NR 509 Week 1 Tina Jones SOAP note PDF

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soap note week 1...

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SOAP Note Template S: Subjective Information the patient or patient representative told you Initials: T.J.

Age: 28

Height

Weight

BP

HR

RR

Temp

SPO2

170cm

90 kg

142/ 82

86

19

101.1 F

99%

Gender: Female Pain Rating

Allergies (and reaction) Medication: Penicillin- Hives Food: Denies Environment: Dust & Cats-sneezing, itchy eyes, & wheezing

History of Present Illness (HPI) Chief Complaint (CC) “I got this scrape on my foot a while ago, and I thought it would heal up on its own, but now it's looking pretty nasty. And the pain is killing me” Onset Injury happened one week ago Location Plantar surface of right foot Duration

Initial injury 7 days ago with increasing pain over the past 2 days

Characteristics

Throbbing and sharp pain with weight bearing. Off-white drainage from wound

Aggravating Factors

Weight-bearing

Relieving Factors

Pain medication, elevation, and rest

Treatment

CC is a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance "headache", NOT "bad headache for 3 days”. Sometimes a patient has more than one complaint. For example: If the patient presents with cough and sore throat, identify which is the CC and which may be an associated symptom

Tramadol for pain. Patient has been cleansing the wound with hydrogen peroxide, soap, and water twice a day. She also stated she applies Neosporin after wound care. Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. Length of Time Medication Reason for Use Dosage Frequency (Rx, OTC, or Homeopathic) Used Tramadol 50mg 3 times a day 1 week Right foot pain Acetaminophen 500mg PRN As needed Headaches Ibuprofen 200mg PRN As needed Menstrual cramps Neosporin 1 application Twice a day As needed-1 wk Right foot wound Albuterol Inhaler 90mcg/spray PRN, 2-3 times a day As needed Asthma/wheezing

Metformin

unknown

1 pill BID

Not currently Type 2 diabetes taking 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.

Patient has a known history of asthma, diagnosed at age 2. Patient was last hospitalized at age 16 related to asthma complications. Denies ever being intubated. Patient has a known history of type 2 diabetes. Non-compliant with diabetes management. States she has not taken her metformin in 3 years. Complaints of polydipsia, nocturia and unexplained weight-loss of 10lbs over the last few months. Patient denies any surgeries. States she is up to date on all immunizations, TDAP booster 1 year ago. Menarche began at age 11. Patient states she has irregular and heavy menstrual cycles. LMP 3 weeks ago. Not currently sexually active. 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. Ms. Jones works as a supervisor at Mid-American Copy & Ship and she’s currently in college studying accounting. Ms. Jones enjoys reading books and volunteering with her church. She lives with her mother and sister after her father passed away about 1 year ago. Denies any current smoking, smokeless tobacco, and drug use. Although she mentioned marijuana use at 21 years old. Ms. Jones drinks alcohol socially a couple times a month. Never been married, currently single and not sexually active. Ms. Jones stated she always wears her seatbelt belt and the smoke detectors in her home are working.

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. Mother has a history of hypertension and hypercholesterolemia. Father has a history of type 2 diabetes, hypertension, and hypercholesterolemia. Father passed away at age 58 related to a motor vehicle crash. Paternal Grandfather has a history of type 2 diabetes, hypertension, hypercholesterolemia and passed away from colon cancer. Paternal grandmother has a history of hypertension and hypercholesterolemia. Maternal grandfather has hypertension and hypercholesterolemia. Maternal grandmother has hypertension and hypercholesterolemia. Report’s sister is diagnosed with asthma. Uncle with alcoholism. No kids.

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. Constitutional Skin HEENT If patient denies all If patient denies all If patient denies all symptoms for this system, check here: ☐ symptoms for this system, symptoms for this check here: ☐ system, check here: ☐ ☐Hoarseness denies ☐Earache denies ☒Fatigue Reports feeling ☐Itching Click or tap ☐Diplopia denies tired lately here to enter text. ☐Oral Ulcers Click or tap here ☐Tinnitus denies ☐Eye Pain denies ☐Weakness Click or tap ☒Rashes Reports to enter text. ☐Epistaxis denies ☐Eye redness denies ☐Vertigo Click or tap here ☒Vision changes Blurred ☐Sore Throat denies here to enter text. acne ☒Fever/Chills 101.1 F oral ☐Nail Changes denies vision when studying and ☐Congestion Click or tap here to enter text. temp during assessment reading ☐Hearing Changes denies to enter text. ☒Skin Color Changes ☐Weight Gain Click or tap reports ☒Rhinorrhea infrequent but ☐Photophobia Click or here to enter text. tap here to enter text. with allergies hyperpigmentation of the posterior neck ☒Weight Loss Reports ☐Eye discharge denies ☐Other: losing 10lbs in just over a Click or tap here to enter text. ☒Other: month Wound to bottom of ☐Trouble Sleeping Click or right foot. 2cm x 1.5cm tap here to enter text. x 2.5mm deep. Report’s acne and ☐Night Sweats denies excessive facial hair. ☐Other: Click or tap here to enter text. Respiratory Neuro Cardiac and Peripheral Vascular If patient denies all symptoms for this If patient denies all symptoms If patient denies all symptoms for this system, check here: ☒ for this system, check here: system, check here: ☐ ☐ ☐Cough denies ☐Syncope or ☐Chest pain denies ☐Palpitations denies

☐Hemoptysis Click or tap here to enter text. ☒Dyspnea on exertion ☒Wheezing When exposed to allergens such as cats and dust ☐Pain on Inspiration denies ☐Sputum Production

☐Other: Click or tap here to enter text.

Lightheadedness denies ☒Headache intermittent headaches when studying/reading. Denies current headache ☐Numbness denies ☐Tingling denies ☐Sensation Changes

☐SOB Click or tap here to enter text. ☐Exercise Intolerance Click or tap here to enter text. ☐Orthopnea Click or tap here to enter text. ☐Edema denies ☐Murmurs denies

☐Faintness Click or tap here to enter text. ☐Claudications Click or tap here to enter text. ☐PND denies ☐Other: Click or tap here to enter text.

☐Speech Deficits Click or tap here to enter text. ☐Other: denies head injury

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 7/10 right foot pain. Describes as sharp and throbbing ☐Stiffness Click or tap here to enter text. ☐Crepitus Click or tap here to enter text. ☒Swelling right foot swelling ☐Limited ROM

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

☐Urgency Click or tap here to enter text. ☐Dysuria Click or tap here to enter text. ☐Burning denies ☐Hematuria denies ☒Polyuria reports frequent urination ☒Nocturia Click or tap here to enter text. ☐Incontinence denies ☐Other: Click or tap here to enter text.

☒Stress Fathers death. Reports coping well at this time ☐Anxiety Click or tap here to enter text. ☐Depression denies ☐Suicidal/Homicidal Ideation denies ☐Memory Deficits Click or tap here to enter text. ☐Mood Changes Click or tap here to enter text. ☐Trouble Concentrating Click or tap here to enter text. ☐Other: Click or tap here to enter text.

☒Redness right foot wound ☐Misalignment Click or tap here to enter text. ☐Other: Click or tap here to enter text.

GYN If patient denies all symptoms for this

Hematology/Lymphatics If patient denies all symptoms for this system,

Endocrine If patient denies all symptoms for this system,

system, check here: ☐ ☐Rash Click or tap here to enter text. ☐Discharge Click or tap here to enter text. ☐Itching Click or tap here to enter text. ☒Irregular Menses reports menstruating every 6 weeks to 2 months ☒Dysmenorrhea Reports heavy, painful menstrual cycles ☐Foul Odor Click or tap here to enter text. ☐Amenorrhea Click or tap here to enter text. ☒LMP: 3 weeks ago ☐Contraception no current use ☒Other: Reports heavy menstrual cycles, changing tampons every 2-3 hours. Reports heavy cramping

check here: ☒ ☐Anemia Click or tap here to enter text. ☐ Easy bruising/bleeding 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.

check here: ☐ ☐ Abnormal growth Click or tap here to enter text. ☒ Increased appetite reports she has been hungrier than usual ☒ Increased thirst reports drinking more water than usual ☐ 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 Diagnosed but non compliant with diabetes management ☐ 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

Body System

Positive Findings

Negative Findings

General None noted.

Alert and oriented x 4. Well-appearing, well-nourished, in no current distress. Normal mood and affect

Open wound to right plantar foot. Size 2cm x 1.5cm x 2.5mm deep.

Aside from foot wound, skin is warm and dry and intact

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Skin

HEENT

Respiratory

Neuro

Cardiovascular

Musculoskeletal

Gastrointestinal

Genitourinary

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1. Acute pain of the right foot 2. Local infection of skin and subcutaneous tissue of the foot 3. uncontrolled type 2 diabetes 4. Asthma 5. Dysmenorrhea

6. Hypertension 7. Menorrhagia 8. Obesity 9. Oligomenorrhea 10. polycystic ovarian syndrome

11. Tension Headaches 12. Noncompliance with other medical treatment and regimen 13. Click or tap here to enter text. 14. Click or tap here to enter text. 15. Click or tap here to enter text.

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 L08.8

Temperature 101.1 F

E11.618

Patient states her foot is red, swollen, warm and produces drainage. Blood glucose level is 238

G89.11

Patient reports symptoms of polyuria, polydipsia, and nocturia. Patient reports 7/10-foot pain for 1 week.

Local infection of skin and subcutaneous tissue of foot

Uncontrolled Type 2 Diabetes

Acute Pain Unable to bear weight without severe 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 CBC & CMP

HbA1C & a Urinalysis

Rationale/Citation The CBC will provide a white blood cell count which indicates infection when it’s elevated (White blood cell count, 2021). The rest of the CBC and the CMP will provide us with a baseline metabolic status. Any abnormal levels could indicate a medical problem and would direct the clinician where to further evaluate (Comprehensive Metabolic Panel, 2021). Ms. Jones glucose at the office was 238 and she reported that she’s noncompliant with her diabetes management. The hbA1c will measure her average blood sugar over the last 3 months and the

urinalysis will check for proteinuria (All about your A1C, 2018). We want to verify that Ms. Jones is not pregnant before starting treatment for PCOS as first line treatment is hormonal birth control (Williams et al., 2016). The TSH and prolactin levels are used to rule out thyroid dysfunction and hyperprolactinemia (Williams et al., 2016). Wound cultures Obtain wound cultures to identify the correct infectious organism. We can start Ms. Jones on a broadspectrum antibiotic until the wound cultures are back (Bacteria Culture Test, 2021). 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 Albuterol Inhaler 90 mcg/spray MDI As needed Continue previous medication. Use for wheezing related to asthma exacerbations. Acetaminophen 650 mg tablets As needed Continue previous medication as needed for tension headaches. Clindamycin 300 mg tablets Every 6 hours for 10 days Clindamycin is an empiric antibiotic that’s effective in treating mild soft tissue infections (Kawn & Armstrong, 2018). It’s also an appropriate medication for those who have a penicillin allergy like Ms. Jones (Kawn & Armstrong, 2018). Hydrocodone 5/325 mg PO Every 4-6 hours PRN for severe Tramadol was ineffective for pain pain management. This medication is an opioid pain medication used to treat moderate to severe pain (Hollier, 2018). Metformin 500 mg PO BID for 30 days This will be restarted at the lowest adult dose to help manage Ms. Jones blood sugar levels (Hollier, 2018). POC Pregnancy test, serum TSH, serum prolactin

Referral/Consults: OB/GYN & Endocrinologist

To rule out PCOS and manage symptoms. Discuss the risks vs. benefit of starting hormonal birth control for the management of irregular, painful menstrual cycles (Williams, et al., 2016).

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Endocrinologists to manage her uncontrolled diabetes (Hollier, 2018).

Education: Wound care/diabetic foot care

Ms. Jones will highly benefit from Click or tap here to enter text. in-person and paper education. InDiabetic diet/managing your glucose levels office education will allow me to assess her understanding and the Education for prescribed medication printed version will allow to reference it with any questions The importance of follow-up care later (Johns Hopkins Medicine, n.d.) 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. Follow-up in the office in 1 week for wound cleaning and assessment. Click or tap here to enter text. The 1-week follow-up will give us Follow up every month thereafter for glucose checks and diabetes an indication if Ms. Jones is management until blood sugar levels are under control. cleansing her wound appropriately and if the antibiotic therapy was effective. Every month will allow us to review her daily glucose logs and assess if the metformin dose is appropriate or needs to be increased.

References Include at least one evidence-based peer-reviewed journal article which relates to this case. Use the correct current APA edition formatting. All about your a1c. (2018, August 21). Centers for Disease Control and Prevention. https://www.cdc.gov/diabetes/managing/managing-bloodsugar/a1c.html Bacteria culture test. (2021). U.S. National Library of Medicine. https://medlineplus.gov/lab-tests/bacteria-culture-test/ Hollier, A. (2018). Endocrine Disorders. In Clinical guidelines in primary care (3rd ed., pp. 216-222). Lafayette, LA: Advance Practice Education Associates, INC Johns Hopkins Medicine. (2020). Diabetes self-management patient education materials. Retrieved from https://www.hokinsmedicine.org/gim/core_resources/patient%20handouts/index.html Kwon, K., & Armstrong, D. G. (2018). Microbiology and antimicrobial therapy for diabetic foot infections. Infection & Chemotherapy, 50(1), 11. https://doi.org/10.3947/ic.2018.50.1.11

U.S. National Library of Medicine. (2021). Comprehensive metabolic panel. https://medlineplus.gov/lab-tests/comprehensive-metabolic-panelcmp/ White blood count. (2021). U.S. National Library of Medicine. https://medlineplus.gov/lab-tests/white-blood-count-wbc/ Williams, T., Mortada, R., & Porter, S. (2016). Diagnosis and Treatment of Polycystic Ovary Syndrome. American Family Physician. https://www.aafp.org/afp/2016/0715/p106.html Click or tap here to enter text....