Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study 1 & 2 to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each.
Below is the case study 1 to be used Case Study 1 : Acute Ankle Injury in a 46-Year-Old Female Soccer Player
A 46-year-old female soccer player presented to the clinic with complaints of severe pain in both ankles, with the right ankle being more concerning. The patient reported that the symptoms began over the weekend during a soccer game when she suddenly heard a ‘pop’ sound. She described the pain as intense, rating it as eight out of 10 on a pain scale. The pain worsened with movement and was slightly relieved by taking Ibuprofen. Although she could bear weight on both limbs, she experienced discomfort while doing so.
Upon further inquiry, the patient denied any history of similar injuries in the past. She reported no previous hospitalizations or surgeries, and her medical history was unremarkable, with no history of chronic conditions such as hypertension, diabetes, or asthma. The patient was not currently on any medications other than Ibuprofen for pain relief, and she had no known allergies to food, drugs, or environmental factors.
During the physical examination, the patient appeared well-nourished and in no acute distress. Her vital signs were within normal limits. In the musculoskeletal examination, the patient exhibited pain in both ankles, with the right ankle being more affected. There were no visible signs of joint swelling or deformities, and she had no limitations in other joints. Case Study 2: Bilateral Knee Pain in a 15-Year-Old Male Baseball Player
Jake Smith, a 15-year-old Caucasian male, presented to the clinic with complaints of bilateral knee pain accompanied by a clicking and catching sensation. He reported that the pain began approximately two weeks ago and described it as a dull ache located in the posterior aspect of both knees. Additionally, he felt pressure behind both knees. Jake attributed the onset of pain to his participation in baseball practice. Activities such as exercise, running in gym class, and sports exacerbated the pain, while rest and ibuprofen provided relief. He rated his pain as 4 out of 10 during the current visit, but noted that it typically increased to 7 out of 10 after baseball practice and gym class.
Jake’s medical history was unremarkable, with no previous surgeries or significant childhood diseases reported. He regularly took Olly Kids Multivitamin + Probiotic as a supplement for immune support and consumed Ibuprofen as needed for pain relief. There were no known allergies to medications, food, latex, or environmental factors.
In terms of social history, Jake lived with his parents, younger brother, and younger sister. He attended Cardinal High School and enjoyed playing baseball in the spring, with plans to participate in football during the fall season. His mother worked as a second-grade schoolteacher, while his father worked as an engineer at a local factory. Jake had access to healthcare providers and maintained a healthy diet. He denied tobacco, alcohol, and illicit drug use, although he mentioned that some of his friends had recently started vaping. Jake denied engaging in sexual activity.
The family history revealed his maternal grandmother had a history of hypertension and breast cancer, resulting in a bilateral mastectomy in 2018. His maternal grandfather had hypertension and high cholesterol levels. On his paternal side, his grandmother had type 2 diabetes, hypertension, and high cholesterol levels. There were no significant medical conditions reported for his paternal grandfather. Jake’s younger brother had asthma, while his younger sister had no significant medical history.
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
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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: Denies weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose,
Throat: Denies hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: Denies rash or itching.
CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations or
edema.
RESPIRATORY: Denies shortness of breath, cough or sputum.
GASTROINTESTINAL: Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or
blood.
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness or
tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: Denies muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: Denies anemia, bleeding or bruising.
LYMPHATICS: Denies enlarged nodes. No history of splenectomy.
PSYCHIATRIC: Denies history of depression or anxiety.
ENDOCRINOLOGIC: Denies reports of sweating, cold or heat intolerance. No polyuria or
polydipsia.
ALLERGIES: Denies history of asthma, hives, eczema or rhinitis.
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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.
Physical Examination
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 7th edition formatting.
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