Impression or Assessment 6 points
Criteria Description Impression or Assessment
Plan (B) 6 points
Criteria Description Plan (C7.5)
Geriatric Speci c Care 6 points
Criteria Description Geriatric Specific Care
Mechanics of Writing 6 points
Criteria Description
Includes spelling, capitalization, punctuation, grammar, language use, sentence structure, etc.
Format/Documentation 6 points
Criteria Description
Uses appropriate style, such as APA, MLA, etc., for college, subject, and level; documents sources using citations, footnotes, references, bibliography, etc., appropriate to assignment and discipline
