1) The document discusses guidelines for a SOAP note case study on an acute kidney injury patient. It includes details on the required sections and formatting of the note. 2) The case involves a 68-year-old male presenting with headaches for 2 weeks and high blood pressure readings. His history, exam, assessments of essential hypertension and differential diagnoses are provided. 3) The treatment plan includes ordering labs and diagnostic tests, prescribing hydrochlorothiazide, and follow up in 1 month.

1. Acute Kidney Injury Case Study MRU Discussion
Acute Kidney Injury Case Study MRU DiscussionAcute Kidney Injury Case Study MRU
DiscussionMust use the sample template for your soap note, keep this template for when
you start clinicals.Follow the MRU Soap Note Rubric as a guideUse APA format and must
include minimum of 2 Scholarly Citations.Soap notes will be uploaded to Moodle and put
through TURN-It-In (anti-Plagiarism program)Turn it in Score must be less than 50% or
will not be accepted for credit, must be your own work and in your own words. You can
resubmit, Final submission will be accepted if less than 50%. Copy paste from websites or
textbooks will not be accepted or tolerated. Please see College Handbook with reference to
Academic Misconduct Statement.The use of templates is ok with regards of Turn it in, but
the Patient History, CC, HPI, The Assessment and Plan should be of your own work and
individualized to your made up patient.ORDER NOW FOR CUSTOMIZED, PLAGIARISM-FREE
PAPERSIdentifying Data (___5pts): The opening list of the note. It contains age, sex, race,
marital status, etc. The patient complaint should be given in quotes. If the patient has more
than one complaint, each complaint should be listed separately (1, 2, etc.) and each
addressed in the subjective and under the appropriate number. 2) Subjective Data
(___30pts.): This is the historical part of the note. It contains the following: a) Symptom
analysis/HPI(Location, quality , quantity or severity, timing, setting, factors that make it
better or worse, and associate manifestations.(10pts). b) Review of systems of associated
systems, reporting all pertinent positives and negatives (10pts). c) Any PMH, family hx,
social hx, allergies, medications related to the complaint/problem (10pts). If more than one
chief complaint, each should be written u in this manner. 3) Objective Data(__25pt.): Vital
signs need to be present. Height and Weight should be included where appropriate. a) b) c)
Appropriate systems are examined, listed in the note and consistent with those identified in
2b.(10pts). Pertinent positives and negatives must be documented for each relevant system.
Any abnormalities must be fully described. Measure and record sizes of things (likes moles,
scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and
normal/abnormal to describe things. (5pts). 4) Assessment (___10pts.): Diagnoses should be
clearly listed and worded appropriately. 5) Plan (___15pts.): Be sure to include any teaching,
health maintenance and counseling along with the pharmacological and non-
pharmacological measures. If you have more than one diagnosis, it is helpful to have this
section divided into separate numbered sections. 6) Subjective/ Objective, Assessment and
Management and Consistent (___10pts.): Does the note the appropriate differential
diagnosis process? Is there evidence that you know what systems and what symptoms go

2. with which complaints? The assessment/diagnoses should be consistent with the subjective
section and then the assessment and plan.Acute Kidney Injury Case Study MRU
DiscussionThe management should be consistent with the assessment/ diagnoses
identified. 7) Clarity of the Write-up(___5pts.): Is it literate, organized and complete?
Comments: Total Score: ____________ Instructor: __________________________________ Guidelines for
Focused SOAP Notes · Label each section of the SOAP note (each body part and system). · Do
not use unnecessary words or complete sentences. · Use Standard Abbreviations S:
SUBJECTIVE DATA (information the patient/caregiver tells you). Chief Complaint (CC): a
statement describing the patient’s symptoms, problems, condition, diagnosis, physician-
recommended return(s) for this patient visit. The patient’s own words should be in quotes.
History of present illness (HPI): a chronological description of the development of the
patient’s chief complaint from the first symptom or from the previous encounter to the
present. Include the eight variables (Onset, Location, Duration, Characteristics, Aggravating
Factors, Relieving Factors, Treatment, Severity-OLDCARTS), or an update on health status
since the last patient encounter. Past Medical History (PMH): Update current medications,
allergies, prior illnesses and injuries, operations and hospitalizations allergies, age-
appropriate immunization status. Family History (FH): Update significant medical
information about the patient’s family (parents, siblings, and children). Include specific
diseases related to problems identified in CC, HPI or ROS. Social History(SH): An age-
appropriate review of significant activities that may include information such as marital
status, living arrangements, occupation, history of use of drugs, alcohol or tobacco, extent of
education and sexual history. Review of Systems (ROS). There are 14 systems for review.
List positive findings and pertinent negatives in systems directly related to the systems
identified in the CC and symptoms which have occurred since last visit; (1) constitutional
symptoms (e.g., fever, weight loss), (2) eyes, (3) ears, nose, mouth and throat, (4)
cardiovascular, (5) respiratory, (6) gastrointestinal, (7) genitourinary, (8) musculoskeletal,
(9}.integument (skin and/or breast), (10) neurological, (11) psychiatric, (12) endocrine,
(13) hematological/lymphatic, {14) allergic/immunologic. Acute Kidney Injury Case Study
MRU DiscussionThe ROS should mirror the PE findings section. 0: OBJECTIVE DATA
(information you observe, assessment findings, lab results). Sufficient physical exam should
be performed to evaluate areas suggested by the history and patient’s progress since last
visit. Document specific abnormal and relevant negative findings. Abnormal or unexpected
findings should be described. You should include only the information which was provided
in the case study, do not include additional data. Record observations for the following
systems if applicable to this patient encounter (there are 12 possible systems for
examination): Constitutional (e.g. vita! signs, general appearance), Eyes, ENT/mouth,
Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin, Neurological, Psychiatric,
Hematological/lymphatic/immunologic/lab testing. The focused PE should only include
systems for which you have been given data. NOTE: Cardiovascular and Respiratory
systems should be assessed on every patient regardless of the chief complaint. Testing
Results: Results of any diagnostic or lab testing ordered during that patient visit. A:
ASSESSMENT: (this is your diagnosis (es) with the appropriate ICD 10 code) List and
number the possible diagnoses (problems) you have identified. These diagnoses are the

3. conclusions you have drawn from the subjective and objective data. Remember: Your
subjective and objective data should your diagnoses and your therapeutic plan. Do not
write that a diagnosis is to be “ruled out” rather state the working definitions of each
differential or primary diagnosis (es). For each diagnoses provide a cited rationale for
choosing this diagnosis. This rationale includes a one sentence cited definition of the
diagnosis (es) the pathophysiology, the common signs and symptoms, the patients
presenting signs and symptoms and the focused PE findings and tests results that the dx.
Include the interpretation of all lab data given in the case study and explain how those
results your chosen diagnosis. P: PLAN (this is your treatment plan specific to this
patient). Each step of your plan must include an EBP citation. 1. Medications write out the
prescription including dispensing information and provide EBP to ordering each
medication. Acute Kidney Injury Case Study MRU DiscussionBe sure to include both
prescription and OTC medications. 2. Additional diagnostic tests include EBP citations to
ordering additional tests 3. Education this is part of the chart and should be brief, this is not
a patient education sheet and needs to have a reference. 4. Referrals include citations to a
referral 5. Follow up. Patient follow-up should be specified with time or circumstances of
return. You must provide a reference for your decision on when to follow up. (Student
Name) Miami Regional University Date of Encounter: Preceptor/Clinical Site: Clinical
Instructor: Dr. David Trabanco DNP, APRN, AGNP-C, FNP-C Soap Note # Main Diagnosis (
Exp: Soap Note #3 DX: Hypertension) PATIENT INFORMATION Name: Mr. DT Age: 68-year-
old Gender at Birth: Male Gender Identity: Male Source: Patient Allergies: PCN, Iodine
Current Medications: • Atorvastatin tab 20 mg, 1-tab PO at bedtime • ASA 81mg po daily •
Multi-Vitamin Centrum Silver PMH: Hypercholesterolemia Immunizations: Influenza last
2018-year, tetanus, and hepatitis A and B 4 years ago. Preventive Care: Coloscopy 5 years
ago (Negative) Surgical History: Appendectomy 47 years ago. Family History: Father- died
81 does not report information Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy Social History: No smoking history or illicit drug use,
occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives
alone. Sexual Orientation: Straight Nutrition History: Diets off and on, Does not each seafood
Subjective Data: Chief Complaint: “headaches” that started two weeks ago Symptom
analysis/HPI: The patient is 65 years old male who complaining of episodes of headaches
and on 3 different occasions blood pressure was measured, which was high (159/100,
158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and
sometimes it is accompanied by dizziness. He states that he has been under stress in his
workplace for the last month. Patient denies chest pain, palpitation, shortness of breath,
nausea or vomiting. Review of Systems (ROS) CONSTITUTIONAL: Denies fever or chills.
Denies weakness or weight loss. NEUROLOGIC: Headache and dizziness as describe above.
Denies changes in LOC. Denies history of tremors or seizures. HEENT: HEAD: Denies any
head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision.
Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage,
congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.
RESPIRATORY: Patient denies shortness of breath, cough or hemoptysis.
CARDIOVASCULAR: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal

4. dyspnea.Acute Kidney Injury Case Study MRU DiscussionGASTROINTESTINAL: Denies
abdominal pain or discomfort. Denies flatulence, nausea, vomiting or diarrhea.
GENITOURINARY: Denies hematuria, dysuria or change in urinary frequency. Denies
difficulty starting/stopping stream of urine or incontinence. MUSCULOSKELETAL: Denies
falls or pain. Denies hearing a clicking or snapping sound. SKIN: No change of coloration
such as cyanosis or jaundice, no rashes or pruritus. Objective Data: VITAL SIGNS:
Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”,
Wt 200 lb, BMI 25. Report pain 2/10. GENERAL APPREARANCE: The patient is alert and
oriented x 3. No acute distress noted. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented
to person, place, and time. Sensation intact to bilateral upper and lower extremities.
Bilateral UE/LE strength 5/5. HEENT: Head: Normocephalic, atraumatic, symmetric, non-
tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visual
acuity and extraocular eye movements intact. No nystagmus noted. Ears: Bilateral canals
patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly
gray with sharp cone of light. Maxillary sinuses no tenderness. Nasal mucosa moist without
bleeding. Oral mucosa moist without lesions,. Lids non-remarkable and appropriate for
race. Neck: supple without cervical lymphadenopathy, no jugular vein distention, no thyroid
swelling or masses. CARDIOVASCULAR: S1S2, regular rate and rhythm, no murmur or gallop
noted. Capillary refill < 2 sec. RESPIRATORY: No dyspnea or use of accessory muscles
observed. No egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath
sounds presents and clear bilaterally on auscultation. GASTROINTESTINAL: No mass or
hernia observed. Upon auscultation, bowel sounds present in all four quadrants, no bruits
over renal and aorta arteries. Abdomen soft non-tender, no guarding, no rebound no
distention or organomegaly noted on palpation MUSKULOSKELETAL: No pain to palpation.
Active and passive ROM within normal limits, no stiffness. INTEGUMENTARY: intact, no
lesions or rashes, no cyanosis or jaundice. ASSESSMENT: Main Diagnosis Essential
(Primary) Hypertension (ICD10 I10): Given the symptoms and high blood pressure (156/92
mmhg), classified as stage 2. Once the organic cause of hypertension has been ruled out,
such as renal, adrenal or thyroid, this diagnosis is confirmed (Codina Leik, 2015). Diagnosis
is based on the clinical evaluation through history, physical examination, and routine
laboratory tests to assess risk factors, reveal identifiable causes and detect target-organ
damage, including evidence of cardiovascular disease (Domino et al,. 2017). Differential
diagnosis: ? Renal artery stenosis (ICD10 I70.1) ? Chronic kidney disease (ICD10 I12.9) ?
Hyperthyroidism (ICD10 E05.90) PLAN: Labs and Diagnostic Test to be ordered: • CMP •
Complete blood count (CBC) • Lipid profile • Thyroid-stimulating hormone (TSH) •
Urinalysis with Micro • Electrocardiogram (EKG 12 lead) Pharmacological treatment: •
Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily. Acute Kidney Injury
Case Study MRU Discussion