NR 509 SOAP Note Week 4 - Shadow Health PDF

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Summary

Soap note example for the patient. This is a great start to your learning and practice....

Description

SOAP Note Template S: Subjective Information the patient or patient representative told you Initials: B.F. Height

Weight

5’11”

197lbs

Age: 58 BP

HR

RR

Temp

SPO2

Gender: M Pain Rating 0/10

Allergies (and reaction)

146/ 104 19 36.7 98% Medication: Codeine (Nausea and Vomiting) 88 bpm Food: denies (L Environment: denies arm) ;146 /90 (R arm History of Present Illness (HPI) Chief Complaint (CC) “Troubling chest pain now and then for a month” CC is a BRIEF statement identifying why the patient is here - in the Onset Pain started earlier in the current month patient’s own words - for instance Location Pain occurs in the middle of the chest over the heart "headache", NOT "bad headache for 3 Duration The pain begins and gets better over a couple of minutes days”. Sometimes a patient has more Characteristics Tightness in the middle of the chest; 5/10 chest pain than one complaint. For example: If the patient presents with cough and Aggravating Factors Physical exertion and exercise (yard work and taking the stairs instead of the sore throat, identify which is the CC elevator) and which may be an associated Relieving Factors Sitting or lying down; Rest symptom Treatment N/A- pt expressed he does not take anything for the pain Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. Length of Time Medication Dosage Frequency Reason for Use (Rx, OTC, or Homeopathic) Used Lisinopril 20mg PO Daily 1 year High Blood Pressure Atorvastatin 20mg PO Daily at bedtime 1 year High Cholesterol Omega-3 Fish Oil 1200mg PO BID 1 year “I hear its good for your cholesterol” Click or tap here Headaches Acetaminophen UTA PRN to enter text. Ibuprofen UTA PRN Click or tap here Headaches

to enter text. Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses, hospitalizations, and surgeries. Depending on the CC, more info may be needed.

The pt was diagnosed with HTN and high cholesterol 1 year ago. Pt denies any past hospitalizations. Pt also denies any surgical history. Pt is up to date on all immunizations. B.F. received the influenza vaccine this current season. Tdap was received 10/2014, next dose should be received in 2024. He expressed that he doesn’t usually check his BP at home. His cholesterol was checked 3 months prior to the current visit. His provider kept him on the same dose of the Lipitor after checking his cholesterol level. EKG performed 3 months prior at annual physical and normal per patient. Annual stress test performed and expressed to be normal. Pt denies any history of heart disease or DM. Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent data. Include health promotion such as use seat belts all the time or working smoke detectors in the house. B.F. is a civil engineer. The pt is happily to his wife of 27 year. With his wife, they have two living children. Pts hobbies include fishing, watching sport, electronics repair, and attending his son’s body building competitions. Pt denies any current exercise activity. His bike was stolen, and he is concerned to start riding again with the intermittent chest pain. Pt denies current use of marijuana or illegal drugs but admits to trying 30 years ago. Denies tobacco usage. Denies secondhand smoke. The pt drinks 2-3 beers on the weekend. He wears his seat belt when driving. Smoke detectors are present in his home. The pt drinks 2 cups of coffee during the week and a whole pot on Sundays. Pt ties to limit sodium and fat in his diet, but he likes to eat red meat. Colonoscopy at the age of 50 which was normal. Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent. The pts father died of colon cancer at 75 years old. His father was diagnosed with HTN, HLD and obesity. The pts mother is diagnosed with DM and HTN. Brother is deceased and died of an MVA. Sister has Type II DM and HTN. His maternal grandmother died of breast CA at the age of 65. His maternal grandfather died of a heart attack at the age of 54 years. Paternal grandmother died of PNA at the age of 78 years. Paternal grandfather died of natural causes at 85 years. His daughter is diagnosed with asthma.

Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive

symptom and provide additional details. Skin Constitutional If patient denies all If patient denies all symptoms for this symptoms for this system, system, check here: ☒ check here: ☐ ☐Itching Click or tap ☐Fatigue denies here to enter text. ☐Weakness denies ☐Fever/Chills denies ☐Rashes Click or tap here to enter text. ☒Weight Gain 20 pounds over last couple of years. ☐Nail Changes Click or tap here to enter ☐Weight Loss denies text. ☐Trouble Sleeping pt sleeps 6-7 hours per night ☐Skin Color Changes Click or tap here to ☐Night Sweats denies enter text. ☐Other: ☐Other: Click or tap here to enter Click or tap here to text. enter text. Respiratory If patient denies all symptoms for this system, check here: ☒ ☐Cough Click or tap here to enter text. ☐Hemoptysis Click or tap here to enter text. ☐Dyspnea Click or tap here to enter text. ☐Wheezing Click or tap here to enter text. ☐Pain on Inspiration Click or tap here to enter text. ☐Sputum Production

HEENT If patient denies all symptoms for this system, check here: ☒

☐Diplopia Click or tap here to enter text. ☐Eye Pain Click or tap here to enter text. ☐Eye redness Click or tap here to enter text. ☐Vision changes Click or tap here to enter text. ☐Photophobia Click or tap here to enter text. ☐Eye discharge Click or tap here to enter text.

Neuro If patient denies all symptoms for this system, check here: ☐ ☐Syncope or Lightheadedness denies ☐Headache Experienced “once in a blue moon”- UTA to assess the causes ☐Numbness denies ☐Tingling denies ☐Sensation Changes ☐Speech Deficits denies ☐Other: denies

☐Earache Click or tap here to enter text. ☐Tinnitus Click or tap here to enter text. ☐Epistaxis Click or tap here to enter text. ☐Vertigo Click or tap here to enter text. ☐Hearing Changes Click or tap here to enter text.

☐Hoarseness Click or tap here to enter text. ☐Oral Ulcers Click or tap here to enter text. ☐Sore Throat Click or tap here to enter text. ☐Congestion Click or tap here to enter text. ☐Rhinorrhea Click or tap here to enter text. ☐Other: Click or tap here to enter text.

Cardiac and Peripheral Vascular If patient denies all symptoms for this system, check here: ☐

☒Chest pain intermittent for the past month with exertion ☐SOB denies ☒Exercise Intolerance chest pain induced by increased activity ☐Orthopnea denies ☐Edema denies ☐Murmurs denies

☐Palpitations denies ☐Faintness denies ☐Claudications denies ☐PND denies ☐Other: denies

☐Other: Click or tap here to enter text.

MSK If patient denies all symptoms for this system, check here: ☒

GI If patient denies all symptoms for this system, check here: ☒

GU If patient denies all symptoms for this system, check here: ☒

PSYCH If patient denies all symptoms for this system, check here: ☐

☐Pain Click or tap here to enter text. ☐Stiffness Click or tap here to enter text. ☐Crepitus Click or tap here to enter text. ☐Swelling Click or tap here to enter text. ☐Limited ROM

☐Nausea/Vomiting Click or tap here to enter text. ☐Dysphasia Click or tap here to enter text. ☐Diarrhea Click or tap here to enter text. ☐Appetite Change Click or tap here to enter text. ☐Heartburn Click or tap here to enter text. ☐Blood in Stool Click or tap here to enter text. ☐Abdominal Pain Click or tap here to enter text. ☐Excessive Flatus Click or tap here to enter text. ☐Food Intolerance Click or tap here to enter text. ☐Rectal Bleeding Click or tap here to enter text. ☐Other:

☐Urgency Click or tap here to enter text. ☐Dysuria Click or tap here to enter text. ☐Burning Click or tap here to enter text. ☐Hematuria Click or tap here to enter text. ☐Polyuria Click or tap here to enter text. ☐Nocturia Click or tap here to enter text. ☐Incontinence Click or tap here to enter text. ☐Other: Click or tap here to enter text.

☐Stress denies ☐Anxiety due to the chest pain ☐Depression denies ☐Suicidal/Homicidal Ideation denies ☐Memory Deficits denies ☐Mood Changes denies ☐Trouble Concentrating denies ☐Other: denies

☐Redness Click or tap here to enter text. ☐Misalignment Click or tap here to enter text. ☐Other: Click or tap here to enter text.

GYN If patient denies all symptoms for this system, check here: N/A ☒ ☐Rash Click or tap here to enter text. ☐Discharge Click or tap here to enter text. ☐Itching Click or tap here to enter text.

Hematology/Lymphatics If patient denies all symptoms for this system, check here: ☒ ☐Anemia Click or tap here to enter text. ☐ Easy bruising/bleeding Click or tap here to enter text.

Endocrine If patient denies all symptoms for this system, check here: ☒ ☐ Abnormal growth Click or tap here to enter text. ☐ Increased appetite Click or tap here to enter

☐Irregular Menses Click or tap here to enter text. ☐Dysmenorrhea Click or tap here to enter text. ☐Foul Odor Click or tap here to enter text. ☐Amenorrhea Click or tap here to enter text. ☐LMP: Click or tap here to enter text. ☐Contraception Click or tap here to enter text.

☐ Past Transfusions Click or tap here to enter text. ☐ Enlarged/Tender lymph node(s) Click or tap here to enter text. ☐ Blood or lymph disorder Click or tap here to enter text. ☐ Other Click or tap here to enter text.

text. ☐ Increased thirst Click or tap here to enter text. ☐ Thyroid disorder Click or tap here to enter text. ☐ Heat/cold intolerance Click or tap here to enter text. ☐ Excessive sweating Click or tap here to enter text. ☐ Diabetes Click or tap here to enter text. ☐ Other Click or tap here to enter text.

☐Other:Click or tap here to enter text.

O: Objective Information gathered during the physical examination by inspection, palpation, auscultation, and percussion. If unable to assess a body system, write “Unable to assess”. Document pertinent positive and negative assessment findings. Pertinent positive are the “abnormal” findings and pertinent “negative” are the expected normal findings. Separate the assessment findings accordingly and be detailed.

Body System

Positive Findings

Negative Findings

General Click or tap here to enter text.

B.F. is a pleasant 58-year-old Caucasian female. He presents today with a chief complaint of intermittent chest upon exertion. No acute distress. He is well developed and nourished. He is hydrated.

Click or tap here to enter text.

Skin is normal for ethnicity. Skin is warm and dry with no tenting.

Click or tap here to enter text.

Head is normal in appearance and atraumatic.

Fine crackles noted upon auscultation of bilateral lower lung lobes.

Chest expansion symmetric. No signs of respiratory distress or increased work of breathing. Breath sounds present in all areas.

Click or tap here to enter text.

Pt is awake, alert and oriented.

Right carotid artery bruit present on auscultation. S3 assessed in mitral area with bell of the stethoscope. Right carotid artery positive for a thrill with an amplitude pf 3+. PMI displaced laterally but is brisk and tapping.

JVD 3 cm above the sternal angle. No sign of edema in bilateral lower extremities. Capillary refill less than 3 seconds in bilateral fingers and toes. No bruit notes upon auscultation of abdominal aorta. No bruit notes in renal, iliac and femoral arteries. No thrill palpable on Left carotid artery and amplitude is 2+ which is expected. Brachial pulses 2+, no thrill bilaterally. Radial pulse 2+, no thrill bilaterally. Femoral pulses 2+, no thrill bilaterally. Popliteal pulses 1+, no thrill bilaterally. Tibial pulses 1+, no thrill bilaterally. Dorsalis pedis 1+, no thrill bilaterally. EKG shows NSR with no ST elevation.

Not assessed.

Click or tap here to enter text.

Click or tap here to enter text.

Abdomen is symmetric and round. Bowel sounds present in all 4 quadrants and normoactive. No masses, guarding or tenderness upon light and deep palpation in all 4 quadrants. Liver palpable 1 cm below right costal margin. Kidneys and spleen not palpable. Tympany noted on all 4 quadrants. Liver span 7 cm in MCL.

N t

Cli k

Skin

HEENT

Respiratory

Neuro

Cardiovascular

Musculoskeletal

Gastrointestinal

Genitourinary d

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A: Assessment Medical Diagnoses. Provide 3 differential diagnoses (DDx) which may provide an etiology for the CC. The first diagnosis (presumptive diagnosis) is the diagnosis with the highest priority. Provide the ICD-10 code and pertinent findings to support each diagnosis. Diagnosis ICD-10 Code Pertinent Findings Atherosclerotic heart disease of native coronary artery without angina pectoris

Angina Pectoris

125.10

120.8

Hx of HTN and HLD; Sedentary lifestyle; Family Hx of MI, HTN, and DM. Displaced PMI displacement could be due to ventricular hypertrophy secondary to decrease O2 supply leafing to remodeling. Occlusion of the blood vessel due to atherosclerotic plaque leads to poor O2 supply to the heart which creates and imbalance between oxygen supply and demand (Ashiq et al., 2019; Malakar et al., 2018) 5/10 intermittent chest pain that is present with increasing O2 demands. Develops due to stenosis and occurs with moderate exercise Signs and symptoms can last minutes and can be induced by emotional stress and exertion (Malakar et al., 2018) “Angina has been described as a recurrent discomfort in the retrosternal chest that is predictably provoked by exertion, anxiety, or stress, crescendos over a period of minutes, and dissipates with rest or nitroglycerin treatment within minutes” (Joshi and de Lemos, 2021).

Other chest pain

R07.89

Ruling out Gastroesophageal reflux disorder with chest pain

P: Plan Address all 5 parts of the comprehensive treatment plan. If you do not wish to order an intervention for any part of the treatment plan, write “None at this time” but do not leave any heading blank. No intervention is self-evident. Provide a rationale and evidence-based in-text citation for each intervention.

Diagnostics: List tests you will order this visit Test Fasting lipid panel; Hemoglobin A1c; BMP; CBC Troponin and BNP Cardiac CT

Rationale/Citation Routine laboratory values can identify comorbidities such as: kidney disease, DM, dyslipidemia and anemia (Joshi and de Lemos, 2021). Biomarkers can provide risk information (Joshi and de Lemos, 2021). It is useful in diagnosis, but also shows prognosis for individuals presenting with anginal symptoms, but currently not diagnosed with CAD (Joshi and de Lemos, 2021). Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Medications: List medications/treatments including OTC drugs you will order and “continue meds” if pertinent. Drug Dosage Length of Treatment Rationale/Citation Lisinopril 20 mg BID (Total of 40mg/day) Continuous Increase d/t persistent HTN Twice daily Lisinopril is more effective than the standard once a day dosing. Increasing the dose of one medication decreases polypharmacy and patient confusion surrounding medication administration (Tsai et al., 2016).

In the American Heart Association (AHA) and American College of Cardiology (ACC) guidelines, normal blood pressure (BP) is deemed to be less than 120/80 mmHg (American Heart Association, 2018; Burnier et al., 2018). A systolic blood pressure (SBP) of 120-129mmHg with a diastolic blood pressure (DBP) less than 80mmHg is said to be elevated BP (Burnier et al., 2018). The AHA and ACC determined that Stage 1 HTN is defined as an SBP of 130-138mmHg and a DBP of 80-89mmHg (American Heart Association, 2018; Burnier et al., 2018). The AHA and ACC defined Stage 2 HTN as a BP greater than 140/90mmHg (American Heart Association, 2018). Atorvastatin Omega-3 fatty acid

Continue previous dosing D/C

Click or tap here to enter text. D/C

Aspirin

81 mg daily

Continuous

Nitroglycerin

1 tablet under the tongue with presentation of symptoms (Mayo

PRN every 5 minutes x’s 3 doses (Mayo Clinic, 2021).

Click or tap here to enter text. Discontinue usage Research has shown that when used in combination with STATIN therapy, there are elevated levels of triglycerides (Joshi and de Lemos, 2021). Antiplatelet therapy is important for reducing cardiac risk in pts with coronary artery disease usually with the use of aspirin less than 100mg (Joshi and de Lemos, 2021). Short-acting nitrates are commonly used for anginal

Clinic, 2021).

attacks or administered prior to exercise to prevent exerciseinduced angina (Joshi and de Lemos).

Referral/Consults: Cardiology

Pt has a family history of heart disease, and currently has HTN and HLD (Penn Medicine, 2020).

Click or tap here to enter text.

Pt should be aware headaches, flushing and hypotension (Joshi and de Lemos, 2021).

Click or tap here to enter text.

Education: Nitroglycerin Management

If anginal symptoms persist after the second dose of Nitroglycerin, call 911. This could be an emergency such as an MI. ACE Inhibitor Education Potential for angioedema Follow Up: Indicate when patient should return to clinic and provide detailed symptomatology indicating if the patient should return sooner than scheduled or seek attention elsewhere. Click or tap here to enter text. Follow-up as necessary and have pt check BPs at home and follow-up in 2 weeks.

References Include at least one evidence-based peer-reviewed journal article which relates to this case. Use the correct current APA edition formatting. Ashiq, S., Ashiq, K., Shahid, S.U., Qayyum, M. & Sadia, H. (2019). Prevalence and role of different risk factors with emphasis on genetics in development of pathophysiology of coronary artery disease (cad). Pakistan Heart Journal, 52(4), 279-287. American Heart Association. (2018). Diagnosing and Managing Hypertension in Adults [Brochure]. https://www.heart.org/-/media/files/healthtopics/high-blood-pressure/tylenol-hbp/aha18hyperpocketguideprint3final-approved.pdf?la=en Burnier, M., Oparil, S., Narkiewicz, K. & Kjeldsen, S.E. (2018). New 2017 American Heart Association and American College of Cardiology guideline for hypertension in the adults: Major paradigm shifts, but will they help to fight against the hypertension disease burden? Blood Pressure, 27(2), 62-65. Doi: 10.1080/08037051.2018.1430504 Joshi, P.H. & de Lemos, J.A. (2021). Diagnosis and management of stable angina. Journal of American Medical Association, 325(17), 1765-1778. Mayo Clinic. (2021, February 1). Nitroglycerin (Oral Route, Sublingual Route) Proper Use. Mayo Clinic. https://www.mayoclinic.org/drugssupplements/nitroglycerin-oral-route-sublingual-route/proper-use/drg 20072863#: ~:text=For%20sublingual%20dosage%20form%20(tablets,3%20tablets...