(Student Name)Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C
Soap Note # ____ Main Diagnosis ______________
PATIENT INFORMATION
Name:
Age:
Gender at Birth:
Gender Identity:
Source:
Allergies:
Current Medications:
•
PMH:
Immunizations:
Preventive Care:
Surgical History:
Family History:
Social History:
Sexual Orientation:
Nutrition History:
Subjective Data:
Chief Complaint:
Symptom analysis/HPI:
The patient is …
Review of Systems (ROS) (This section is what the patient says, therefore should state Pt
denies, or Pt states….. )
CONSTITUTIONAL:
NEUROLOGIC:
HEENT:
RESPIRATORY:
CARDIOVASCULAR:
GASTROINTESTINAL:
GENITOURINARY:
MUSCULOSKELETAL:
SKIN:
Objective Data:
VITAL SIGNS:
GENERAL APPREARANCE:
NEUROLOGIC:
HEENT:
CARDIOVASCULAR:
RESPIRATORY:
GASTROINTESTINAL:
MUSKULOSKELETAL:
INTEGUMENTARY:
ASSESSMENT:
(In a paragraph please state “your encounter with your patient and your
findings ( including subjective and objective data)
Example : “Pt came in to our clinic c/o of ear pain. Pt states that the pain
started 3 days ago after swimming. Pt denies discharge etc… on examination I
noted this and that etc.)
Main Diagnosis
(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example
provided) Include the in-text reference/s as per APA style 6th or 7th Edition.
Differential diagnosis (minimum 3)
–
–
PLAN:
Labs and Diagnostic Test to be ordered (if applicable)
•
–
•
–
Pharmacological treatment:
Non-Pharmacologic treatment:
Education (provide the most relevant ones tailored to your patient)
Follow-ups/Referrals
References (in APA Style)
Examples
Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).
ISBN 978-0-8261-3424-0
Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010
(25th ed.). Print (The 5-Minute Consult Series).
(Student Name)
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C
Soap Note # ____ Main Diagnosis ______________
PATIENT INFORMATION
Name:
Age:
Gender at Birth:
Gender Identity:
Source:
Allergies:
Current Medications:
•
PMH:
Immunizations:
Preventive Care:
Surgical History:
Family History:
Social History:
Sexual Orientation:
Nutrition History:
Subjective Data:
Chief Complaint:
Symptom analysis/HPI:
The patient is …
Review of Systems (ROS) (This section is what the patient says, therefore should state Pt
denies, or Pt states….. )
CONSTITUTIONAL:
NEUROLOGIC:
HEENT:
RESPIRATORY:
CARDIOVASCULAR:
GASTROINTESTINAL:
GENITOURINARY:
MUSCULOSKELETAL:
SKIN:
Objective Data:
VITAL SIGNS:
GENERAL APPREARANCE:
NEUROLOGIC:
HEENT:
CARDIOVASCULAR:
RESPIRATORY:
GASTROINTESTINAL:
MUSKULOSKELETAL:
INTEGUMENTARY:
ASSESSMENT:
(In a paragraph please state “your encounter with your patient and your
findings ( including subjective and objective data)
Example : “Pt came in to our clinic c/o of ear pain. Pt states that the pain
started 3 days ago after swimming. Pt denies discharge etc… on examination I
noted this and that etc.)
Main Diagnosis
(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example
provided) Include the in-text reference/s as per APA style 6th or 7th Edition.
Differential diagnosis (minimum 3)
–
–
PLAN:
Labs and Diagnostic Test to be ordered (if applicable)
•
–
•
–
Pharmacological treatment:
Non-Pharmacologic treatment:
Education (provide the most relevant ones tailored to your patient)
Follow-ups/Referrals
References (in APA Style)
Examples
Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).
ISBN 978-0-8261-3424-0
Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010
(25th ed.). Print (The 5-Minute Consult Series).
1
Miami Regional University Department of Nursing SOAP Note
Student’s Name: Yolanda Calas Isaac.
Date of Encounter: 06-05-2023.
Preceptor/Clinical Site: Carlos Gonzalez , El Retiro Medical Center.
Clinical Instructor: Patricio Bidart MSN , APRN, FNP-C.
SOAP Note #__1___Main Diagnosis: Nephrotic Syndrome
Patient Information
Name: Mrs. MG
Age: 75 years
Gender at Birth: Female
Patient Allergies: Sulphur, lactose intolerant
Current Medications:
·
Insulin mixstard 30units in the morning and 15 units in the evening
·
Metformin 1000 mg, one tablet PO once a day
·
Rosuvastatin 10 mg, one tablet PO at bedtime
Past Medical History:
2
·
Diabetes mellitus type II, Hyperlipidemia
Immunizations:
·
Flu vaccine in 2021
·
COVID-19 (Pfizer) vaccine in 2022
Preventive Care:
·
Gynecological visit on 4/22
Surgical History: C-sections during the birth of her children, no history of blood transfusion
Family History:
·
The daughter, 54years is diabetic, and the son is 47 years has dyslipidemia
Social History:
The widow is single, of Muslim faith, does not drink, does not smoke, has never used drugs,
has a sedentary lifestyle, and is straight in her sexual orientation.
Nutrition History: Regular diet, low in carbohydrates and fat
Subjective:
·
Chief Complaint (CC): “I have been experiencing swelling in my legs and ankles.”
·
History of Present Illness (HPI): The patient, Mrs. MG, a 75-year-old Hispanic woman,
presents with a chief complaint of swelling in her legs and ankles. The swelling started
gradually and has been persistent for the past two weeks. She reports that the swelling
worsens throughout the day and is associated with tightness and discomfort. She also reports
3
occasionally having facial swelling, especially in the morning. The patient denies any recent
trauma, fever, or changes in urinary frequency. She also mentions a history of diabetes
mellitus type II and hyperlipidemia. No new medications have been started recently.
Objective:
Physical Examination:
Vital Signs: Temperature: 98.6°F, Pulse: 80 bpm, Blood Pressure: 130/80 mmHg, Spo2:
94%, weight: 105kgs Height: 170cm
Respiratory Rate: 18 breaths per minute
Review of the system: Unremarkable for all systems
General Appearance: Alert and oriented, no acute distress, no pallor, no cyanosis, no
jaundice, no lymphadenopathy, and the patient is of good nutritional status.
Systemic Examination:
HEENT: No ear discharge, no nasal discharge, no abnormalities
Skin: Bilateral pitting edema noted in the lower extremities, extending from the ankles to the
knees. No erythema or signs of infection were observed. No other skin abnormalities were
noted.
Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops. Peripheral pulses
are intact and symmetrical.
Respiratory: normal chest movements, no palpable mass, the chest is resonant to percussion,
normal vesicular breath sounds heard.
Abdomen: Soft and non-tender; no hepatomegaly or splenomegaly palpated.
Urinary System: No costovertebral angle tenderness. No palpable renal masses.
4
Neurological: Alert and oriented to person, place, and time. Cranial nerves are intact. No
signs of meningeal irritation, normal coordination, and sensation, and No focal deficits were
observed.
Musculoskeletal: No visible deformities, swollen lower limbs, normal muscle power bulk
and tone, normal gait.
Assessment: The patient, Ms. GP, presents with a chief complaint of lower extremity
swelling for the past two weeks. Physical examination reveals bilateral pitting edema in the
lower extremities. Based on the patient’s history and examination findings, the provisional
diagnosis is nephrotic syndrome.
Diagnosis: ICD-10 code N04.9 for the nephrotic syndrome: A kidney condition known as
nephrotic syndrome is characterized by severe proteinuria, hypoalbuminemia, edema, and
hyperlipidemia (Saleem, 2019). The glomerular filtration barrier’s increased permeability as a
result of glomerular injury is the usual cause. More diagnostic tests will be performed to
ascertain the root cause of nephrotic syndrome.
Differential Diagnoses:
1. Congestive Heart Failure (ICD-10: I50.9)
2. Cirrhosis (ICD-10: K74.60)
3. Hypothyroidism (ICD-10: E03.9)
Plan: Diagnostic Tests:
·
Urinalysis: To assess for proteinuria and evaluate urine sediment.
5
·
Blood tests: Complete blood count (CBC), comprehensive metabolic panel (CMP), lipid
profile, and thyroid-stimulating hormone (TSH) to evaluate renal function, electrolytes, lipid
levels, and thyroid function (Tomo et al., 2020).
·
Serum protein electrophoresis: To assess the pattern of protein abnormalities and identify
potential underlying causes.
·
Renal ultrasound: To assess kidney size and shape and detect structural abnormalities.
Medications:
·
Diuretics: Initiate furosemide 40 mg orally once daily to alleviate edema.
·
Steroids: Prednisolone 20mg twice daily
Immune suppressing agents: Mycophenolate mofetil 200mg once daily
·
Statin: Continue atorvastatin 20 mg orally at bedtime for hyperlipidemia management
(Politano, Colbert & Hamiduzzaman, 2020).
·
Diabetes management: Continue insulin mustard 30 units in the morning and 15 units in the
evening subcutaneously, along with metformin 1000 mg orally once daily.
Non-Pharmacological Measures:
·
Sodium restriction: Instruct the patient to reduce sodium intake to help manage fluid
retention.
·
Fluid management: Advise the patient to monitor fluid intake and output, aiming for balance.
·
Compression stockings: Recommend wearing compression stockings to aid in reducing lower
extremity edema.
·
Rest and elevation: Encourage the patient to elevate her legs while resting to promote venous
return and reduce edema.
Referrals:
6
·
Nephrologist: Refer the patient to a nephrologist for further evaluation, confirmation of
diagnosis, and management of nephrotic syndrome (Tomo et al., 2020).
·
Dietitian: Refer the patient to a dietitian to develop a personalized renal-friendly diet plan.
Follow-up: Schedule a follow-up appointment with the patient in one week to review the
results of the diagnostic tests and adjust the treatment plan accordingly.
Education:
1. Describe the nephrotic syndrome diagnosis, its causes, and any probable consequences.
2. Go through the significance of sticking to the recommended drug schedule and lifestyle changes.
3. Follow the dietitian’s nutritional advice, which may include a low-sodium diet and probable
potassium limitations (Wang & Greenbaum, 2019).
4. Inform the patient of routine follow-up appointments with the nephrologist to monitor kidney
function and modify therapy as necessary.
5. Tell the patient to let you know if their symptoms worsen, such as swelling, breathlessness, or
changing urination habits.
7
References
Politano, S. A., Colbert, G. B., & Hamiduzzaman, N. (2020). Nephrotic syndrome. Primary
Care: Clinics in Office Practice, 47(4), 597-613.
Saleem, M. A. (2019). Molecular stratification of idiopathic nephrotic syndrome. Nature
Reviews Nephrology, 15(12), 750-765.
Tomo, S., Birdi, A., Yadav, D., Chaturvedi, M., & Sharma, P. (2022). Klotho: A possible role
in the pathophysiology of nephrotic syndrome. EJIFCC, 33(1), 3.
Wang, C. S., & Greenbaum, L. A. (2019). Nephrotic syndrome. Pediatric Clinics, 66(1), 7385.
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