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Chapter 3: Documentation Strategies
Describe the SOAP approach for documenting patient data.
Label each type of data as subjective or objective.
HPI that states that the patient is a 47-year-old female who has recently been complaining of chest pains
Family history of type II diabetes
Physical examination of the patient’s respiratory system
Patient is given a blood test
Limited income
MRI is given to patient complaining of frequent headaches
Chapter 4: Mental Health
CASE STUDY
Chief Complaint:
A 26 y.o. female presents to the student health center with c/o insomnia. She attributes her difficulty sleeping to extreme stress, as she is in her final year of study toward a PhD in history. Since she does not sleep more than a couple of hours per night, she feels listless during the day and tends to just lay around and accomplish little. She has trouble concentrating, and her studies are suffering. She is very anxious about what this means for her studies but cannot get motivated and has begun skipping classes. She knows she is letting her parents down, as they are very proud of her achievements.
Patient believes that once she is able to catch up on her sleep, she will perk up and requests something to help her sleep. When you discuss depression, she expresses confidence that her symptoms are simply from stress, unless she has some medical condition. This is way beyond depression. She says she is not at all sad and has never considered hurting herself. She agrees to return in 48 hours when laboratory studies return.
Past Medical History
Negative; describes her health as good
Usually no over-the-counter or prescriiption drugs other than her etonogestrel implant, but lately has begun trying a variety of over-the-counter sleeping aides
Psychosocial History
Usually a non-drinker but often tries a glass of wine before bed. Has not been helpful for sleeping. On further questioning, admits to having premenstrual mood swings off and on over the years, but nothing persistent and has not experienced this in years. Describes these premenstrual episodes as just being easily irritated or upset, withdrawn for days at a time. Appetite is nonexistent and eats little, but has gained five pounds in the past month. Until recently, worked out daily and was active in a number of campus activities, all of which she has stopped. Loss of sleep has sapped interest in everything.
Family History
Mother, thyroid disease and atrial fibrillation
Paternal grandfather, heart disease
Maternal grandmother, breast cancer and depression
Physical Examination
Vital signs: T 96.9, HR 88, BP 96/54, HT 64, WT 130 lbs.
General: Casually dressed, quiet spoken, intermittent eye contact, and fidgeting with hair while talking. Skin warm, pink, and intact. Moves all extremities.
Neck: Thyroid midline, symmetrical, barely palpable.
CV: Heart regular rhythm, S1/S2 without murmur.
Respiratory: Lungs clear.
Questions
1. What three conditions would be considered in your differential diagnosis, with most likely condition listed first (with rationale)?
2. What further history, further examination, and diagnostic studies are warranted to explore your differential diagnosis?
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