Make a SOAP Note: Assessing the Heart, Lungs, and Peripheral Vascular System

Scenario

Vital signs:
Temperature: 100.9 oral
Respiratory rate: 20, labored
Heart rate: 82 BP right arm: 128/70
Oxygen saturation: 89% on room air
Weight: 210 lbs, stable
Skin: Warm, moist

Thorax and lungs: Thorax symmetrical; diminished breath sounds with rales and expiratory wheezes throughout; no rhonchi; wet, productive cough noted during exam

Cardiovascular: Heart rate regular with good S1, S2; no S3 or S4; no murmur

Abdomen: Protuberant, with normoactive bowel sounds auscultated x4 quadrants

Peripheral vascular: No pedal edema; 2+ dorsalis pedis pulses bilaterally

Neurologic: Awake, alert, and oriented to person, place, and time

Instructions: Your Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to the Comprehensive SOAP Template/Exemplar on the attachments below.

Address all these in the SOAP Note:

1. A description of the health history you would need to collect from the patient in the case study 3.
2. Explain what physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis.
3. List five different possible conditions for the patient's differential diagnosis, and justify why you selected each.
4. Final diagnosis and justify it.

REMINDER: Please make a SOAP NOTE for this case. Make your own patient's data, applicable health history, review of systems, P.E., labs, etc. Incorporate the data from the case 2 in the SOAP note that you will do... This is not essay ok.... I need SOAP note (Nurse Practitioner/RN/MD makes SOAP note)... Be guided with the templates/exemplar... Don't copy paste. Formulate your own... Don't forget to cite the Five different possible conditions (Differential diagnosis) and have Reference lists too.

RESOURCES:

Readings

• Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel's guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

o Chapter 13, "Chest and Lungs" (pp. 260-293)

This chapter explains the physical exam process for the chest and lungs. The authors also include descriptions of common abnormalities in the chest and lungs.

o Chapter 14, "Heart" (pp. 294-331)

The authors of this chapter explain the structure and function of the heart. The text also describes the steps used to conduct an exam of the heart.

o Chapter 15, "Blood Vessels" (pp. 332-349)

This chapter describes how to properly conduct a physical examination of the blood vessels. The chapter also supplies descriptions of common heart disorders.

• Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

o Chapter 8, "Chest Pain" (pp. 81-96)

This chapter focuses on diagnosing the cause of chest pain and highlights the importance of first determining whether the patient is in a life-threatening condition. It includes questions that can help pinpoint the type and severity of pain and then describes how to perform a physical examination. Finally, the authors outline potential laboratory and diagnostic studies.

o Chapter 11, "Cough" (pp. 118-147)

A cough is a very common symptom in patients and usually indicates a minor health problem. This chapter focuses on how to determine the cause of the cough through asking questions and performing a physical exam.

o Chapter 14, "Dyspnea" (pp. 159-173)

The focus of this chapter is dyspnea, or shortness of breath. The chapter includes strategies for determining the cause of the problem through evaluation of the patient's history, through physical examination, and through additional laboratory and diagnostic tests.

o Chapter 26, "Palpitations" (pp. 310-317)

This chapter describes the different causes of heart palpitations and details how the specific cause in a patient can be determined.

o Chapter 33, "Syncope" (pp. 390-397)

This chapter focuses on syncope, or loss of consciousness. The authors describe the difficulty of ascertaining the cause, because the patient is usually seen after the loss of consciousness has happened. The chapter includes information on potential causes and the symptoms of each.

• Sullivan , D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis.

o Chapter 6, "Outpatient Charting and Communications" (pp. 119-141)

Note: Download these Adult Examination Checklists and Physical Exam Summaries to use during your practice cardiac and respiratory examination.

• Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical exam summary: Blood vessels. In Mosby's guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.

This Blood Vessels Physical Exam Summary was published as a companion to Seidel's guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). Fromhttps://evolve.elsevier.com/

• Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Adult examination checklist: Guide for cardiovascular assessment. In Mosby's guide to physical examination(7th ed.). St. Louis, MO: Elsevier Mosby.

This Adult Examination Checklist: Guide for Cardiovascular Assessment was published as a companion to Seidel's guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). Fromhttps://evolve.elsevier.com/

• Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Adult examination checklist: Guide for chest and lung assessment. In Mosby's guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.

This Adult Examination Checklist: Guide for Chest and Lung Assessment was published as a companion to Seidel's guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). Fromhttps://evolve.elsevier.com/

• Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical exam summary: Chest and lungs. In Mosby's guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.

This Chest and Lungs Physical Exam Summary was published as a companion to Seidel's guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). Fromhttps://evolve.elsevier.com/

• Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical exam summary: Heart. In Mosby's guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.

This Heart Physical Exam Summary was published as a companion to Seidel's guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/

• McCabe, C., & Wiggins, J. (2010a). Differential diagnosis of respiratory disease part 1. Practice Nurse,40(1), 35-41.

Retrieved from the Walden Library databases.

This article describes the warning signs of impending deterioration of the respiratory system. The authors also explain the features of common respiratory conditions.

• McCabe, C., & Wiggins, J. (2010b). Differential diagnosis of respiratory diseases part 2. Practice Nurse, 40(2), 33-41.

Retrieved from the Walden Library databases.

The authors of this article specify how to identify the major causes of acute breathlessness. Additionally, they explain how to interpret a variety of findings from respiratory investigations.

• SkillStat Learning, Inc. (2014). The 6 second ECG. Retrieved from http://www.skillstat.com/tools/ecg-simulator#/-home

This interactive website allows you to explore common cardiac rhythms. It also offers the Six Second ECG game so you can practice identifying rhythms.

• University of Virginia. (n.d.). Introduction to radiology: An online interactive tutorial. Retrieved fromhttp://www.med-ed.virginia.edu/courses/rad/index.html

This website provides an introduction to radiology and imaging. For this week, focus on cardiac radiography and chest radiology.

Media

• Laureate Education. (Producer). (2012). Advanced health assessment and diagnostic reasoning. Baltimore, MD: Author.

Note: You will use the case studies presented in the media, Advanced Health Assessment and Diagnostic Reasoning, to complete this week's Discussion.

• Online media for Seidel's Guide to Physical Examination

In addition to this week's media, it is highly recommended that you access and view the resources included with the course text, Seidel's Guide to Physical Examination. Focus on the videos and animations in Chapters 13, 14, and 15 that relate to the assessment of the heart, lungs, and peripheral vascular system. Refer to Week 4 for access instructions on https://evolve.elsevier.com/.

Optional Resources

• LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2009). DeGowin's diagnostic examination (9th ed.). New York, NY: McGraw Hill Medical.

o Chapter 8, "The Chest: Chest Wall, Pulmonary, and Cardiovascular Systems; The Breasts" (Section 1, "Chest Wall, Pulmonary, and Cardiovascular Systems," pp. 302-433)

Note: Section 2 of this chapter will be addressed in Week 10.

This section of Chapter 8 describes the anatomy of the chest wall, pulmonary, and cardiovascular systems. Section 1 also explains how to properly conduct examinations of these areas.