Case Study 1:
HPI: Mario is a 66-year-old Hispanic male who presents to the emergency room at his local hospital with acute aphasia, right facial droop, and right-sided weakness. The sudden onset of symptoms occurred at the post office where he works part-time. One of his co-workers called 911. On the way to the hospital, the advanced squad team evaluated Mario’s neurologic deficits and glucose levels. The squad team then notified the receiving hospital of a possible stroke patient.
Upon Mario’s arrival at the hospital, the ER nurse practitioner proceeds to gather the patient’s medical history from his wife, Lucinda, who accompanied him in the ambulance. She tells the nurse practitioner that Mario has a history of uncontrolled hypertension (and he was often non-compliant with his anti-hypertensive medications). His recent diagnosis of diabetes also was noted, as well as the oral hypoglycemic agents he was taking.
The wife states both of Mario’s parents passed away from myocardial infarctions when they were in their late 60s.
Smoking history: Mario is a smoker, usually smoking about a pack and a half each day.
Exercise history: Mario leads a sedentary lifestyle that had contributed to his excess weight.
At 5’5” inches, Mario weighs 255 pounds. BMI of: ____
What other family history, social history, and vital signs will you obtain from the wife and the patient?
What diagnostic tests will you order for Mario to determine what type of stroke he is having? List at least four diagnostic tests you would order and explain the rationale of each test.
The CT scan indicated a diagnosis of stroke. However, the lab tests and CT scan performed on Mario indicated there was no hemorrhage or early signs of ischemia. What education can you provide the family about the results of a CT scan for the diagnosis of a brain stroke?
You tell Mario’s wife that it is crucial to recognize the signs of an impending stroke. Describe at least four symptoms and signs of stroke you will educate the patient and family to look for.
You also discuss the RISK factors for stroke with Mario’s family. Lucinda realizes that Mario meets the criteria for all of them. List at least four risk factors for having a stroke:
List at least three differential diagnoses for the symptoms listed above:
What referrals will you make for Mario after his stroke?
Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S (subjective)
CC (chief complaint): a BRIEF statement identifying why the patient is here, stated in the
patient’s own words (for instance “headache,” NOT “bad headache for 3 days”).
HPI (history of present illness): This is the symptom analysis section of your note.
Thorough documentation in this section is essential for patient care, coding, and billing
analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to
complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34year-old AA male). You must include the seven attributes of each principal symptom in
paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might
look like the following example:
•
•
•
•
•
•
•
Location: Head
Onset: 3 days ago
Character: Pounding, pressure around the eyes and temples
Associated signs and symptoms: Nausea, vomiting, photophobia, phonophobia
Timing: After being on the computer all day at work
Exacerbating/relieving factors: Light bothers eyes; Aleve makes it tolerable but
not completely better
Severity: 7/10 pain scale
Current Medications: Include dosage, frequency, length of time used, and reason for
use; also include over the counter (OTC) or homeopathic products.
Allergies: Include medication, food, and environmental allergies separately, including a
description of what the allergy is (i.e., angioedema, anaphylaxis, etc.). This will help
determine a true reaction versus intolerance.
PMHx: Include immunization status (note date of last tetanus for all adults), past major
illnesses, and surgeries. Depending on the CC, more info is sometimes needed.
Soc and Substance Hx: Include occupation and major hobbies, family status, tobacco
and alcohol use (previous and current use), and any other pertinent data. Always add
some health promo question here, such as whether they use seat belts all the time or
whether they have working smoke detectors in the house, living environment, text/cell
phone use while driving, and support system.
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Fam Hx: Illnesses with possible genetic predisposition, contagious, or chronic illnesses.
Reason for death of any deceased first-degree relatives should be included. Include
parents, grandparents, siblings, and children. Include grandchildren if pertinent.
Surgical Hx: Prior surgical procedures.
Mental Hx: Diagnosis and treatment. Current concerns (anxiety and/or depression).
History of self-harm practices and/or suicidal or homicidal ideation.
Violence Hx: Concern or issues about safety (personal, home, community, sexual
(current and historical).
Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no),
Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse
(oral, anal, vaginal, other, any sexual concerns).
ROS (review of symptoms): Cover all body systems that may help you include or rule
out a differential diagnosis You should list each system as follows:
•
•
•
•
General:
Head:
EENT (eyes, ears, nose, and throat):
Etc.:
Note: You should list these in bullet format, and document the systems in order from
head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT:
•
•
Eyes: No visual loss, blurred vision, double vision or yellow sclerae.
Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore
throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations
or edema.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain
or blood.
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GENITOURINARY: Burning on urination. Last menstrual period (LMP), MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or
tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or
polydipsia.
REPRODUCTIVE: Not pregnant and no recent pregnancy. No reports of vaginal or
penile discharge. Not sexually active.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
O (objective)
Physical exam: From head-to-toe, include what you see, hear, and feel when doing your
physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and
History. Do not use “WNL” or “normal.” You must describe what you see. Always
document in head to toe format (i.e., General: Head: EENT: etc.).
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop
the differential diagnoses (support with evidenced and guidelines).
A (assessment)
Differential diagnoses: List a minimum of three differential diagnoses. Your primary or
presumptive diagnosis should be at the top of the list. For each diagnosis, provide
supportive documentation with evidence-based guidelines.
P (plan)
Includes documentation of diagnostic studies that will be obtained, referrals to other
health-care providers, therapeutic interventions, education, disposition of the patient,
and any planned follow up visits. Each diagnosis or condition documented in the
assessment should be addressed in the plan. The details of the plan should follow an
orderly manner.
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Also included in this section is the reflection. Reflect on this case, and discuss what
you learned, including any “aha” moments or connections you made.
Also include in your reflection, a discussion related to health promotion and disease
prevention taking into consideration patient factors (such as, age, ethnic group, etc.),
PMH, and other risk factors (e.g., socio-economic, cultural background, etc.).
References
You are required to include at least three evidence-based peer-reviewed journal articles
or evidenced-based guidelines, which relate to this case to support your diagnostics and
differentials diagnoses. Be sure to use correct APA 7th edition formatting.
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