Discussion Topic: Soap Note External otitis Requirements – The discussion must address the topic – Rationale must be provided mainly in the differential diagnosis – Use at least 600 wo


Discussion Topic: Soap Note External otitis


– The discussion must address the topic

– Rationale must be provided mainly in the differential diagnosis

– Use at least 600 words (no included 1st page or references in the 600 words)

– May use examples from your nursing practice

– Formatted and cited in current APA 7

– Use 3 academic sources, not older than 5 years. Not Websites are allowed.

– Plagiarism is NOT permitted

I have attached the SOAP note template, a SOAP note sample, and the rubric.

Discussion Topic: Soap Note


– The discussion must address the topic

– Rationale must be provided mainly in the differential diagnosis

– Use at least 600 words (no included 1st page or references in the 600 words)

– May use examples from your nursing practice

– Formatted and cited in current APA 7

– Use 3 academic sources, not older than 5 years. Not Websites are allowed.

– Plagiarism is NOT permitted

I have attached the SOAP note template, a SOAP note sample, and the rubric.

Soap Note # ____ Main Diagnosis ______________




Gender at Birth:

Gender Identity:



Current Medications:




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….. )










Objective Data:











(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 7th Edition.

Differential diagnosis (minimum 4)


Labs and Diagnostic Test to be ordered (if applicable)

· –

· –

Pharmacological treatment:

Non-Pharmacologic treatment:

Education (provide the most relevant ones tailored to your patient)


References (in APA Style)


Student’s Name

Miami Regional University

Date of Encounter: Mo/day/year

Preceptor/Clinical Site: MSN5600L Class

Clinical Instructor: Patricio Bidart MSN, APRN-IP, FNP-C

Soap Note # _____ Main Diagnosis: Dx: Herpes Zoster


Name: Ms. GP

Age: 78

Gender at Birth: Female

Gender Identity: Female

Source: Patient

Allergies: Peanut. Iodine

Current Medications:

 Insulin Lantus 100 u/ml 15 unit in the morning and at bedtime

 Metformin 500 mg 1 tablet PO once a day

 Atorvastatin 20 mg 1 tablet PO at bedtime


 Diabetes mellitus type II

 Hyperlipidemia

 Varicella (Chickenpox) at the age of 20 year-old

Immunizations: Flu vaccine in 2020, Covid -19 (Pfizer) in 2021

Preventive Care: Wellness exam on 03/2021

Surgical History: appendicectomy 20 years ago

Family History: daughter 48 years old / hyperlipidemia

Social History: Patient is widow, lives with her daughter. Catholic religion. No alcohol. No

smoker. No history of drug used, sedentary lifestyle. Does not work.

Sexual Orientation: Straight

Nutrition History: Regular diet, low in carbohydrates and fat.

Subjective Data:

Chief Complaint: I have been feeling itching and pain on my right lower back” started 3 day


Symptom analysis/HPI: The patient is Ms. GP is 78-year-old Hispanic woman, who is

complaining about itching, pain or tingling on her right lower back. Patient stated that 3 days ago

she started to feel an increase in burning sensation on the area taking all right lower back and

don’t relieve the pain with analgesic, she stated that wear any clothes that touch the area is very

uncomfortable. Denies any episodes of fever but she feels fatigue and chills and mild headache.

She stated that today in the morning she feel worse and noted some redness in the area and

decided to come to the clinic to PCP evaluation.

Review of Systems (ROS)

CONSTITUTIONAL: fatigue, chills, denies weakness, no thirsty, no loss of weight. No fever.

NEUROLOGIC: mild headache, no dizziness, no changes in LOC, no loss of strength or

weakness/paresis/paralysis on extremities, no Hx of tremors or seizures.

HEENT: denies any head injury, denies any pain

 Eyes: patient denies blurred vision, no diplopia, no wear glasses for reading

 Ears: patient denies tinnitus, ear pain, no ear drainage through ear canal.

 Nose: no presence of nasal obstruction, no nasal discharge, denies nasal bleeding. (No


 Throat: no sore throat, no hoarse voice, no difficult to swallow

RESPIRATORY: patient denies shortness of breath, cough, expectoration, or hemoptysis.

CARDIOVASCULAR: patient denies chest pain, tachycardia. No orthopnea or paroxysmal

nocturnal dyspnea.

GASTROINTESTINAL: patient denies abdominal pain or discomfort. Denies flatulence,

nausea, vomiting or diarrhea. (BM pattern) every other day, last BM: today, no rectal bleeding

visible for her.

GENITOURINARY: patient denies polyuria, no dysuria, no burning urination, no hematuria, no

lumbar pain, no urinary incontinence.

MUSCULOSKELETAL: denies falls or pain. Denies hearing a clicking or snapping sound

SKIN: patient states itching, pain, or tingling sensation on her right lower back.

HEMO/LYMPH/ENDOCRINE: glands swelling on groin, denies bruising or abnormal


PSYCHIATRIST: patient denies anxiety, depression, denies hallucinations or delusions, no

mood changes

Objective Data:


Temperature: 98.4 °F, Pulse: 82x ‘, BP: 122/71 mm hg, RR 19, PO2-97% on room air, Ht- 5’3”,

Wt 164 lb, BMI 30.2. Report pain 6/10.

GENERAL APPREARANCE: Adult, female. Alert and oriented x 3.

NEUROLOGIC: Alert, oriented to person, place, and time. Cranial nerves from I to XII intact.

Sensation intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5. Pupil

normal in size and equal. Deep tendon reflex presents.

HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no


 Eyes: No conjunctival injection, no icterus, visual acuity, and extraocular eye movements

intact. No nystagmus noted. Wear glasses.

 Ears: BL external canal pattern, permeable, no redness, no drainage, tympanic membrane

intact, pearly gray with sharp cone of light. No pain or edema noted.

 Nose: Nasal mucosa normal. No irritations.

 Mouth: oral mucosa pink, tongue central, papillaes normal distributed, no lesions

detected, present of upper and lower denture, fitting properly. Lips with no lesions.

 Neck: No lymphadenopathy noted. No jugular vein distention. No thyroid swelling or

masses, no thrills on auscultation.

CARDIOVASCULAR: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary

refill < 2 sec. Peripheral pulses present and symmetric. No edema on BLE.

RESPIRATORY: Lungs sounds clear. Chest wall symmetric and no deformities, no intercostal

retractions, patient no noticed dyspnea, no orthopnea. No egophony, no pectoriloquy, no fremitus

or sign of condensation tissue on palpation. Resonance equal in both hemithorax. Lungs: breath

sounds present and clear on auscultation, no rales, no wheezing, no rhonchi.

GASTROINTESTINAL: Abdomen soft and non-tender. Continent to BB. Bowel sounds

present in all four quadrants; no bruits present over aortic or renal arteries. Last BM today.

GENITOURINARY: Costovertebral angles non-tenders, kidneys no palpable. External

genitalia present, no enlargement, no tumors palpable. Groins area noted with redness.

MUSKULOSKELETAL: No pain to palpation. Active and passive ROM within normal limits,

no stiffness.

INTEGUMENTARY: painful redness rash, with crops of vesicles on an erythematous base

with a few satellite lesions in linear distribution, do not cross midline, some of the blisters are

filled with purulent fluids and other are crusted. Area is swollen and redness.


Patient Ms. GP is 78-year-old Hispanic woman with Hx of DM Type II and Hyperlipidemia,

came into our clinic today complaining about itching, pain and tingling on her right lower back

starting 3 days ago. During the physical exam was noted painful redness rash, with crops of

vesicles on an erythematous base with a few satellite lesions in linear distribution, which do not

cross midline. Diagnosis is based on the clinical evaluation through history and physical

examination. According to patient presentation, signs and symptoms patient is diagnosed with

herpes zoster. Patients falls into the high risk group based on Buttaro (2017). Herpes zoster is

viral infection that occurs with reactivation of the varicella-zoster virus and the patient referred

has history of Chickenpox when she was 20 years old.

Main Diagnosis

Herpes Zoster (ICD10 B02.9): Herpes zoster is infection that results when varicella-zoster virus

reactivates from its latent state in a posterior dorsal root ganglion. Symptoms usually begin with

pain along the affected dermatome, followed within 2 to 3 days by a vesicular eruption that is

usually diagnostic. (Domino, Baldor, Golding, &Stephens,2017).

Other diagnosis:

Diabetes mellitus type II. (ICD-10 E11.9)

Hyperlipidemia. (ICD-10 E78.5)

Differential diagnosis

 Irritant contact dermatitis (ICD10 L24)

 Impetigo. (ICD10 L01.0)

 Varicella. (ICD 10 B01)

 Dermatitis herpetiformis. (ICD10 L13.0)


Labs and Diagnostic Test to be ordered (if applicable)

 Viral culture, polymerase chain reaction for VZV

Pharmacological treatment:

 Valtrex 1 gm TID x 7 days ideally during the prodrome, and is less likely to be effective if

given > 72 hours after skin lesions appear,

 VZV vaccine

 Pain-reliever NSAIDs

 Management of post herpetic neuralgia (Treatments include gabapentin, pregabalin)

Continue with current medication for chronic condition:

 Insulin Lantus 100 u/ml 15 unit in the morning and at bedtime

 Metformin 500 mg 1 tablet PO once a day

 Atorvastatin 20 mg 1 tablet PO at bedtime

Non-Pharmacologic treatment:

 Do not scratch the area with dirty hands. Use lotion like calamine to refresh the area.

 Keep the area clean and dry.


 Isolation precaution – Type Contact

 Avoid contact with susceptible person like pregnancy woman, kids and

Immunocompromised patient.

 Education about hand washing.

 Avoid ABT cream.


Follow up appointment 2 weeks / No referral needed at this time

Call if the symptoms are worse or you noticed any adverse reaction.


Buttaro, T. M., Trybulski, J. A., Polgar-Bailey, P., & Sandberg-Cook, J. (2017). Primary care: a

collaborative practice. St. Louis, MO: Elsevier.

Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Clinical Consult 2017

(25th ed.). Print (The 5-Minute Consult Series).

McCance, K. L., & Huether, S. E. (2019). Pathophysiology: the biologic basis for disease in

adults and children. St. Louis, MO: Elsevier.

Graduatewriterhelp.com Plagiarism Free Papers

Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we\’ll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.

Why Hire Graduatewriterhelp.com writers to do your paper?

Quality- We are experienced and have access to ample research materials.

We write plagiarism Free Content

Confidential- We never share or sell your personal information to third parties.

Support-Chat with us today! We are always waiting to answer all your questions.

Graduatewriterhelp.com is an online academic writing site catering to students from all educational levels, from high school and college to graduate level and beyond. The website has a team of experienced writers who are equipped with the knowledge and skills required to provide top-notch custom writing services for any task assigned by our customers.

At Graduatewriterhelp.com, we specialize in offering assistance with the following tasks: essays, research papers, projects, case studies, book reviews, lab reports, presentations, term papers and even editing or proofreading services as well. All these tasks can be done according to the instructions provided by our clients without compromising on the quality or accuracy of work delivered within shorter periods of time as per customer requirements. Clients also have access to knowledgeable customer support staff, which assists them with their queries at any time during the day or night when placing orders through our website interface.

In addition to the regular services offered by Graduatewriterhelp.com such as essay writing help for high school and college assignments; dissertation/thesis preparation for postgraduate programs; coursework composition for undergraduates; editing/proofreading services for students who require revisions on pre-written works; we also offer specialized services like grant proposal writing assistance for those seeking funds from external bodies; data analysis report creation based on statistical information collected from relevant sources; CV/resume formatting according to employer expectations; literature reviews postulating various interpretations on certain topics etcetera based on customer needs..
We also facilitate the completion of important applications such as those needed while applying abroad or enrolling into some universities where thoroughness is critical in order secure admissions favorably that meet admission criteria demandingly set forth by these institutions due to intense competition witnessed globally today among prospective applicants vying places available therein limited vacancies so created thereupon every academic year…

Moreover, our experts are qualified in diverse fields being well versed in different areas of knowledge too, thus enabling us to cover almost any topic that may come your way thereby providing comprehensive solutions pertaining same conclusively efficient manner possible, meeting customer deadlines within the desired timeframe successfully sans excuses whatsoever implicated concerning inconsistency matters grade expectation meeting provided via us hereunder…

By availing our services at Graduatewriterhelp.com, clients can rest assured that their work will be completed accurately within their specified deadlines without compromising quality standards expected out of professional service providers like ourselves.

Place your order
(550 words)

Approximate price: $22

Calculate the price of your order

550 words
We'll send you the first draft for approval by September 11, 2018 at 10:52 AM
Total price:
The price is based on these factors:
Academic level
Number of pages
Basic features
  • Free title page and bibliography
  • Unlimited revisions
  • Plagiarism-free guarantee
  • Money-back guarantee
  • 24/7 support
On-demand options
  • Writer’s samples
  • Part-by-part delivery
  • Overnight delivery
  • Copies of used sources
  • Expert Proofreading
Paper format
  • 275 words per page
  • 12 pt Arial/Times New Roman
  • Double line spacing
  • Any citation style (APA, MLA, Chicago/Turabian, Harvard)

Our guarantees

Delivering a high-quality product at a reasonable price is not enough anymore.
That’s why we have developed 5 beneficial guarantees that will make your experience with our service enjoyable, easy, and safe.

Money-back guarantee

You have to be 100% sure of the quality of your product to give a money-back guarantee. This describes us perfectly. Make sure that this guarantee is totally transparent.

Read more

Zero-plagiarism guarantee

Each paper is composed from scratch, according to your instructions. It is then checked by our plagiarism-detection software. There is no gap where plagiarism could squeeze in.

Read more

Free-revision policy

Thanks to our free revisions, there is no way for you to be unsatisfied. We will work on your paper until you are completely happy with the result.

Read more

Privacy policy

Your email is safe, as we store it according to international data protection rules. Your bank details are secure, as we use only reliable payment systems.

Read more

Fair-cooperation guarantee

By sending us your money, you buy the service we provide. Check out our terms and conditions if you prefer business talks to be laid out in official language.

Read more
Are you sure want to unlock this post?
Unlock left : 0
Are you sure want to cancel subscription?