NURS 5220 SOAP NOTE ASSIGNMENT 1 – COMPLETE
LATEST VERSION STUDY GUIDE
1. Immediate Management (Acute Decompensated HF)
• Oxygen: 2L NC to maintain SpO2 >94% (currently 96% on 2L)
• IV Diuresis: Furosemide 40 mg IV push now, then 40 mg IV every 8
hours. Monitor urine output, electrolytes, and renal function closely.
Goal: 2-3L negative fluid balance over 24-48 hours.
• Strict I&O: Foley catheter if unable to accurately measure output.
• Daily weights: Same scale, same time each morning.
• Fluid restriction: 1.5-2L/day (including oral intake and IV medications).
• Sodium restriction: <2g/day. Nutrition consult for heart-healthy diet.
2. Medication Optimization
• Continue carvedilol 12.5 mg BID (hold if hypotensive or acute
decompensation worsens).
• Continue lisinopril 20 mg daily (hold if acute kidney injury develops with
diuresis).
• Continue spironolactone 25 mg daily (potassium-sparing diuretic;
monitor K+ closely).
• Continue aspirin 81 mg, atorvastatin 40 mg, metformin, tamsulosin, and
warfarin.
• Medication reconciliation: Ensure all prescriptions filled. Arrange
pharmacy delivery or family assistance to prevent future lapses.
3. Diagnostic Workup
• EKG: Rule out acute ischemia, assess rhythm (AF with RVR vs.
controlled).
• Chest X-ray: Assess pulmonary edema, cardiomegaly, pleural effusions.
, • BNP/NT-proBNP: Baseline and trend (expected elevation; >400 pg/mL
supports HF diagnosis).
• Troponin I: Rule out ACS as precipitant.
• CBC, CMP, Mg, Phos: Baseline and monitor with diuresis.
• INR: Check (on warfarin).
• HbA1c: If not recent.
• Echocardiogram: If not done in past 6 months or if clinical deterioration.
4. Monitoring
• Telemetry monitoring for arrhythmia surveillance (AF, potential
ventricular arrhythmias).
• Vital signs every 4 hours.
• Daily weights.
• BMP and Mg every 24 hours while on IV diuresis.
• Urine output goal: >0.5 mL/kg/hr.
5. Patient/Family Education
• Importance of daily weights (call if gain >3 lbs in 1 day or >5 lbs in 1
week).
• Sodium and fluid restriction.
• Medication adherence strategies (pill organizer, pharmacy auto-refill,
family involvement).
• When to seek emergency care (worsening dyspnea, chest pain,
syncope).
• Smoking cessation reinforcement (already quit; congratulate).
6. Discharge Planning
• Social work consult for medication assistance program and home health
evaluation.
• Consider cardiac rehabilitation referral once stabilized.
• Ensure follow-up appointment within 7 days of discharge.
, • Provide written discharge instructions and medication list.
7. Follow-Up
• Daily assessment while inpatient.
• Cardiology follow-up within 1 week of discharge.
• Primary care follow-up within 3-5 days.
• Repeat echocardiogram in 3 months if EF not recently assessed.
8. Billing Codes
• 99223 – Initial hospital care, high complexity
• ICD-10: I50.23 (Acute on chronic systolic HF), I48.91 (AF), N18.31 (CKD
3a), I10 (HTN), E11.9 (T2DM), I25.10 (CAD), E78.5 (Hyperlipidemia),
N40.0 (BPH)
CASE 5: ADULT MALE – LOWER BACK PAIN (MUSCULOSKELETAL)
SUBJECTIVE
Chief Complaint: "I threw my back out lifting a box at work three days ago, and
the pain is getting worse."
History of Present Illness: Mr. David Chen is a 45-year-old Asian male who
presents to the urgent care clinic with acute lower back pain. He reports that 3
days ago, while lifting a heavy box at his warehouse job, he felt a sudden "pop"
in his lower back followed by immediate sharp pain. He describes the pain as
aching and stabbing, localized to the right lower lumbar region (L4-L5 area),
radiating occasionally to the right buttock but not below the knee. Pain is rated
7/10 at worst, 4/10 at rest.
He reports difficulty bending, twisting, and standing for prolonged periods. He
has been unable to work since the injury. He reports that the pain is worse in
the morning and improves slightly with movement but worsens with prolonged
sitting or standing. He has tried ibuprofen 400 mg every 6 hours with minimal
relief and has been using a heating pad.
He denies numbness, tingling, or weakness in the legs. Denies bowel or bladder
dysfunction, saddle anesthesia, fever, chills, or unexplained weight loss. No
history of similar episodes. No recent trauma other than lifting incident.
LATEST VERSION STUDY GUIDE
1. Immediate Management (Acute Decompensated HF)
• Oxygen: 2L NC to maintain SpO2 >94% (currently 96% on 2L)
• IV Diuresis: Furosemide 40 mg IV push now, then 40 mg IV every 8
hours. Monitor urine output, electrolytes, and renal function closely.
Goal: 2-3L negative fluid balance over 24-48 hours.
• Strict I&O: Foley catheter if unable to accurately measure output.
• Daily weights: Same scale, same time each morning.
• Fluid restriction: 1.5-2L/day (including oral intake and IV medications).
• Sodium restriction: <2g/day. Nutrition consult for heart-healthy diet.
2. Medication Optimization
• Continue carvedilol 12.5 mg BID (hold if hypotensive or acute
decompensation worsens).
• Continue lisinopril 20 mg daily (hold if acute kidney injury develops with
diuresis).
• Continue spironolactone 25 mg daily (potassium-sparing diuretic;
monitor K+ closely).
• Continue aspirin 81 mg, atorvastatin 40 mg, metformin, tamsulosin, and
warfarin.
• Medication reconciliation: Ensure all prescriptions filled. Arrange
pharmacy delivery or family assistance to prevent future lapses.
3. Diagnostic Workup
• EKG: Rule out acute ischemia, assess rhythm (AF with RVR vs.
controlled).
• Chest X-ray: Assess pulmonary edema, cardiomegaly, pleural effusions.
, • BNP/NT-proBNP: Baseline and trend (expected elevation; >400 pg/mL
supports HF diagnosis).
• Troponin I: Rule out ACS as precipitant.
• CBC, CMP, Mg, Phos: Baseline and monitor with diuresis.
• INR: Check (on warfarin).
• HbA1c: If not recent.
• Echocardiogram: If not done in past 6 months or if clinical deterioration.
4. Monitoring
• Telemetry monitoring for arrhythmia surveillance (AF, potential
ventricular arrhythmias).
• Vital signs every 4 hours.
• Daily weights.
• BMP and Mg every 24 hours while on IV diuresis.
• Urine output goal: >0.5 mL/kg/hr.
5. Patient/Family Education
• Importance of daily weights (call if gain >3 lbs in 1 day or >5 lbs in 1
week).
• Sodium and fluid restriction.
• Medication adherence strategies (pill organizer, pharmacy auto-refill,
family involvement).
• When to seek emergency care (worsening dyspnea, chest pain,
syncope).
• Smoking cessation reinforcement (already quit; congratulate).
6. Discharge Planning
• Social work consult for medication assistance program and home health
evaluation.
• Consider cardiac rehabilitation referral once stabilized.
• Ensure follow-up appointment within 7 days of discharge.
, • Provide written discharge instructions and medication list.
7. Follow-Up
• Daily assessment while inpatient.
• Cardiology follow-up within 1 week of discharge.
• Primary care follow-up within 3-5 days.
• Repeat echocardiogram in 3 months if EF not recently assessed.
8. Billing Codes
• 99223 – Initial hospital care, high complexity
• ICD-10: I50.23 (Acute on chronic systolic HF), I48.91 (AF), N18.31 (CKD
3a), I10 (HTN), E11.9 (T2DM), I25.10 (CAD), E78.5 (Hyperlipidemia),
N40.0 (BPH)
CASE 5: ADULT MALE – LOWER BACK PAIN (MUSCULOSKELETAL)
SUBJECTIVE
Chief Complaint: "I threw my back out lifting a box at work three days ago, and
the pain is getting worse."
History of Present Illness: Mr. David Chen is a 45-year-old Asian male who
presents to the urgent care clinic with acute lower back pain. He reports that 3
days ago, while lifting a heavy box at his warehouse job, he felt a sudden "pop"
in his lower back followed by immediate sharp pain. He describes the pain as
aching and stabbing, localized to the right lower lumbar region (L4-L5 area),
radiating occasionally to the right buttock but not below the knee. Pain is rated
7/10 at worst, 4/10 at rest.
He reports difficulty bending, twisting, and standing for prolonged periods. He
has been unable to work since the injury. He reports that the pain is worse in
the morning and improves slightly with movement but worsens with prolonged
sitting or standing. He has tried ibuprofen 400 mg every 6 hours with minimal
relief and has been using a heating pad.
He denies numbness, tingling, or weakness in the legs. Denies bowel or bladder
dysfunction, saddle anesthesia, fever, chills, or unexplained weight loss. No
history of similar episodes. No recent trauma other than lifting incident.
