Harold SOAP Note Analysis

Harold SOAP Note Analysis
SOAP Note Template
Subjective Data
ID: Harold James
male
10/01/1948
72 years
African American
CC: Otitis Externa and TIA
HPI: The patient presents in the company of her daughter who expresses the complaints. She reports that over the past year, Harold has been developing memory loss. She noticed that he was becoming forgetful and regularly forgot the conversations of the day. She also reports an incident in which Harold stared at her for 30 seconds with a slurred speech. The incident happened a few days ago. Also, he complains of pain in the left ear that he rates at 8/10. The pain has no reliever and has lasted one week. The daughter reports a swollen left ear opening with a yellowish-tan discharge, a recurring problem. She relates the problem with his habit of aggressively using cotton swabs on the ear. She also noticed that her father was not compliant with medication because of the omission of some daily fills in the medication container.

PMH/ surgical history: He has a history of HTN and hypercholesterolemia. There is a history of surgery where there was the placement of right coronary artery stent and repair of right inguinal hernia.

Family and Social History: His father and paternal uncle had Alzheimer’s disease and CAD. The patient is a smoker, lives alone and drives 5 miles daily.

ROS: Positive findings relating to otitis media include pain, swollen left ear opening, and yellowish-tan discharge from the left ear. The negative results include the absence of fever, visible injury, and perforations. The ear landmarks are all visible. Relating to TIA, the positive findings include slurred speech, memory loss and history of 30 seconds staring. The negative results include no difficulties in walking and no facial muscle numbness.

Allergies: no allergies were reported

Current medication: Bystolic 5mg daily, Lisinopril and hydrochlorothiazide 20/25 daily, Plavix 75mg daily, ASA 325 daily, and Lipitor 40mg daily.

Objective Data

Vital signs: BP-178/98 P- 72 RR- 16 PULSE- 72 TEMPERATURE- 99.2 HT- 70’’ WT- 197 BMI- 28.3 PAIN- 8/10

Physical Examination

General: The patient is well-groomed and healthy. He is oriented to place, date, and time. The patient shows no signs of distress. The thought process is good, and mood and affect are flat.

HEENT: On physical exam, the head is symmetrical, and no baldness. The eyes have no discharge, no pallor, and no signs of jaundice. On observation, the left ear skin is reddened and swollen with a yellowish-tan discharge present. There is no smelling from the ear canals. Left ear canals reddened and swollen. On palpation, the left ear is tender.

Neck/Lymph: On assessment, there is no neck stiffness, the neck is midline, and the trachea is midline. The lymph nodes are palpable and not swollen.

Breasts: No breast tenderness noted and all breasts present and symmetrical. The breasts have no tenderness.

Chest/Respiratory: The chest is symmetrical, and the bilateral expansions are equal. On auscultation, the lungs are clear with no wheezing sounds. No breathing difficulties were noted.

CV: RRR, normal S1/S2, no murmurs, rubs, gallops, thrills, or edema.

GI/Abdomen: The abdomen is round, soft, and no distention. On palpation, there is no tenderness. On auscultation, the bowel sounds are present and normal.

GU/Rectal: No foul smell, pubic hair present. The anus is patent.

Back: The backbone is straight and continuous. No back pains.

MSK: Joints, bones and muscles symmetrical. No swollen or tender joints. There is the ease of movement.

Skin: the skin is warm and dry. No redness or tenderness.

Neuro: The patient is conscious, alert and oriented to time, date, and place. The levels of cognition and judgement are appropriate. No headache, dizziness, syncope, paralysis, ataxia, tingling sensations in the extremities. No change in the bowel and bladder controls.

Psych: On mental status examination, the patient showed no signs of depression and anxiety. The MSE score was 24.

Problem list:

Left ear pain

Left ear yellowish-tan discharge

Memory loss

Brief slurred speech and staring

Differential Diagnoses:

Differential diagnoses	How was the diagnosis ruled?
Brain tumour	The patient had no signs of severe unilateral headache, nausea, and vomiting common in brain tumour findings. Harold no severe headache: thus, TIA remained the only diagnosis.
Carcinoma of the ear canal	Carcinoma is characterized by abnormal tissue growth in the ear canal with pain. The pain in carcinoma is mild compared to the pain in otitis externa.
Contact dermatitis	Contact dermatitis develops after exposure to topical agents, and it is associated with itching. Harold had no history of exposure to topical agents. Her daughter related the problems of her father with his aggressive use of cotton swabs.

Plan

Plan	Rationale and EBP/ Supporting documentation
Ciprofloxacin 2 drops twice a day for 7 days.	An antimicrobial drug that inhibits bacterial growth
Tramadol 50mg QID for 3 days.	Acts on the opioid receptors to relieve pain
Asprin 75mg once a day for 21 days.	It acts to reduce inflammation.
Stop the use of Lisinopril.	Seriously interacts with aspirin.
Culture and sensitivity.	To determine the presence of any bacteria.
CT and MRI scan in TIA.	To determine the extent of brain damage and rule out other diseases
Patient education on the conditions and risk factors such as smoking for TIA.	Patient educations enable the patient to understand the management and avoid risk factors of diseases.
Daily follow-ups	To ensure the patient’s well-being and maintain medication compliance.
Referral to the psychiatrist and cardiologist	Psychiatrists initiate therapies to reverse memory loss. The cardiologist will examine the carotid artery for any signs of blockage.

ICD-10- codes:

Otitis Externa: H60.92

TIA: G45.9

E$M code: 99214

HPI: Extended history

ROS: Extended

PMH/FH/SH: Complete

PE: Detailed

Reflection

Questions

Open-ended questions provide healthcare providers with an opportunity to obtain in-depth information from the patient concerning the presenting illness. The information is used in the formulation of a treatment plan for the patient and guide in ruling out other diseases. (Jarvis, 2018). Some of the questions that I would ask include:

What worsens the ear pain? Harold reported ear pain, which he rated at 8/10, which made it difficult to lie on it. The rationale for asking the question is to understand the source of the pain. Information obtained is also used to develop a plan for the patient. The plan focusses at helping the patient to avoid the factors that aggravate the pain.
Do you experience any loss of hearing? Since Harold presented with problems related to the ear, the healthcare provider would try to understand the extent of the damages resulting from the problem. The question opens room for further information that the patient could have omitted when giving a history of the complaints. Presence or absence of hearing is used to the development of a differential diagnosis.
What medication has he used since the problem started? Harold’s daughter ought to describe any interventions if any, that the patient has tried to alleviate the problems. In cases of pain, some patients use local applications on the skin to ease the pain. Substances that are not medically approved can bring more harm than cure. Any medical interventions before the visitation can be used to plan for the care of the patient. (Kruk et al., 2018).
Do you have any history of seizure, TIA, or central nervous infections? The question would aim at determining the causal factors of the disease. Identifying the risk factors that the patient would be exposed to aids in the management of the condition and prevention of future occurrence.
What major experiences preceded the onset of memory loss? The question aims at identifying factors that could be associated with the problem. For example, patients with traumatic brain injuries have been reported to be experiencing memory loss.

The rationale for Physical Examination

There was an in-depth assessment of the neurological examination to obtain findings that are used to develop a differential diagnosis. The exam identifies the level of consciousness of patients. Through the exam, the healthcare provider can understand the factors that predisposed the patient to the condition and identify any complications developing. Risk factors get used in the prevention of the condition from future occurrence. (Nuttall, 2016). Infections from the ear can spread to the brain; thus, a thorough neurological exam is critical.

Another area of focus is the HEENT assessment. Since otitis externa is associated with the ears, there was a need to assess if the patient had developed any hearing loss. Hearing loss determines the severity of the condition and can be used to rule out other diseases. Hearing loss is assessed using the Whispered Voice Test. The psychiatry assessment is useful in determining the level of memory loss. A cognitive loss gets determined through the mental status examination. (Nuttall, 2016). Harold scored 24, which indicates normal cognitive functioning.

Evidence-Based Articles

The authors aimed at identifying the extent of the use of systemic antibiotics by patients with acute otitis externa. The authors also assessed the impacts of the use of Acute Otitis Externa guideline, published in 2006. An interrupted time-series study of retrospective data was carried out using the Medicaid billing data from 29 states between 2000 and 2010. The authors identified no significant change in the use of systemic antibiotics after the introduction of the guidelines. The link to the article is provided: https://journals.lww.com/otology-neurotology/fulltext/2018/10000/use_of_systemic_antibiotics_for_acute_otitis.4.aspx

The second article, the authors researched the incidence and prevalence of dementia in patients before and after suffering from TIA and stroke. Pre-event and post-event dementia patients who had TIA in the UK were followed up for five years. The results of the study showed an increased incidence of dementia in patients who had suffered from TIA. Therefore, it is critical to focus on early intervention and prevention of TIA to prevent further complications. The link to the article is provided: https://www.sciencedirect.com/science/article/pii/S1474442218304423

Barriers

Harold is likely to have little or no knowledge concerning the diagnosed conditions. Aggressive introduction of cotton swabs into the ear canal is evidence of a lack of understanding of the risk factors of ear conditions. He frequently smokes despite smoking being a risk factor of TIA. The nurse practitioner needs to educate the family about the conditions emphasizing on their risk factors. Family education is critical to prevent future occurrence of health problems. (Nuttall, 2016).

Another barrier is loneliness. The patient lives alone despite suffering from memory loss. The factor raises questions on Harold’s medication compliance. The nurse practitioner is responsible for making follow-ups on the compliance of the patient to medication. The family ought to be advised to be close to the patient until he recovers. Being forgetful subjects an individual to such serious social problems. (Kruk et al., 2018). For example, Harold can forget and carelessly touch an iron box that he could have forgotten to put off.

References

Jarvis, C. (2018). Physical Examination and Health Assessment-Canadian E-Book. Elsevier Health Sciences.

Kruk, M. E., Gage, A. D., Arsenault, C., Jordan, K., Leslie, H. H., Roder-DeWan, S., … & English, M. (2018). High-quality health systems in the Sustainable Development Goals era: time for a revolution. The Lancet Global Health, 6(11), e1196-e1252.

Li, L., Yiin, G. S., Geraghty, O. C., Schulz, U. G., Kuker, W., Mehta, Z., … & Study, O. V. (2015). Incidence, outcome, risk factors, and long-term prognosis of cryptogenic transient ischaemic attack and ischaemic stroke: a population-based study. The Lancet Neurology, 14(9), 903-913.

Nuttall, T. (2016). Successful management of otitis externa. In Practice, 38(Suppl 2), 17-21.

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