MSN 6609 Advanced Physical Assessment for Nurse Leaders
SOAP TEMPLATE
Student Name: Lauren Rogers
Mentor: Catherine Luko, PMHNP, BC
Setting: Behavioral Health
Target Group/Population: Medically complex behavioral health patients
Current Support and Resources available for population: One psychiatrist and two nurse
practitioners
Proposed support and resources: Current staff has requested increase in clinicians to allow for
more concentrated time and assessments during visits and to increase bandwidth and practice
capacity
SOAP NOTE Patient #__1__
Clinical Hours#____20________________
Diagnosis____Bi-polar disorder_________________________________________________
_____________________________________________________________________________
Criteria
Data obtained
Team Members: Include mentor and
Catherine Luko, PMH NP, BC
identify additional team member.
(Final plan includes collaboration)
Subjective The “history” section
HPI: include symptom dimensions,
chronological narrative of patient’s
complaints, information obtained from
other sources (always identify source if
not the patient).
Pertinent past medical history.
Pertinent review of systems, for
example, “Patient has not had any
stiffness or loss of motion of other
joints.”
Current medications (list with daily
dosages).
Social history:
Married for over thirty years to his wife with two sons
and several grandchildren. Endorses being emotionally
distant from wife, living in two separate levels of home.
However, despite distance, he states obligation to care
for wife and has not shared with her details of his
medical condition, the return of his cancer, or the new
diagnosis of prostate cancer. He worked as a Special
Project Manager for an oil company before going out on
disability for cancer. Relates he began employment with
high school diploma but proudly states he continued his
education to first obtain Associates Degree, and then
undergrad and graduate degrees to become practical
engineer.
Medical history:
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Acquired angioedema (AAE)
o ED visit 4/26/22 due to abdominal pain,
constipation, and to obtain script for
icatibant after using last dose of this PRN
emergency medication.
Chronic lymphocytic leukemia (CLL)
o Unable to tolerate traditional chemotherapy
due to allergies. Participated in clinical trial
in Ohio where he was hospitalized x 16
weeks and was remission until 2018.
Currently treated at University of
Pennsylvania
MSN 6609 Advanced Physical Assessment for Nurse Leaders
SOAP TEMPLATE
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Patient states new chemotherapeutic agent
planned, requiring hospitalization x 5 days
for monitoring. States will not consider
bone marrow transplant if suggested.
Monthly IVIG treatments.
Follows with immunologist weekly.
Ear, Nose, Throat (ENT)
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Recent infection in ear with MRSA.
Has been unable to wear hearing aids
Cardiac:
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States diagnostics show “arteries going to heart
highly calcified”
No access to UPenn EMR for details
Gastrointestinal (GI):
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“Can’t eat” and “bowels messed up”
Complains of extreme bowel pain
Complains of ongoing issues with constipation.
States laxatives cause tremendous gas and are
ineffective.
States diet consists of wheaties, soy milk, yogurt, high
pH water due to heartburn. Recent weight loss of 35
lbs.
Two abdominal hernias aggravated by constipation.
Colonoscopy due 2024
Urinary (GU):
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Endorses urinary incontinence without opportunity
for frequent voiding and burning with urination. Has
lab requisition for Urinalysis with Culture &
Sensitivity but has not yet gone to lab.
Complains of nocturia, endorses voiding 6x per
night.
PMH for partial nephrectomy secondary to renal
cancer
Last PSA jumped up to 11
First biopsy positive for prostate cancer while
second biopsy did not detect any cancerous cells.
Urology appointment this week.
MSN 6609 Advanced Physical Assessment for Nurse Leaders
SOAP TEMPLATE
Behavioral Health
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Attention deficit hyperactivity disorder (ADHD)
Denies auditory or visual hallucinations.
No noted paranoia or delusions
Had been on Ritalin for ADHD but psychiatrist
discontinued due to concerns for mania and weight
loss. Patient reports without Ritalin he feels
overwhelmed and unable to focus.
Previous psychiatric hospitalizations: Inpatient in a
hospital in Philadelphia for several weeks previously
following admission of suicidal ideation.
Subsequently attended partial program and group
therapy.
Denies previous suicidal attempts or current suicidal
ideation. States medications are helping improve
mood and affect.
Reports difficulty sleeping, both following asleep
and waking up with nightmares.
Low interest in activities.
States he is “really angry and short tempered,” and
wife does not understand severity of his illnesses
and adds to his frustration with requests for
assistance around the house.
Reports significant history of anger, and states when
he was still working “everyone was afraid of me.”
His anger continued to culminate and resulted in
several instances in which Human Resources was
involved due to his behavior. He also reports his
anger resulted in several lawsuits against him.
States he got really upset at PCP for lack of
collaboration with oncologist. Patient became loud
and visibly upset while relaying this information.
3/16/22 Depression Screening - PHQ9 Score 13
3/16/22 Columbia Suicidal Severity Scale (CSSRS –
Screen Part 1) Score 8 (low risk)
8/21 GAD-7 score 17
Substance use history:
o Drinks alcohol on occasion
o Former smoker
o Denies any other substance use
History of abuse
o Verbal and emotional abuse by parents
MSN 6609 Advanced Physical Assessment for Nurse Leaders
SOAP TEMPLATE
SDOH:
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States financial concerns with monies owed to IRS.
Wife and sons unaware.
Medications:
CLL and AAE:
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Zanubrutinib 160 mg orally twice daily
Acalabrutinib 100 mg orally twice daily
Intravenous immunoglobulin (IVIg), intravenously
monthly
Icatibant 30 mg subcutaneously as needed for acute
symptoms of acquired angioedema
Gastric:
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Metoclopramide 5 mg orally twice daily
Lansoprazole 30 mg delayed release capsule orally
each morning
Cyanocobalamin 1000 mcg one tablet orally daily
Depression and hypomania
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Buproprion 300 mg XL orally each day
Divalproex sodium extended release 500 mg orally
each morning and 250 mg orally at bedtime
Trazodone 100 mg orally daily
Fluoxetine 40 mg orally daily
Other
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Flonase 50 mcg two sprays both nostril twice daily
for sinus congestion
Tamsulosin 0.4 mg daily for prostatic enlargement
Valtrex 500 mg orally daily for viral infection
Clonidine 0.1 mg orally daily for elevated blood
pressure
Allergies:
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Objective – The physical exam and
laboratory data section Vital signs
including oxygen saturation when
indicated. Focuses physical exam.
Fludarabine (fever and neutropenia)
Vancomycin (fever and neutropenia)
Vital Signs
T 97.9 (oral)
P 74
R 18
BP 122/88
MSN 6609 Advanced Physical Assessment for Nurse Leaders
SOAP TEMPLATE
All pertinent labs, x-rays, etc.
completed at the visit.
SaO2 97%
Ht 5’ 11”
Weight 172 lb 8 oz
BMI 24.06
Mental status exam:
Alert and oriented x 3, calm and cooperative
Speech is loud, hyperverbal normal articulation, normal
coherence, normal spontaneity.
Thought process is normal rate, normal content, normal
abstract reasoning, normal computation, linear and
logical
Mood is “depressed and frustrated”
Affect is within normal range, appropriate to context.
Mood and affect are congruent.
Associations intact
No hallucinations, no delusions, no preoccupation with
violence, not homicidal, no obsessions, no suicidal
ideation.
Judgement intact
Insight intact
Insight to illness and situation is good.
Oriented to person, place and time.
Memory is immediate, recent and remote memory
intact.
Attention is impaired
Concentration is poor
Language intact
Impulse control good.
Detailed depression screen: 16 (critical)
CSSR Suicide Risk Calculation: 8 (low risk)
Assessment/ Problem List
Your assessment of the patient’s
problems
Assessment: A one sentence description
of the patient and major problem
Problem list: A numerical list of
problems identified
All listed problems need to be
supported by findings in subjective and
objective areas above. Try to take the
assessment of the major problem to the
highest level of diagnosis that you can,
for example, “low back sprain caused
Summary:
Patient presents as hyperverbal, and describes mood
as “depressed and frustrated,” with past medical
history of ADHD, hypomania and hospitalization for
suicidal ideation.
Problem List:
1. Depression: Condition is uncontrolled and
exacerbated by significant health issues including
recent diagnosis of prostate cancer, upcoming
hospitalization for treatment of chronic
lymphocytic anemia, ongoing symptoms of
acquired angioedema, pain associated with
hernias, and lack of support system within family.
Differential diagnoses include Bipolar Disorder II
MSN 6609 Advanced Physical Assessment for Nurse Leaders
SOAP TEMPLATE
by radiculitis involving left 5th LS
nerve root.”
Provide at least 2 differential diagnoses
for the major new problem identified in
your note.
and Major Depressive Disorder. A diagnosis of
bipolar disorder II most likely with positive
history of impaired attention, hyperverbalization,
hypomania, suicidal ideation, depression and
anxiety, and history of ADHD (Mayo Clinic, n.d.).
2. Insomnia: Ongoing and uncontrolled, likely with
multifactorial causes. The primary cause likely to
be Bipolar Disorder II as identified above. A
differential diagnosis of major depressive
disorder must also be considered, with
associated poor health, upcoming medical
treatments, new diagnosis of cancer, and worries
about caring for wife and issues with IRS as
triggers for difficulty sleeping. A third differential
diagnosis is an independent or co-existing anxiety
disorder, demonstrated by agitation and
frustration, restlessness, pain, and difficulty
going to sleep and staying asleep (Mayo Clinic,
n.d.).
3. Anxiety: Anxiety is long known to be associated
with bipolar disorders, which, combined with
the rest of the patients history, further increases
the likelihood of a diagnosis of Bipolar II. (See
above for additional symptoms. A differential
diagnosis of Major Depressive Disorder is also a
potential, given the correlation between
depression and anxiety (McCance & Huether,
2019).
4. Decreased attention: Patient endorses inability
to concentrate, focus or to complete tasks.
States he is overwhelmed and is having difficulty
with basic life activities as a result of attention
deficit. Formerly on Ritalin but medication
discontinued due to weight loss and hypomania.
Differential diagnoses include ADHD, Bipolar
Disorder II, Major Depressive Disorder as well as
Anxiety Disorder, all described above (Mayo
Clinic, n.d.).
Plan
Add your plan for the patient based on
the problems identified
Develop a diagnostic and treatment
plan for each differential diagnosis.
1. Depression
a. Diagnostics: Complete depression CSSR
suicide risk screenings each visit.
b. Pharmacotherapy: Continue Wellbutrin,
Divalproex and Prozac. Consider
MSN 6609 Advanced Physical Assessment for Nurse Leaders
SOAP TEMPLATE
Your diagnostic plan may include tests,
procedures, other laboratory studies,
consultations, etc.
Your treatment plan should include:
patient education, pharmacotherapy if
any, other therapeutic procedures. You
must also address plans for follow-up
(next scheduled visit, etc.).
Also see your Jarvis Guide to Physical
Examination & Health Assessment
Prazosin at next visit for recurring
nightmares.
c. Instruction: Continue with therapist. Call
for worsening symptoms or for suicidal
ideation.
2. Insomnia
a. Diagnostics: evaluate results of
depression and suicide risk screenings
and correlate to reports of insomnia.
Sleep journal to correlate diet, use of
anxiolytics and sleep quality.
b. Pharmacotherapy: See medications for
depression and anxiety. As indicated
above, consider Prazosin for control of
nightmares if ongoing at follow up.
c. Instruction: Sleep hygiene, relaxation
techniques, minimize caffeine, sugar
and alcohol consumption.
3. Anxiety
a. Diagnostics: None. CMP and thyroid
panel completed 4/19/22 and reviewed.
b. Pharmacotherapy: Klonopin 0.5 mg
orally twice daily as needed for
moderate to severe anxiety (Adams,
Holland & Urban, 2020).
c. Instruction:
i. Education on medication
includes medication is long
acting (up to 12 hours) and
causing drowsiness. Do not
drive after taking Klonopin.
Benzodiazepines may become
addictive and should only be
used for moderate to severe
anxiety as an adjunct to routine
medications. If anxiety persists,
routine medications may be
adjusted or started for long
term control of condition
(Adams, Holland & Urban,
2020).
ii. Encourage communication with
spouse and adult sons to
develop support system.
MSN 6609 Advanced Physical Assessment for Nurse Leaders
SOAP TEMPLATE
iii. Educate on relaxation
techniques, minimize caffeine,
sugar and alcohol consumption
as described above.
4. Decreased attention:
a. Diagnostics: None.
b. Pharmacotherapy: Strattera 40 mg
orally twice daily.
c. Instruction: Strattera is a non-stimulant
that improves focus and concentration.
Medication is less likely than stimulants
to cause insomnia but can be
discontinued if symptoms of insomnia
worsen. At onset of therapy medication
may cause abdominal pain, nausea and
drowsiness, which should subside. May
also cause constipation, dry mouth and
difficulty urinating.
Follow-up: In 4 weeks. Please bring sleep log/journal
for review.
References
Adams, M., Holland, N. & Urban, C. (2020). Pharmacology for nurses: A
pathophysiologic approach. Pearson Education.
Mayo Clinic. (n.d.). Bipolar disorder. Retrieved June 23, 2022 from
https://www.mayoclinic.org/diseases-conditions/bipolar-disorder/symptomscauses/syc-20355955
McCance, K.L. & Huether, S.E. (2019). Pathophysiology: the biologic basis for disease
in adults and children. Elsevier.
Bains, N. & Abdijadid, S. (2022, April 12). Major depressive disorder. Stat Pearls.
Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK559078/