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Episodic/Focused SOAP Note Template   Patient Information: Initials, Age, Sex, Race S. CC (chief complaint) a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance headache, NOT bad headache for 3 days”. HPI: 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., 34-year-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 OTC or homeopathic products. Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs 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 Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), 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. 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. ROS: 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: etc. 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. GENITOURINARY:  Burning on urination. Pregnancy. Last menstrual period, 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. ALLERGIES:  No history of asthma, hives, eczema or rhinitis. O. 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 . Differential Diagnoses (list a minimum of 3 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.    This section is not required for the assignments in this course (NURS 6512) but will be required for future courses. References You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 6th edition formatting. © 2019 Walden University Page 1 of 3 21-3 Student Checklist Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Ball: Seidel’s Guide to Physical Examination, 8th Edition Chapter 2 1 : Musculoskeletal System Student Checklist Assessed Appropriately by Student? Yes No Comments I. Inspection and palpation of the musculoskeletal system A. Skeleton and extremities: compare sides for alignment, contour and symmetry, size, gross deformity B. Skin and subcutaneous tissues over muscles and joints for color, number of skinfolds, swelling, masses C. Inspect muscles and compare sides for size, symmetry, fasciculations, or spasms. D. Palpate all bones, joints, and surrounding muscles for muscle tone, heat, tenderness, swelling, and crepitus. E. Test each major joint for active and passive range of motion and compare sides. F. Test major muscle groups for strength and compare sides. G. Hands and wrists 1. Dorsum and palm of hands for contour, position, shape, number and completeness of digits 2. Palpate each joint in the hand and wrist. 3. Test range of motion: metacarpophalangeal flexion and hyperextension; thumb opposition; forming a fist; finger adduction and abduction; wrist extension, hyperextension and flexion; radial and ulnar motion H. Elbows 1. Inspect the elbows in flexed and extended position for contour and carrying angle. 2. Palpate the extensor surface of the ulna, olecranon process, and the medial and lateral epicondyles of the humerus. 3. Test range of motion: flexion, extension, pronation, and supination. I. Shoulders 1. Shoulders and shoulder girdle for contour. 2. Palpate the joint spaces and bones of the shoulders. 3. Test range of motion: shrugging, forward flexion and hyperextension, abduction and adduction, internal and external rotation. 4. Test muscle strength: shrugging, abduction with forward flexion, medial rotation, lateral rotation. J. Temporomandibular joint 1. Palpate the joint space for clicking, popping, and pain. 2. Test range of motion: opening and closing mouth, moving jaw laterally to each side, protruding and retracting jaw. 3. Test strength of temporalis muscles. K. Cervical spine 1. Neck for alignment, symmetry of skinfolds and muscles 2. Test range of motion: forward flexion, hyperextension, lateral bending, and rotation. 3. Test strength of sternocleidomastoid and trapezius muscles. L. Thoracic and lumbar spine 1. Spine for alignment. 2. Palpate the spinal processes and paravertebral muscles. 3. Percuss for spinal tenderness. 4. Test range of motion: forward flexion, hyperextension, lateral bending, rotation. M. Hips 1. Hips for symmetry and level of gluteal folds 2. Palpate hips and pelvis for instability, tenderness, and crepitus. 3. Test range of motion: flexion, extension, and hyperextension; adduction; abduction; internal and external rotation. 4. Test muscle strength: knee in flexion and extension, abduction and adduction. N. Legs and knees 1. Knees for natural concavities 2. Palpate the popliteal space and joint space. 3. Test range of motion: flexion and extension. 4. Test the strength of muscles in flexion and extension. O. Feet and ankles 1. Feet and ankles during weight bearing and non–weight bearing for contour, alignment with tibias, size, number of toes 2. Palpate the Achilles tendon and each metatarsal joint. 3. Test range of motion: dorsiflexion and plantar flexion, inversion and eversion, and flexion and extension of the toes. 4. Test strength of muscles in plantar flexion and dorsiflexion. 21-4 Key Points Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Ball: Seidel’s Guide to Physical Examination, 8th Edition Chapter 21: Musculoskeletal System Key Points This review discusses examination of the musculoskeletal system. Before the exam, gather the necessary equipment: a skin-marking pencil, goniometer, tape measure, and reflex hammer. Begin by simply observing the patient’s gait and posture. Inspect the skeleton and extremities when the patient stands, sits, and walks. Compare sides for alignment. Note the contour, symmetry, and size of body parts as well as any gross deformity. When examining each region, observe the following guidelines. Inspect the skin and subcutaneous tissues over the muscles and joints, noting the skin color and number of skinfolds. Observe for any discoloration, swelling, or masses. Inspect the muscles and compare contralateral sides for size and symmetry. Stay alert for gross hypertrophy or atrophy, fasciculations, and spasms. Palpate the bones, joints, and surrounding muscles to evaluate muscle tone and detect any heat, tenderness, swelling, joint fluctuation, crepitus, pain, or resistance to pressure. Examine each major joint for active and passive range of motion. If the range of motion seems increased or decreased, use a goniometer to measure the angle at the joint. Test muscle strength by applying resistance as the patient moves. Grade muscle strength from 0 (for no movement) to 5 (for full range of motion against gravity and full resistance). To examine the joints of the upper extremities, perform the following. Examine the hands and wrists in four ways. First, inspect the dorsum and palm of the hands. Note their contour, position, and shape and the number and completeness of fingers. Second, palpate each joint in the hand and wrist. Joint surfaces should be smooth and without nodules, swelling, bogginess, or tenderness. Third, test the range of motion. Metacarpophalangeal flexion should be 90 degrees. Metacarpophalangeal hyperextension should be 30 degrees. The patient should be able to demonstrate thumb opposition, form a fist, and adduct and abduct the fingers. You should see wrist flexion of 90 degrees and wrist hyperextension of 70 degrees. Expect radial motion to be 20 degrees and ulnar motion to be 55 degrees. Fourth, evaluate muscle strength by testing wrist flexion and hyperextension and hand grip. Assess the elbows with four methods. First, inspect the elbows in the flexed and extended positions. Note their contour and carrying angle, which should be 5 to 15 degrees laterally. Second, palpate the extensor surface of the ulna, olecranon process, and medial and lateral epicondyles of the humerus. Third, check the range of motion. With elbow flexion, range of motion should be 160 degrees. With extension, it should be 180 degrees. With pronation and supination, it should be 90 degrees. Fourth, assess muscle strength during elbow flexion and extension. Evaluate the shoulders using four techniques. First, inspect the contour of the shoulders, shoulder girdle, clavicles, scapulae, and surrounding muscles. All shoulder structures should be symmetrical in size and contour. Second, palpate the sternoclavicular joint, clavicle, acromioclavicular joint, scapula, coracoid process, greater tubercle of the humerus, biceps groove, and area muscles. Third, examine range of motion. The patient should be able to shrug their shoulders, perform forward flexion to 180 degrees and hyperextension to 50 degrees, complete abduction to 180 degrees and adduction to 50 degrees, and do internal and external rotation of 90 degrees. Fourth, test the muscle strength as the patient shrugs their shoulders. This maneuver also tests cranial nerve (CN) XI . To examine the joints of the head and neck, perform the following. Assess the temporomandibular joint in three ways. First, palpate the joint space for clicking, pain, crepitus, locking, or popping. Second, assess range of motion by having the patient open and close their mouth, move the lower jaw to each side, and protrude and retract the jaw. Third, test the strength of the temporalis and masseter muscles with the patient’s teeth clenched. With this test, remember you are also evaluating CN V . Examine the cervical spine using four techniques. First, inspect the neck for alignment as well as symmetry of the skinfolds and muscles. Second, palpate the posterior neck, cervical spine, and paravertebral, trapezius, and sternocleidomastoid muscles. Third, evaluate range of motion by forward flexion (which should be about 45 degrees), extension (about 45 degrees), lateral bending (about 40 degrees), and rotation (about 70 degrees). Fourth, test the strength of the sternocleidomastoid and trapezius muscles. This test also assesses CN XI . To examine the joints of the spine and hips, perform the following. Assess the thoracic and lumbar spine with four maneuvers. First, inspect the landmarks of the back for alignment. Note the curves of the spine. Remember that lordosis (or inward curvature of the spine) is common in patients who are obese or pregnant. Second, palpate along the spinal processes and paravertebral muscles. Third, percuss for spinal tenderness. Fourth, examine range of motion. Expect forward flexion of 75 to 90 degrees, hyperextension of 30 degrees, lateral bending of 35 degrees, and forward and backward rotation of the upper trunk of 30 degrees. Evaluate the hips in three ways. First, inspect the hips, checking for symmetry, size of the buttocks, and numbers and level of the gluteal folds. Second, check the hip range of motion. Hip flexion with the knee extended should be 90 degrees; with the knee flexed, it should be 120 degrees. Hip hyperextension with the knee extended should be 30 degrees. Hip abduction should be 45 degrees, and adduction should be 30 degrees. Internal rotation should be 40 degrees, and external rotation should be 45 degrees. Third, test the muscle strength during hip flexion with the knee flexed and then extended, during abduction and adduction, and when the seated patient uncrosses their legs. To examine the joints of the lower extremities, perform the following. Assess the legs and knees using four techniques. First, inspect the knees, their popliteal spaces, and lower leg alignment. The expected angle between the femur and tibia is less than 15 degrees. Second, palpate the popliteal space and tibiofemoral joint space, particularly noting tenderness, swelling, bogginess, nodules, or crepitus. Third, evaluate knee range of motion. Expect 130 degrees of flexion, full extension, and up to 15 degrees of hyperextension. Fourth, test the strength of the knee muscles while the patient maintains flexion and extension. Examine the feet and ankles with four methods. First, inspect the feet and ankles while the patient is bearing weight and while sitting. Observe landmarks; contour; arches; foot alignment with the tibia; toe alignment with the other toes; and the position, size, and number of toes. Second, palpate the Achilles tendon, anterior surface of the ankle, medial and lateral malleoli, and each metatarsophalangeal joint. Third, check the range of motion with the patient seated. Dorsiflexion should be 20 degrees. Plantar flexion should be 45 degrees. Expect inversion of 30 degrees and eversion of 20 degrees. Expect abduction of 10 degrees and adduction of 20 degrees. Expect flexion and extension of the toes, especially the great toes. Fourth, test the muscle strength during dorsiflexion and plantar flexion and possibly during ankle abduction and adduction and great toe flexion and extension. To further evaluate specific joints, perform these additional procedures. If you need to evaluate the median nerve in the hand, have the patient mark the locations of pain, numbness, and tingling on the Katz hand diagram. Also test for Tinel sign and perform the thumb abduction and Phalen tests. To assess the rotator cuff in the shoulder for impingement or a tear, perform the Neer test and the Hawkins test. Also test the strength of the supraspinatus, subscapularis, infraspinatus, and teres minor muscles. Note any weakness and pain. To further evaluate the lower spine, use the straight leg raising test and the femoral stretch (or hip extension) test. For suspected hip problems, use the Thomas test to identify flexion contractures and the Trendelenburg test to spot weak hip abductor muscles. For additional knee assessment, use ballottement and check for the bulge sign to detect excess fluid in the knee. Perform the McMurray test to detect a torn medial or lateral meniscus. Use the anterior and posterior drawer test, Lachman test, and varus and valgus stress tests to identify instability in specific ligaments. When you suspect a difference in length or circumference of matching extremities, measure and compare the size of both limbs. A 46-year-old female reports pain in both of her ankles, but she is more concerned about her right ankle. She was playing soccer over the weekend and heard a pop. She is able to bear weight, but it is uncomfortable. In determining the cause of the ankle pain, based on your knowledge of anatomy, what foot structures are likely involved? What other symptoms need to be explored? What are your differential diagnoses for ankle pain? What physical examination will you perform? What special maneuvers will you perform? Should you apply the Ottawa ankle rules to determine if you need additional testing? Your Discussion post should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style Discussion posting format Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patients differential diagnosis, and justify why you selected each.  · Consider what history would be necessary to collect from the patient in the case study you were assigned. · Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patients condition. How would the results be used to make a diagnosis? · Identify at least five possible conditions that may be considered in a differential diagnosis for the patient. Case 2: Ankle Pain  Knee Pain A 15-year-old male reports dull pain in both knees. Sometimes one or both knees click, and the patient describes a catching sensation under the patella. In determining the causes of the knee pain, what additional history do you need? What categories can you use to differentiate knee pain? What are your specific differential diagnoses for knee pain? What physical examination will you perform? What anatomic structures are you assessing as part of the physical examination? What special maneuvers will you perform? Your Discussion post should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style Discussion posting format Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patients differential diagnosis, and justify why you selected each.  · Consider what history would be necessary to collect from the patient in the case study you were assigned. · Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patients condition. How would the results be used to make a diagnosis? · Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.