[Solved] soap note pt 2

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Assignment Prompt & Instructions

review by rubric and add references

– 2 years ago

**files (2)**

– ## MSNSoapNoteRubricElsaPreceptor.pdf

– ## SoapNotetrachandStentPatient.docx

**## MSNSoapNoteRubricElsaPreceptor.pdf**

SOAP NOTE RUBRIC

Criteria Points Competent Need Improvement Not Acceptable

Score

Subjective (35 points) Provides
complete, concise,
and accurate
information,
which is well
organized and
easy to
understand.

Provides most of the
pertinent
information, but is
not well organized
and/or is slightly
challenging to
understand. May be
missing pertinent
negative information
(e.g., patient
denies…).

Limited or no
summary of
pertinent
information, is
organized
poorly, contains
inaccurate
information,
and/or is
difficult to
understand.

Chief complaint 5 5 3 1
HPI 10 10 8 6
Relevant PMH & FH 5 5 3 1
ROS 10 10 8 6
Currents: Allergies,
Meds/OTCs, Tobacco,
Immunizations, Diet, Exercise,
Sleep

5 5 3 1

Objective (40 points) Provides
complete, concise,
and accurate
information,
which is well
organized and
easy to
understand.

Provides most of the
pertinent
information, but is
not well organized
and/or is slightly
challenging to
understand. May be
missing pertinent
negative information
(e.g., patient denies)

Limited or no
summary of
pertinent
information, is
organized
poorly, contains
inaccurate
information,
and/or is
difficult to
understand.

General survey (Describe the
state of the patient at the time
of the examination)

10 10 8 6

Vital signs
Height, Weight, BMI

10 10 8 6

Physical exam-systematic,
organized and thorough and
related to the reason of the visit

20 20 18 16

Diagnosis/ Differentials
Diagnosis (10 points)

Main diagnosis/
Differentials
Diagnosis is
supported by the
objective and
subjective
assessment and
rationale for
choosing the

Main diagnosis/
Differentials
Diagnosis is
supported by the
objective and
subjective assessment
but the rationale for
choosing the
diagnosis is not

Main diagnosis/
Differentials
Diagnosis is not
supported by
the objective
and subjective
assessment and
the rationale for
choosing the

SOAP NOTE RUBRIC

diagnosis is
supported by the
evidence

supported by the
evidence

diagnosis is not
supported by
the evidence

Diagnosis/(Assessment) 5 5 3 1
List of differentials supported
by S+O findings (5 points)
Must provide 3 differential
diagnoses with one citation
for each diagnosis.

5 5 3 1

Plan of care (10 Points) Complete and
appropriate plan
for the main
problem and
other active
problems.
Includes
pharmacologic
and/or non-
pharmacologic
and/or complete
sig components.

Mostly complete and
appropriate plan for
the main problem
and other active
problems. May be
missing appropriate
non-pharmacologic
treatments and/or sig
components.

Missing or
inappropriate
treatment plan
for the main
problem and
other active
problems.

Diagnostic
tests/therapies/medications

5 5 3 1

Follow-up/Pt. Education and
Health Promotion

5 5 3 1

References (5 Points) Provides a
complete and
appropriate list of
references that
are in APA
format.

References listed are
appropriate (i.e.
guidelines or
primary), but not
complete and some
may be missing. Not
APA formatted.

References
missing or very
limited.
References
listed are
inappropriate
(i.e. tertiary)
and/or not
relevant.

References 5 5 3 1
Total 100

Comment:

**## SoapNotetrachandStentPatient.docx**

| | | |
| — | — | — |
| **Patient Initials: MR** | **Pt. Encounter Number: 2-5** |
| **Date: 1/15/2025** | **Age: 70 y.o** | **Sex: Male** |
| **Allergies: NKA Advanced Directives: On File** |
| **SUBJECTIVE** |
| **CC:** _Nurse from Step down reports increased Shortness of breath, sputum production, labored breathing, hypoxia and fever._ |
| **HPI:** 70 year old male presents to the hospital with shortness of breath, cough and fever for 5 days. Today with worsening dyspnea, reports increased thick yellow secretions through tracheostomy and hypoxia. Hx of HIV, multinodular goiter, COPD, tracheal compression most likely due to extrinsic compression due to enlarged thyroid s/p Bronchoscopy Rigid with Placement Tracheal Stent with Airway Dilation, Laser on 1/12/25. Pt was transferred to ICU do to hypoxemic respiratory insufficiency, placed on Bipap overnight, switch to HFNC 40L/100, and stent migration to carina level that needed close monitoring in the ICU. **_Onset:_** 5 days ago **_Location:_** Chest Discomfort with Inspiration, throat pain **_Duration:_** Intermittent **_Characteristics:_** Sore throat, sore back and chest. **_Aggravating Factors:_** While coughing. When Laying Flat **_Relieving Factors:_** Respiratory treatments, Sleeping with HOB elevated, Suctioning. **_Treatment:_** CT ABD Scan STAT ordered, Surgical team on board, labs CBC, BMP, Aptt, PT/INR, blood cx. Close monitoring in ICU. |
| **Current Medications:** Albuterol 180 mcg Inhaler, Mucomyst 200 mg/ml solution 600 mg, Ipratropium-albuterol (Duoneb) 0.5 mg-3 mg Neb Solution, Cefepime 2 G in sodium chloride 0.9 % 100 ml IVPB, Peridex 0.12 % solution 15 ml. Solumedrol 60 mg IV push Insulin regular 100 unit/ml Sliding scale. Cardura 4 mg HS Flomax 0.4 mg QD Pantoprazole 40 mg IV Push QD Cobicistat 150 mg Tab, Darunavir 800 mg tab, Dolutegravir 50 mg tab. Precedex 400 mcg in sodium chloride 0.9 % infusion titrate as per orders. Lexapro 20 tab. Zyprexa 20 mg HS Zolpidem (Ambien) 10 mg Tab HS. |
| **PMH:** HIV, multinodular goiter, COPD, DM, BPH, Depression, Tracheostomy. **Medication Intolerances: None** **Chronic Illnesses/Major traumas:** HIV, COPD, IDDM **Screening Hx/Immunizations Hx:** Up to Date, Influenza and Pneumococcal. **Hospitalizations/Surgeries:** s/p Bronchoscopy Rigid with Placement Tracheal Stent with Airway Dilation, Laser on 1/12/25 |
| **Family History:** Father-60 years old died from Lung Cancer. Mother-72 years old died from Heart Attack. |
| **Social History:** _Patient comes from LTACH. Smoked in the past, denies alcohol or drug us. Non-Ambulatory. Requires frequent repositioning to prevent bedsores. Fall precautions and Aspiration precautions in place._ |
| **ROS** |
| **General** AAOx1. Appears fatigued and mild respiratory distress. | **Cardiovascular** · Hemodynamic monitoring and management. · Continue Cardura 4 mg. |
| **Skin** Normal, Warm and Dry. Good skin turgor. | **Respiratory** · Strict airway monitoring due to mass and stent migration to carina. · Continue Cefepime for multifocal PNA · HFNC, NRM w/ heliox treatment · Continue nebulizer · Keep FiO2 >92% · Suction PRN |
| **Eyes** Denies visual loss, blurred vision, or double vision. Denies history of cataracts or glaucoma. Uses glasses. | **Gastrointestinal** · NPO Status · Gi Px: Protonix |
| **Ears** Denies recent infections, ear pain, or tinnitus. Hard of hearing. | **Genitourinary/Gynecological** No acute issues: Denies urinary urgency, frequency, dysuria, odorous urine, suprapubic pain. · Continue monitoring of renal function, I/O, and electrolytes. Replace PRN. · Maintenance IV Fluids at 50 ml/hr. · CKD (Baseline Cr 1.5) · Continue Flomax to prevent urinary retention. |

| | | |
| — | — | — |
| | |
| **Nose/Mouth/Throat** Denies nasal pain, drainage, congestion, or other sinus issues. Denies throat pain or swelling. | **Musculoskeletal** ROM limited. Bedbound. · PT/OT ordered · OOB to Chair |
| **Breast** Denies discharge, tenderness. No palpable mass during exam. | **Neurological** Sleeping, arousable upon calling. AAOx1 |
| **Heme/Lymph/Endo** · Afebrile · Leukocytosis · Continue HART Meds. · Pending OR this week for migrated Stent in the Carina. | **Psychiatric** · AAOx1 · Continue Lexapro 20 QD · Continue Zyprexa 20 mg and Ambien 10 mg HD · Titrate Precedex as ordered. |
| **OBJECTIVE** |
| **Weight 167 lbs BMI 26.30 kg/m** | **Temp 98.1** | **BP 107/57** |
| **Height 5’7”** | **Pulse 65** | **Resp 20** |
| **PHYSICAL EXAMINATION** |
| **General Appearance** Patients currently sleeping, easy to arouse. Weakness, fatigued. No distress noted. Denies pain or discomfort at the moment. |
| **Skin** Skin is intact, warm, dry, and adequate color. Normal skin turgor. Capillary refills < 3 seconds. |
| **HEENT** Head in normocephalic/atraumatic. Visual field full by confrontation. Conjunctiva pink, sclera white. Pupils 3 mm equally, round react to light and accommodation. EOM intact. No nose discharged noted. Fontal sinuses non-tender to palpation. No bleeding gum noted. Buccal mucosa dry, pink, and intact. Uvula midline, no exudate noted. Tracheostomy noted. No JVD noted. |
| **Cardiovascular** Currently NSR. No murmurs noted upon auscultation. Denies Chest Pain. |
| **Respiratory** Diminished breath sounds to auscultation bilaterally. No wheezing or stridor noted. Saturation 99-100 % on HFNC 40 L/100%. |
| **Gastrointestinal** Abdomen soft, non-distended, round. Bowel sounds present. Last BM reported yesterday. |
| **Breast** No lumps noted on palpation. Symmetrical. |
| **Genitourinary** No inguinal Hernias or CVA tenderness. Urine clear and yellow. Monitor I/O. |
| **Musculoskeletal** Frequent repositioning. OOB to chair with PT. Weaknesses. Limited ROM. No cyanosis or pedal edema. |
| **Neurological** AAOx1 to self, disoriented to situation, time, place. Speech clear. Following simple commands. Weakness BL upper and Lower extremities. Denies headache or dizziness. |
| **Psychiatric** Patient with hx depression and anxiety. Calm and pleasantly confused at the moment. |
| **Lab Tests:** CBC, BMP, aPtt, PT/INR, Blood cx, Urine Analysis, Sputum Cultures ABG to evaluate hypoxemia and hypercapnia. CD4 count and HIV viral load to assess immune status |

| |
| — |
| |
| **Special Tests:** Surgical Consult, CT Chest and Neck w/o contrast, Chest Xray To asses for PNA and stent positioning. |
| **Diagnosis** |
| · Primary Diagnosis- · J96.01 – Acute Respiratory Failure with Hypoxia · Z93.0 Tracheostomy status · R09.02- Hypoxemia · R50.9- Fever, unspecified. · J38.4 – Edema of Larynx o Differential Diagnoses **:** Acute COPD exacerbation. Thyroid-Related Airway Compression. Stent related Complications. Infectious Process likely bacterial tracheitis or Pneumonia. o **Plan:**  Daily CT chest and neck, Chest Xray, and Labs. · Possible emergent Bronchoscopy if stent causes obstruction. · Referrals for Pulmonology for airway management, Surgical Consult for multinodular goiter and removal of stent. ID following, and PT/OT to mobilize patient and prevent skin breakdown.  Continue antibiotics, steroids and Nebulizers Tx.  Education: NPO status, importance of repositioning |
| **References** |

SOAP NOTE

**## SoapNotetrachandStentPatient.docx**

| | | |
| — | — | — |
| **Patient Initials: MR** | **Pt. Encounter Number: 2-5** |
| **Date: 1/15/2025** | **Age: 70 y.o** | **Sex: Male** |
| **Allergies: NKA Advanced Directives: On File** |
| **SUBJECTIVE** |
| **CC:** _Nurse from Step down reports increased Shortness of breath, sputum production, labored breathing, hypoxia and fever._ |
| **HPI:** 70 year old male presents to the hospital with shortness of breath, cough and fever for 5 days. Today with worsening dyspnea, reports increased thick yellow secretions through tracheostomy and hypoxia. Hx of HIV, multinodular goiter, COPD, tracheal compression most likely due to extrinsic compression due to enlarged thyroid s/p Bronchoscopy Rigid with Placement Tracheal Stent with Airway Dilation, Laser on 1/12/25. Pt was transferred to ICU do to hypoxemic respiratory insufficiency, placed on Bipap overnight, switch to HFNC 40L/100, and stent migration to carina level that needed close monitoring in the ICU. **_Onset:_** 5 days ago **_Location:_** Chest Discomfort with Inspiration, throat pain **_Duration:_** Intermittent **_Characteristics:_** Sore throat, sore back and chest. **_Aggravating Factors:_** While coughing. When Laying Flat **_Relieving Factors:_** Respiratory treatments, Sleeping with HOB elevated, Suctioning. **_Treatment:_** CT ABD Scan STAT ordered, Surgical team on board, labs CBC, BMP, Aptt, PT/INR, blood cx. Close monitoring in ICU. |
| **Current Medications:** Albuterol 180 mcg Inhaler, Mucomyst 200 mg/ml solution 600 mg, Ipratropium-albuterol (Duoneb) 0.5 mg-3 mg Neb Solution, Cefepime 2 G in sodium chloride 0.9 % 100 ml IVPB, Peridex 0.12 % solution 15 ml. Solumedrol 60 mg IV push Insulin regular 100 unit/ml Sliding scale. Cardura 4 mg HS Flomax 0.4 mg QD Pantoprazole 40 mg IV Push QD Cobicistat 150 mg Tab, Darunavir 800 mg tab, Dolutegravir 50 mg tab. Precedex 400 mcg in sodium chloride 0.9 % infusion titrate as per orders. Lexapro 20 tab. Zyprexa 20 mg HS Zolpidem (Ambien) 10 mg Tab HS. |
| **PMH:** HIV, multinodular goiter, COPD, DM, BPH, Depression, Tracheostomy. **Medication Intolerances: None** **Chronic Illnesses/Major traumas:** HIV, COPD, IDDM **Screening Hx/Immunizations Hx:** Up to Date, Influenza and Pneumococcal. **Hospitalizations/Surgeries:** s/p Bronchoscopy Rigid with Placement Tracheal Stent with Airway Dilation, Laser on 1/12/25 |
| **Family History:** Father-60 years old died from Lung Cancer. Mother-72 years old died from Heart Attack. |
| **Social History:** _Patient comes from LTACH. Smoked in the past, denies alcohol or drug us. Non-Ambulatory. Requires frequent repositioning to prevent bedsores. Fall precautions and Aspiration precautions in place._ |
| **ROS** |
| **General** AAOx1. Appears fatigued and mild respiratory distress. | **Cardiovascular** · Hemodynamic monitoring and management. · Continue Cardura 4 mg. |
| **Skin** Normal, Warm and Dry. Good skin turgor. | **Respiratory** · Strict airway monitoring due to mass and stent migration to carina. · Continue Cefepime for multifocal PNA · HFNC, NRM w/ heliox treatment · Continue nebulizer · Keep FiO2 >92% · Suction PRN |
| **Eyes** Denies visual loss, blurred vision, or double vision. Denies history of cataracts or glaucoma. Uses glasses. | **Gastrointestinal** · NPO Status · Gi Px: Protonix |
| **Ears** Denies recent infections, ear pain, or tinnitus. Hard of hearing. | **Genitourinary/Gynecological** No acute issues: Denies urinary urgency, frequency, dysuria, odorous urine, suprapubic pain. · Continue monitoring of renal function, I/O, and electrolytes. Replace PRN. · Maintenance IV Fluids at 50 ml/hr. · CKD (Baseline Cr 1.5) · Continue Flomax to prevent urinary retention. |

| | | |
| — | — | — |
| | |
| **Nose/Mouth/Throat** Denies nasal pain, drainage, congestion, or other sinus issues. Denies throat pain or swelling. | **Musculoskeletal** ROM limited. Bedbound. · PT/OT ordered · OOB to Chair |
| **Breast** Denies discharge, tenderness. No palpable mass during exam. | **Neurological** Sleeping, arousable upon calling. AAOx1 |
| **Heme/Lymph/Endo** · Afebrile · Leukocytosis · Continue HART Meds. · Pending OR this week for migrated Stent in the Carina. | **Psychiatric** · AAOx1 · Continue Lexapro 20 QD · Continue Zyprexa 20 mg and Ambien 10 mg HD · Titrate Precedex as ordered. |
| **OBJECTIVE** |
| **Weight 167 lbs BMI 26.30 kg/m** | **Temp 98.1** | **BP 107/57** |
| **Height 5’7”** | **Pulse 65** | **Resp 20** |
| **PHYSICAL EXAMINATION** |
| **General Appearance** Patients currently sleeping, easy to arouse. Weakness, fatigued. No distress noted. Denies pain or discomfort at the moment. |
| **Skin** Skin is intact, warm, dry, and adequate color. Normal skin turgor. Capillary refills < 3 seconds. |
| **HEENT** Head in normocephalic/atraumatic. Visual field full by confrontation. Conjunctiva pink, sclera white. Pupils 3 mm equally, round react to light and accommodation. EOM intact. No nose discharged noted. Fontal sinuses non-tender to palpation. No bleeding gum noted. Buccal mucosa dry, pink, and intact. Uvula midline, no exudate noted. Tracheostomy noted. No JVD noted. |
| **Cardiovascular** Currently NSR. No murmurs noted upon auscultation. Denies Chest Pain. |
| **Respiratory** Diminished breath sounds to auscultation bilaterally. No wheezing or stridor noted. Saturation 99-100 % on HFNC 40 L/100%. |
| **Gastrointestinal** Abdomen soft, non-distended, round. Bowel sounds present. Last BM reported yesterday. |
| **Breast** No lumps noted on palpation. Symmetrical. |
| **Genitourinary** No inguinal Hernias or CVA tenderness. Urine clear and yellow. Monitor I/O. |
| **Musculoskeletal** Frequent repositioning. OOB to chair with PT. Weaknesses. Limited ROM. No cyanosis or pedal edema. |
| **Neurological** AAOx1 to self, disoriented to situation, time, place. Speech clear. Following simple commands. Weakness BL upper and Lower extremities. Denies headache or dizziness. |
| **Psychiatric** Patient with hx depression and anxiety. Calm and pleasantly confused at the moment. |
| **Lab Tests:** CBC, BMP, aPtt, PT/INR, Blood cx, Urine Analysis, Sputum Cultures ABG to evaluate hypoxemia and hypercapnia. CD4 count and HIV viral load to assess immune status |

| |
| — |
| |
| **Special Tests:** Surgical Consult, CT Chest and Neck w/o contrast, Chest Xray To asses for PNA and stent positioning. |
| **Diagnosis** |
| · Primary Diagnosis- · J96.01 – Acute Respiratory Failure with Hypoxia · Z93.0 Tracheostomy status · R09.02- Hypoxemia · R50.9- Fever, unspecified. · J38.4 – Edema of Larynx o Differential Diagnoses **:** Acute COPD exacerbation. Thyroid-Related Airway Compression. Stent related Complications. Infectious Process likely bacterial tracheitis or Pneumonia. o **Plan:**  Daily CT chest and neck, Chest Xray, and Labs. · Possible emergent Bronchoscopy if stent causes obstruction. · Referrals for Pulmonology for airway management, Surgical Consult for multinodular goiter and removal of stent. ID following, and PT/OT to mobilize patient and prevent skin breakdown.  Continue antibiotics, steroids and Nebulizers Tx.  Education: NPO status, importance of repositioning |
| **References** |

SOAP NOTE

**## MSNSoapNoteRubricElsaPreceptor.pdf**

SOAP NOTE RUBRIC

Criteria Points Competent Need Improvement Not Acceptable

Score

Subjective (35 points) Provides
complete, concise,
and accurate
information,
which is well
organized and
easy to
understand.

Provides most of the
pertinent
information, but is
not well organized
and/or is slightly
challenging to
understand. May be
missing pertinent
negative information
(e.g., patient
denies…).

Limited or no
summary of
pertinent
information, is
organized
poorly, contains
inaccurate
information,
and/or is
difficult to
understand.

Chief complaint 5 5 3 1
HPI 10 10 8 6
Relevant PMH & FH 5 5 3 1
ROS 10 10 8 6
Currents: Allergies,
Meds/OTCs, Tobacco,
Immunizations, Diet, Exercise,
Sleep

5 5 3 1

Objective (40 points) Provides
complete, concise,
and accurate
information,
which is well
organized and
easy to
understand.

Provides most of the
pertinent
information, but is
not well organized
and/or is slightly
challenging to
understand. May be
missing pertinent
negative information
(e.g., patient denies)

Limited or no
summary of
pertinent
information, is
organized
poorly, contains
inaccurate
information,
and/or is
difficult to
understand.

General survey (Describe the
state of the patient at the time
of the examination)

10 10 8 6

Vital signs
Height, Weight, BMI

10 10 8 6

Physical exam-systematic,
organized and thorough and
related to the reason of the visit

20 20 18 16

Diagnosis/ Differentials
Diagnosis (10 points)

Main diagnosis/
Differentials
Diagnosis is
supported by the
objective and
subjective
assessment and
rationale for
choosing the

Main diagnosis/
Differentials
Diagnosis is
supported by the
objective and
subjective assessment
but the rationale for
choosing the
diagnosis is not

Main diagnosis/
Differentials
Diagnosis is not
supported by
the objective
and subjective
assessment and
the rationale for
choosing the

SOAP NOTE RUBRIC

diagnosis is
supported by the
evidence

supported by the
evidence

diagnosis is not
supported by
the evidence

Diagnosis/(Assessment) 5 5 3 1
List of differentials supported
by S+O findings (5 points)
Must provide 3 differential
diagnoses with one citation
for each diagnosis.

5 5 3 1

Plan of care (10 Points) Complete and
appropriate plan
for the main
problem and
other active
problems.
Includes
pharmacologic
and/or non-
pharmacologic
and/or complete
sig components.

Mostly complete and
appropriate plan for
the main problem
and other active
problems. May be
missing appropriate
non-pharmacologic
treatments and/or sig
components.

Missing or
inappropriate
treatment plan
for the main
problem and
other active
problems.

Diagnostic
tests/therapies/medications

5 5 3 1

Follow-up/Pt. Education and
Health Promotion

5 5 3 1

References (5 Points) Provides a
complete and
appropriate list of
references that
are in APA
format.

References listed are
appropriate (i.e.
guidelines or
primary), but not
complete and some
may be missing. Not
APA formatted.

References
missing or very
limited.
References
listed are
inappropriate
(i.e. tertiary)
and/or not
relevant.

References 5 5 3 1
Total 100

Comment:

**## SoapNotetrachandStentPatient.docx**

| | | |
| — | — | — |
| **Patient Initials: MR** | **Pt. Encounter Number: 2-5** |
| **Date: 1/15/2025** | **Age: 70 y.o** | **Sex: Male** |
| **Allergies: NKA Advanced Directives: On File** |
| **SUBJECTIVE** |
| **CC:** _Nurse from Step down reports increased Shortness of breath, sputum production, labored breathing, hypoxia and fever._ |
| **HPI:** 70 year old male presents to the hospital with shortness of breath, cough and fever for 5 days. Today with worsening dyspnea, reports increased thick yellow secretions through tracheostomy and hypoxia. Hx of HIV, multinodular goiter, COPD, tracheal compression most likely due to extrinsic compression due to enlarged thyroid s/p Bronchoscopy Rigid with Placement Tracheal Stent with Airway Dilation, Laser on 1/12/25. Pt was transferred to ICU do to hypoxemic respiratory insufficiency, placed on Bipap overnight, switch to HFNC 40L/100, and stent migration to carina level that needed close monitoring in the ICU. **_Onset:_** 5 days ago **_Location:_** Chest Discomfort with Inspiration, throat pain **_Duration:_** Intermittent **_Characteristics:_** Sore throat, sore back and chest. **_Aggravating Factors:_** While coughing. When Laying Flat **_Relieving Factors:_** Respiratory treatments, Sleeping with HOB elevated, Suctioning. **_Treatment:_** CT ABD Scan STAT ordered, Surgical team on board, labs CBC, BMP, Aptt, PT/INR, blood cx. Close monitoring in ICU. |
| **Current Medications:** Albuterol 180 mcg Inhaler, Mucomyst 200 mg/ml solution 600 mg, Ipratropium-albuterol (Duoneb) 0.5 mg-3 mg Neb Solution, Cefepime 2 G in sodium chloride 0.9 % 100 ml IVPB, Peridex 0.12 % solution 15 ml. Solumedrol 60 mg IV push Insulin regular 100 unit/ml Sliding scale. Cardura 4 mg HS Flomax 0.4 mg QD Pantoprazole 40 mg IV Push QD Cobicistat 150 mg Tab, Darunavir 800 mg tab, Dolutegravir 50 mg tab. Precedex 400 mcg in sodium chloride 0.9 % infusion titrate as per orders. Lexapro 20 tab. Zyprexa 20 mg HS Zolpidem (Ambien) 10 mg Tab HS. |
| **PMH:** HIV, multinodular goiter, COPD, DM, BPH, Depression, Tracheostomy. **Medication Intolerances: None** **Chronic Illnesses/Major traumas:** HIV, COPD, IDDM **Screening Hx/Immunizations Hx:** Up to Date, Influenza and Pneumococcal. **Hospitalizations/Surgeries:** s/p Bronchoscopy Rigid with Placement Tracheal Stent with Airway Dilation, Laser on 1/12/25 |
| **Family History:** Father-60 years old died from Lung Cancer. Mother-72 years old died from Heart Attack. |
| **Social History:** _Patient comes from LTACH. Smoked in the past, denies alcohol or drug us. Non-Ambulatory. Requires frequent repositioning to prevent bedsores. Fall precautions and Aspiration precautions in place._ |
| **ROS** |
| **General** AAOx1. Appears fatigued and mild respiratory distress. | **Cardiovascular** · Hemodynamic monitoring and management. · Continue Cardura 4 mg. |
| **Skin** Normal, Warm and Dry. Good skin turgor. | **Respiratory** · Strict airway monitoring due to mass and stent migration to carina. · Continue Cefepime for multifocal PNA · HFNC, NRM w/ heliox treatment · Continue nebulizer · Keep FiO2 >92% · Suction PRN |
| **Eyes** Denies visual loss, blurred vision, or double vision. Denies history of cataracts or glaucoma. Uses glasses. | **Gastrointestinal** · NPO Status · Gi Px: Protonix |
| **Ears** Denies recent infections, ear pain, or tinnitus. Hard of hearing. | **Genitourinary/Gynecological** No acute issues: Denies urinary urgency, frequency, dysuria, odorous urine, suprapubic pain. · Continue monitoring of renal function, I/O, and electrolytes. Replace PRN. · Maintenance IV Fluids at 50 ml/hr. · CKD (Baseline Cr 1.5) · Continue Flomax to prevent urinary retention. |

| | | |
| — | — | — |
| | |
| **Nose/Mouth/Throat** Denies nasal pain, drainage, congestion, or other sinus issues. Denies throat pain or swelling. | **Musculoskeletal** ROM limited. Bedbound. · PT/OT ordered · OOB to Chair |
| **Breast** Denies discharge, tenderness. No palpable mass during exam. | **Neurological** Sleeping, arousable upon calling. AAOx1 |
| **Heme/Lymph/Endo** · Afebrile · Leukocytosis · Continue HART Meds. · Pending OR this week for migrated Stent in the Carina. | **Psychiatric** · AAOx1 · Continue Lexapro 20 QD · Continue Zyprexa 20 mg and Ambien 10 mg HD · Titrate Precedex as ordered. |
| **OBJECTIVE** |
| **Weight 167 lbs BMI 26.30 kg/m** | **Temp 98.1** | **BP 107/57** |
| **Height 5’7”** | **Pulse 65** | **Resp 20** |
| **PHYSICAL EXAMINATION** |
| **General Appearance** Patients currently sleeping, easy to arouse. Weakness, fatigued. No distress noted. Denies pain or discomfort at the moment. |
| **Skin** Skin is intact, warm, dry, and adequate color. Normal skin turgor. Capillary refills < 3 seconds. |
| **HEENT** Head in normocephalic/atraumatic. Visual field full by confrontation. Conjunctiva pink, sclera white. Pupils 3 mm equally, round react to light and accommodation. EOM intact. No nose discharged noted. Fontal sinuses non-tender to palpation. No bleeding gum noted. Buccal mucosa dry, pink, and intact. Uvula midline, no exudate noted. Tracheostomy noted. No JVD noted. |
| **Cardiovascular** Currently NSR. No murmurs noted upon auscultation. Denies Chest Pain. |
| **Respiratory** Diminished breath sounds to auscultation bilaterally. No wheezing or stridor noted. Saturation 99-100 % on HFNC 40 L/100%. |
| **Gastrointestinal** Abdomen soft, non-distended, round. Bowel sounds present. Last BM reported yesterday. |
| **Breast** No lumps noted on palpation. Symmetrical. |
| **Genitourinary** No inguinal Hernias or CVA tenderness. Urine clear and yellow. Monitor I/O. |
| **Musculoskeletal** Frequent repositioning. OOB to chair with PT. Weaknesses. Limited ROM. No cyanosis or pedal edema. |
| **Neurological** AAOx1 to self, disoriented to situation, time, place. Speech clear. Following simple commands. Weakness BL upper and Lower extremities. Denies headache or dizziness. |
| **Psychiatric** Patient with hx depression and anxiety. Calm and pleasantly confused at the moment. |
| **Lab Tests:** CBC, BMP, aPtt, PT/INR, Blood cx, Urine Analysis, Sputum Cultures ABG to evaluate hypoxemia and hypercapnia. CD4 count and HIV viral load to assess immune status |

| |
| — |
| |
| **Special Tests:** Surgical Consult, CT Chest and Neck w/o contrast, Chest Xray To asses for PNA and stent positioning. |
| **Diagnosis** |
| · Primary Diagnosis- · J96.01 – Acute Respiratory Failure with Hypoxia · Z93.0 Tracheostomy status · R09.02- Hypoxemia · R50.9- Fever, unspecified. · J38.4 – Edema of Larynx o Differential Diagnoses **:** Acute COPD exacerbation. Thyroid-Related Airway Compression. Stent related Complications. Infectious Process likely bacterial tracheitis or Pneumonia. o **Plan:**  Daily CT chest and neck, Chest Xray, and Labs. · Possible emergent Bronchoscopy if stent causes obstruction. · Referrals for Pulmonology for airway management, Surgical Consult for multinodular goiter and removal of stent. ID following, and PT/OT to mobilize patient and prevent skin breakdown.  Continue antibiotics, steroids and Nebulizers Tx.  Education: NPO status, importance of repositioning |
| **References** |

SOAP NOTE

**## MSNSoapNoteRubricElsaPreceptor.pdf**

SOAP NOTE RUBRIC

Criteria Points Competent Need Improvement Not Acceptable

Score

Subjective (35 points) Provides
complete, concise,
and accurate
information,
which is well
organized and
easy to
understand.

Provides most of the
pertinent
information, but is
not well organized
and/or is slightly
challenging to
understand. May be
missing pertinent
negative information
(e.g., patient
denies…).

Limited or no
summary of
pertinent
information, is
organized
poorly, contains
inaccurate
information,
and/or is
difficult to
understand.

Chief complaint 5 5 3 1
HPI 10 10 8 6
Relevant PMH & FH 5 5 3 1
ROS 10 10 8 6
Currents: Allergies,
Meds/OTCs, Tobacco,
Immunizations, Diet, Exercise,
Sleep

5 5 3 1

Objective (40 points) Provides
complete, concise,
and accurate
information,
which is well
organized and
easy to
understand.

Provides most of the
pertinent
information, but is
not well organized
and/or is slightly
challenging to
understand. May be
missing pertinent
negative information
(e.g., patient denies)

Limited or no
summary of
pertinent
information, is
organized
poorly, contains
inaccurate
information,
and/or is
difficult to
understand.

General survey (Describe the
state of the patient at the time
of the examination)

10 10 8 6

Vital signs
Height, Weight, BMI

10 10 8 6

Physical exam-systematic,
organized and thorough and
related to the reason of the visit

20 20 18 16

Diagnosis/ Differentials
Diagnosis (10 points)

Main diagnosis/
Differentials
Diagnosis is
supported by the
objective and
subjective
assessment and
rationale for
choosing the

Main diagnosis/
Differentials
Diagnosis is
supported by the
objective and
subjective assessment
but the rationale for
choosing the
diagnosis is not

Main diagnosis/
Differentials
Diagnosis is not
supported by
the objective
and subjective
assessment and
the rationale for
choosing the

SOAP NOTE RUBRIC

diagnosis is
supported by the
evidence

supported by the
evidence

diagnosis is not
supported by
the evidence

Diagnosis/(Assessment) 5 5 3 1
List of differentials supported
by S+O findings (5 points)
Must provide 3 differential
diagnoses with one citation
for each diagnosis.

5 5 3 1

Plan of care (10 Points) Complete and
appropriate plan
for the main
problem and
other active
problems.
Includes
pharmacologic
and/or non-
pharmacologic
and/or complete
sig components.

Mostly complete and
appropriate plan for
the main problem
and other active
problems. May be
missing appropriate
non-pharmacologic
treatments and/or sig
components.

Missing or
inappropriate
treatment plan
for the main
problem and
other active
problems.

Diagnostic
tests/therapies/medications

5 5 3 1

Follow-up/Pt. Education and
Health Promotion

5 5 3 1

References (5 Points) Provides a
complete and
appropriate list of
references that
are in APA
format.

References listed are
appropriate (i.e.
guidelines or
primary), but not
complete and some
may be missing. Not
APA formatted.

References
missing or very
limited.
References
listed are
inappropriate
(i.e. tertiary)
and/or not
relevant.

References 5 5 3 1
Total 100

Comment:

**## SoapNotetrachandStentPatient.docx**

| | | |
| — | — | — |
| **Patient Initials: MR** | **Pt. Encounter Number: 2-5** |
| **Date: 1/15/2025** | **Age: 70 y.o** | **Sex: Male** |
| **Allergies: NKA Advanced Directives: On File** |
| **SUBJECTIVE** |
| **CC:** _Nurse from Step down reports increased Shortness of breath, sputum production, labored breathing, hypoxia and fever._ |
| **HPI:** 70 year old male presents to the hospital with shortness of breath, cough and fever for 5 days. Today with worsening dyspnea, reports increased thick yellow secretions through tracheostomy and hypoxia. Hx of HIV, multinodular goiter, COPD, tracheal compression most likely due to extrinsic compression due to enlarged thyroid s/p Bronchoscopy Rigid with Placement Tracheal Stent with Airway Dilation, Laser on 1/12/25. Pt was transferred to ICU do to hypoxemic respiratory insufficiency, placed on Bipap overnight, switch to HFNC 40L/100, and stent migration to carina level that needed close monitoring in the ICU. **_Onset:_** 5 days ago **_Location:_** Chest Discomfort with Inspiration, throat pain **_Duration:_** Intermittent **_Characteristics:_** Sore throat, sore back and chest. **_Aggravating Factors:_** While coughing. When Laying Flat **_Relieving Factors:_** Respiratory treatments, Sleeping with HOB elevated, Suctioning. **_Treatment:_** CT ABD Scan STAT ordered, Surgical team on board, labs CBC, BMP, Aptt, PT/INR, blood cx. Close monitoring in ICU. |
| **Current Medications:** Albuterol 180 mcg Inhaler, Mucomyst 200 mg/ml solution 600 mg, Ipratropium-albuterol (Duoneb) 0.5 mg-3 mg Neb Solution, Cefepime 2 G in sodium chloride 0.9 % 100 ml IVPB, Peridex 0.12 % solution 15 ml. Solumedrol 60 mg IV push Insulin regular 100 unit/ml Sliding scale. Cardura 4 mg HS Flomax 0.4 mg QD Pantoprazole 40 mg IV Push QD Cobicistat 150 mg Tab, Darunavir 800 mg tab, Dolutegravir 50 mg tab. Precedex 400 mcg in sodium chloride 0.9 % infusion titrate as per orders. Lexapro 20 tab. Zyprexa 20 mg HS Zolpidem (Ambien) 10 mg Tab HS. |
| **PMH:** HIV, multinodular goiter, COPD, DM, BPH, Depression, Tracheostomy. **Medication Intolerances: None** **Chronic Illnesses/Major traumas:** HIV, COPD, IDDM **Screening Hx/Immunizations Hx:** Up to Date, Influenza and Pneumococcal. **Hospitalizations/Surgeries:** s/p Bronchoscopy Rigid with Placement Tracheal Stent with Airway Dilation, Laser on 1/12/25 |
| **Family History:** Father-60 years old died from Lung Cancer. Mother-72 years old died from Heart Attack. |
| **Social History:** _Patient comes from LTACH. Smoked in the past, denies alcohol or drug us. Non-Ambulatory. Requires frequent repositioning to prevent bedsores. Fall precautions and Aspiration precautions in place._ |
| **ROS** |
| **General** AAOx1. Appears fatigued and mild respiratory distress. | **Cardiovascular** · Hemodynamic monitoring and management. · Continue Cardura 4 mg. |
| **Skin** Normal, Warm and Dry. Good skin turgor. | **Respiratory** · Strict airway monitoring due to mass and stent migration to carina. · Continue Cefepime for multifocal PNA · HFNC, NRM w/ heliox treatment · Continue nebulizer · Keep FiO2 >92% · Suction PRN |
| **Eyes** Denies visual loss, blurred vision, or double vision. Denies history of cataracts or glaucoma. Uses glasses. | **Gastrointestinal** · NPO Status · Gi Px: Protonix |
| **Ears** Denies recent infections, ear pain, or tinnitus. Hard of hearing. | **Genitourinary/Gynecological** No acute issues: Denies urinary urgency, frequency, dysuria, odorous urine, suprapubic pain. · Continue monitoring of renal function, I/O, and electrolytes. Replace PRN. · Maintenance IV Fluids at 50 ml/hr. · CKD (Baseline Cr 1.5) · Continue Flomax to prevent urinary retention. |

| | | |
| — | — | — |
| | |
| **Nose/Mouth/Throat** Denies nasal pain, drainage, congestion, or other sinus issues. Denies throat pain or swelling. | **Musculoskeletal** ROM limited. Bedbound. · PT/OT ordered · OOB to Chair |
| **Breast** Denies discharge, tenderness. No palpable mass during exam. | **Neurological** Sleeping, arousable upon calling. AAOx1 |
| **Heme/Lymph/Endo** · Afebrile · Leukocytosis · Continue HART Meds. · Pending OR this week for migrated Stent in the Carina. | **Psychiatric** · AAOx1 · Continue Lexapro 20 QD · Continue Zyprexa 20 mg and Ambien 10 mg HD · Titrate Precedex as ordered. |
| **OBJECTIVE** |
| **Weight 167 lbs BMI 26.30 kg/m** | **Temp 98.1** | **BP 107/57** |
| **Height 5’7”** | **Pulse 65** | **Resp 20** |
| **PHYSICAL EXAMINATION** |
| **General Appearance** Patients currently sleeping, easy to arouse. Weakness, fatigued. No distress noted. Denies pain or discomfort at the moment. |
| **Skin** Skin is intact, warm, dry, and adequate color. Normal skin turgor. Capillary refills < 3 seconds. |
| **HEENT** Head in normocephalic/atraumatic. Visual field full by confrontation. Conjunctiva pink, sclera white. Pupils 3 mm equally, round react to light and accommodation. EOM intact. No nose discharged noted. Fontal sinuses non-tender to palpation. No bleeding gum noted. Buccal mucosa dry, pink, and intact. Uvula midline, no exudate noted. Tracheostomy noted. No JVD noted. |
| **Cardiovascular** Currently NSR. No murmurs noted upon auscultation. Denies Chest Pain. |
| **Respiratory** Diminished breath sounds to auscultation bilaterally. No wheezing or stridor noted. Saturation 99-100 % on HFNC 40 L/100%. |
| **Gastrointestinal** Abdomen soft, non-distended, round. Bowel sounds present. Last BM reported yesterday. |
| **Breast** No lumps noted on palpation. Symmetrical. |
| **Genitourinary** No inguinal Hernias or CVA tenderness. Urine clear and yellow. Monitor I/O. |
| **Musculoskeletal** Frequent repositioning. OOB to chair with PT. Weaknesses. Limited ROM. No cyanosis or pedal edema. |
| **Neurological** AAOx1 to self, disoriented to situation, time, place. Speech clear. Following simple commands. Weakness BL upper and Lower extremities. Denies headache or dizziness. |
| **Psychiatric** Patient with hx depression and anxiety. Calm and pleasantly confused at the moment. |
| **Lab Tests:** CBC, BMP, aPtt, PT/INR, Blood cx, Urine Analysis, Sputum Cultures ABG to evaluate hypoxemia and hypercapnia. CD4 count and HIV viral load to assess immune status |

| |
| — |
| |
| **Special Tests:** Surgical Consult, CT Chest and Neck w/o contrast, Chest Xray To asses for PNA and stent positioning. |
| **Diagnosis** |
| · Primary Diagnosis- · J96.01 – Acute Respiratory Failure with Hypoxia · Z93.0 Tracheostomy status · R09.02- Hypoxemia · R50.9- Fever, unspecified. · J38.4 – Edema of Larynx o Differential Diagnoses **:** Acute COPD exacerbation. Thyroid-Related Airway Compression. Stent related Complications. Infectious Process likely bacterial tracheitis or Pneumonia. o **Plan:**  Daily CT chest and neck, Chest Xray, and Labs. · Possible emergent Bronchoscopy if stent causes obstruction. · Referrals for Pulmonology for airway management, Surgical Consult for multinodular goiter and removal of stent. ID following, and PT/OT to mobilize patient and prevent skin breakdown.  Continue antibiotics, steroids and Nebulizers Tx.  Education: NPO status, importance of repositioning |
| **References** |

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