Use the Episodic/Focused SOAP Template for an episodic/focused note about the patient in the case study 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.

Case Study 3: Facial Droop

A 22-year-old African American female looks in the mirror and notices the left side of her mouth is slanted when she smiles. She notes she has had some headaches off and on for a few days. Her taste has decreased as well when she started brushing her teeth.

 Episodic/Focused SOAP Note Template

Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint) is 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 and current use), and any other pertinent data. Always add some health promo questions 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. The reason for the 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  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 a 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.

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 evidence 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.

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

You are required to include at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure to use the correct  edition formatting.

ANSWER

Episodic/Focused SOAP Note: Facial Droop

Patient Information:
S.L., 22-year-old, female, African American

CC:
Facial droop, headaches, decreased taste while brushing teeth

HPI:
The patient is a 22-year-old African American female who presents with a facial droop noticed while smiling in front of a mirror. She reports experiencing headaches on and off for a few days. Additionally, she mentions a decreased sense of taste when brushing her teeth.

LOCATES

Location: Left side of the mouth
Onset: Acute, noticed while smiling in the mirror
Character: Slanting of the mouth on the left side
Associated signs and symptoms: Headaches, decreased taste during brushing
Timing: Present for a few days
Exacerbating/relieving factors: Not specified
Severity: Mild, impacting facial appearance

Current Medications:
None reported

Allergies:
No known allergies

PMHx:
No significant past medical history reported

Soc Hx:
Occupation: Student
Tobacco & alcohol use: Denies any tobacco or alcohol use
Health promo questions: Seat belt use, working smoke detectors at home

Fam Hx
Unremarkable, no family history of similar symptoms

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. Last menstrual period: MM/DD/YYYY.

NEUROLOGICAL: Headaches, facial droop, decreased taste while brushing teeth. No dizziness, syncope, paralysis, ataxia, numbness, or tingling.

MUSCULOSKELETAL: Denies muscle or joint pain or stiffness.

HEMATOLOGIC: Denies anemia, bleeding, or bruising.

LYMPHATICS: Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC: Denies a 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.

Physical Exam

GENERAL: The patient appears well and in no acute distress.

HEENT: The cranial nerves examination reveals left-sided facial droop when smiling.

Diagnostic Results

MRI of the brain: To evaluate for any possible neurological causes of the facial droop.

Complete Blood Count (CBC): To rule out any potential infectious or inflammatory processes.

Blood glucose level: To assess for any abnormal glucose levels that may be contributing to the symptoms.

Differential Diagnoses

Bell’s Palsy: Bell’s Palsy is a common cause of sudden, unilateral facial droop, often associated with headaches. An MRI of the brain can help differentiate Bell’s Palsy from other potential causes.

Cerebrovascular Accident (CVA): A stroke may present with facial droop and headaches. An MRI can help identify any ischemic or hemorrhagic changes in the brain.

Dental Issue: Dental problems can cause localized facial droop and may lead to a decreased sense of taste while brushing teeth.

Parotitis: Inflammation of the parotid gland can cause facial droop and may be associated with headaches. A CBC can help assess for any signs of infection.

Infection: Certain viral infections, such as herpes zoster, may cause facial droop and headaches. An MRI and CBC can assist in evaluating for any infectious etiologies.

This section is not required for this assignment.