Our Jack Baldwin VE iHuman Episodic SOAP Note Writing Services offer expert assistance for nursing students tackling complex clinical case studies. With a focus on helping you document accurate and detailed SOAP notes, our service ensures comprehensive assessments, precise diagnoses, and well-structured treatment plans. Whether you’re working on differential diagnosis or clinical decision-making, our team provides guidance tailored to your specific needs, enhancing your learning experience while meeting academic standards. Perfect for those seeking high-quality support in their nursing courses.
Jack Baldwin VE iHuman Episodic SOAP Note and Differential Diagnoses Examples
In this guide, we focus on creating a comprehensive SOAP note for the Jack Baldwin VE iHuman episodic case. A SOAP note breaks down into Subjective, Objective, Assessment, and Plan sections, allowing for systematic clinical documentation.
Subjective (S)
Includes the patient’s chief complaint (CC), history of present illness (HPI), and relevant details like past medical history (PMH), medications, allergies, and review of systems (ROS).
Example for Jack Baldwin VE:
CC: “Sharp chest pain radiating to my left arm.”
HPI: The patient reports sharp pain that began 2 days ago and worsens with exertion.
Objective (O)
The objective section records measurable data, including vital signs, general appearance, physical exam findings, and lab results.
Example:
- Temp: 98.6°F, BP: 140/90, HR: 82 bpm, RR: 18
- Findings: Mild chest tenderness, no wheezing or crackles in lung auscultation.
Assessment (A)
This includes the differential diagnoses. Based on the subjective and objective data, create three possible diagnoses, ranked by likelihood, and justify them with evidence from literature.
Example Differential Diagnoses:
- Myocardial Ischemia: Supported by exertional chest pain radiating to the arm, worsened by physical activity.
- Gastroesophageal Reflux Disease (GERD): Considered due to the presence of burning chest discomfort.
- Costochondritis: Localized chest pain upon palpation supports this musculoskeletal cause.
Plan (P)
This section outlines the treatment plan, including further diagnostic tests, medications, lifestyle modifications, and follow-up care.
Example Treatment Plan:
- Order an ECG and cardiac enzymes to rule out myocardial infarction.
- Prescribe antacids for symptomatic relief if GERD is suspected.
- Recommend NSAIDs for pain management in case of costochondritis.
- Follow up in 48 hours if symptoms persist or worsen.
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Genitourinary/ Gynecological Examination
Bladder is non-distended with no CVA tenderness. Coarse pubic hair is observed in normal distribution. Skin color matches the general pigmentation, and no vulvar lesions are seen. The patient appears well estrogenized. During the speculum exam, the vaginal walls are pink and rugated, with no lesions present. The cervix is pink and nulliparous with scant, clear to cloudy drainage. A bimanual exam reveals a firm cervix with no cervical motion tenderness (CMT). The uterus is anteverted and lies behind a slightly distended bladder, with no masses, fullness, or tenderness. Ovaries are non-palpable.
Male Examination
Both testes are palpable with no masses, lesions, or hernia detected, and no urethral discharge is noted. Rectal examination reveals no evidence of hemorrhoids, fissures, bleeding, or masses. For males, the prostate is smooth, non-tender, and free of nodules, with normal size and firm sphincter tone.
Musculoskeletal Examination:
Full range of motion (ROM) is observed in all four extremities as the patient moves about the exam room.
Neurological Examination:
The patient demonstrates clear speech, good tone, an erect posture, stable balance, and a normal gait.
Psychiatric Examination:
The patient is alert and oriented, dressed appropriately in clean clothes. Eye contact is maintained, and the patient’s speech is soft but clear, with a normal rate and cadence. Responses to questions are appropriate.
Lab Tests:
- Urinalysis: Pending
- Urine culture: Pending
- Wet prep: Pending
Special Tests:
None performed.
Diagnosis:
Presumptive Diagnosis:
- Herpes zoster without mention of complication (ICD-10 code: 053.9)
Differential Diagnosis:
- Herpes zoster without mention of complication (053.9)
- Rash and other nonspecific skin eruption (782.1)
- Other malaise and fatigue (780.79)
Plan/Therapeutics:
- Diagnosis: Herpes zoster without complication (053.9)
- Further Testing: None required.
- Medication: Valtrex 1000 mg PO every 8 hours for 7 days.
- Education: The patient should continue using Tylenol 650 mg PO to manage pain, limiting it to less than 4 g per day. Cool compresses may help with discomfort. Inform the patient that vesicles may burst and crust over, with pain subsiding in 2-3 days, although healing may take up to six weeks. The patient should monitor for signs of infection (redness, fever, purulent drainage) and avoid contact with vulnerable groups (e.g., children, pregnant women, immunocompromised individuals) until blisters dry. A future shingles flare-up is possible, and managing stress and maintaining a healthy lifestyle may help reduce recurrence risk.
- Non-Medication Treatment: Maintain hydration by drinking 6-8 glasses of water daily and continue regular workouts.
- Return to Clinic: Follow-up in one week if pain persists or if infection symptoms develop. Otherwise, return as needed (PRN).
Evaluation of Patient Encounter
The SOAP note should include a complete review of symptoms (ROS) and a thorough history of present illness (HPI) with details about onset, severity, and symptoms. Descriptions of findings are preferred over using terms like “normal” in learning environments. Each encounter should reflect an ideal examination and documentation process, including the completion of a total ROS for every patient.
Section | Details |
Objective | Weight: 180 lbs, BMI: 24.4, Temp: 99°F (oral), BP: 170/94 mmHg, Height: 6’0″, Pulse: 130 bpm (tachycardia), RR: 18 bpm, Oxygen Sat: 98% on RA |
General Appearance | Healthy, acute distress, well-groomed, fit, cheerful, alert, and oriented x4. |
Skin | Warm, diaphoretic, no delayed healing, rashes, bruising, bleeding, discoloration, or lesion/mole changes. |
HEENT | Normocephalic, atraumatic, PERRLA, EOMs intact, no conjunctival/scleral injection, patent canals, pearly grey TMs, normal nasal mucosa, no septal deviation, full ROM, no lymphadenopathy, oral mucosa pink/moist, no pharyngeal erythema/exudate. |
Carotids | No JVD, bruits. |
Cardiovascular | Tachycardia, S1/S2 regular, no extra sounds, capillary refill 2 sec, pulses 3+, no edema. |
Respiratory | Clear lungs bilaterally, regular and easy respirations, symmetric chest wall. |
Gastrointestinal | Abdomen flat, hyperactive bowel sounds, soft, non-tender, no hepatosplenomegaly. |
Genitourinary | Left groin swollen, tenderness in left inguinal canal, right normal, scrotum swollen (left), testicles normal. |
Musculoskeletal | Full ROM in all extremities. |
Neurological | Clear speech, stable gait, normal balance, erect posture. |
Psychiatric | Alert to person only, well-dressed, soft but clear speech, unable to answer questions appropriately. |
Lab Results | Elevated WBCs (19500 mm³), normal RBC (5.0 million/µl), Hgb (14.2 g/dl), Hct (45%), platelets (310 k/dL). |
Urinalysis | Light amber, clear, pH 5.1, 1 mg/dL protein, specific gravity 1.013, no glucose, RBCs, WBCs, or bacteria. |
Electrolytes | Na+ 141 mmol/L, K+ 4.0 mmol/L, Cl- 99 mmol/L, CO2 25 mmol/L. |
Diagnosis | Inguinal hernia. |
Differential Diagnoses | Testicular torsion, epididymitis, kidney stones. |
Plan of Care | Cancer screening, smoking cessation, increased exercise, better nutrition, hernia truss use, surgery as needed. |
References |
Buttaro, T., Trybulski, J., Bailey, P., & Sandberg-Cook, J. (2013). Primary care: A collaborative practice (4th ed.). Mosby/Elsevier. |
Cash, J. C. (2014). Family Practice Guidelines (3rd ed.). South University. |
Fischbach, F. T., & Dunning, M. B. (2014). A manual of laboratory and diagnostic tests. Wolters Kluwer Health/Lippincott Williams & Wilkins. |
Goolsby, M. J., & Grubbs, L. (2015). Advanced assessment: Interpreting findings and formulating differential diagnoses. F.A. Davis Company. |
FAQ
What is included in your Jack Baldwin VE iHuman SOAP Note Writing Service?
Our service includes comprehensive SOAP notes, covering Subjective, Objective, Assessment, and Plan sections, based on your clinical case study. We ensure thoroughness and accuracy in documenting patient information, diagnoses, and treatment plans.
Can you help with differential diagnoses in the SOAP notes?
Yes, we provide detailed assistance with differential diagnoses, helping you formulate a well-supported clinical assessment.
Who are the writers for your SOAP note services?
Our writers are experienced healthcare professionals with expertise in nursing and medical documentation, ensuring high-quality and accurate SOAP notes.
Do you offer revisions for SOAP notes?
Yes, we offer revisions to ensure the SOAP notes meet your specific requirements and academic guidelines.
How quickly can I receive my completed SOAP note?
We offer flexible turnaround times, including expedited services, to meet your deadlines efficiently.
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