SOAP note primary health 2 PDF

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CC: Chronic diarrhea x 10 months “I think it all started in November, but it’s gotten much worse since late July”. HPI: R-M is a 78 y/o female c/o diarrhea since November. Patient reports history of diarrhea about 1-2x a week from November through July and complains starting in late July that the episodes increased in frequency to about 2-3x each day. Patient describes the diarrhea as “thin, watery”. Patient reports seeing GI in January who ordered a colonoscopy, which was negative for abnormal findings. Endoscopy in March was also negative for abnormal findings. Stool sample collected, which was negative. Patient reports taking Pepto Bismol prn with minimal relief. Denies dizziness. Appetite ok. Denies abdominal pain. PMHx: acid reflux, hypertension, hyperlidemia, glaucoma Family Hx: Mother deceased 46 colon cancer, Father deceased 76 esophagus cancer, Siblings: sister 74 deceased esophagus cancer Social Hx: denies tobacco use or alcohol, denies caffeine, denies coffee use, denies exerice Personal Hx: white, retired. Vaccinations UTD Occupational Saftey: negative Meds: ASA 81mg PO QD Zantac 150 mg PO prn Diovan 160mg PO QD Chlorthalidone 25mg PO QD Metoprolol Succinate 50mg PO QD Labs: Comprehensive Metabolic Panel significant for K 3.2 Allergies: NKDA, denies food allergies VS: Temp 98.5, HR 76/min, BP 120/80 mm Hg, Ht 65 in, Wt 155 lbs Review of Systems (ROS) Constitutional symptoms Denies fever Denies chills Denies night sweats Denies weight gain Positive fatigue Eyes Denies acute vision change Denies eye pain Denies photophobia Ears, Nose, Mouth, Throat Denies ear pain Denies vertigo Denies tinnitus

Denies hearing loss Denies runny nose Denies sinus pressure Denies nasal congestion Denies nasal discharge Denies sore throat Denies tooth pain Cardiovascular Denies chest tightness Denies palpitations Denies orthopnea Denies syncope Respiratory Denies shortness of breath Denies cough Gastrointestinal Denies abdominal pain Positive bloating Denies flatulence Denies nausea Positive diarrhea Denies bloody stools Denies urinary complaints Denies hematuria Musculoskeletal Denies pain Denies weakness Neurological Denies parenthesis Denies headache OBJECTIVE Constitutional: Appears comfortable, appearance consistent with age, appears sad and verbalizes sadness and worry with regards to the chronic diarrhea. Well developed, no acute distress. Skin: Pink, warm, dry, intact, turgor good, no edema. No lesions, birthmarks, edema noted. Hair is normally distributed, no pest or inhabitants noted. No biting of nails, no clubbing noted. Nail beds pink and firm with cap refill < 2 sec. Head, Face: normocephalic, no lesions, lumps, scaling, parasites or tenderness noted. Face symmetric, no facial swelling, no erythema, no tenderness over maxillary sinus Eyes: Conjuctiva clear, sclera white, no lesions, redness, or discharge. PERRLA Ears: Pinna reveals no mass, lesions, scaling, discharge, or tenderness to palpation. Canals are clear, OD tympanic membrane pearly gray, OS bulging tympanic membrane, no perforations Nose, Throat: No deformities, no enlargement of nasal turbinates noted, no purulent nasal discharge noted, no halitosis, neck is supple with full ROM, tracheal ML, no lymphadenopathy, mucosa and gingivae pink, no exudates, uvula rises midline, tonsils 0, gag reflex is present,

thyroid is non-palpable and non-tender, no JVD. Cardiac: S1S2 (-) m/r/g (-) bruits Respiratory: Respiratory effort even and unlabored, lungs clear bilaterally. No wheezing, no rhonchi, no rales/crackles were heard. Abdomen: soft, non-tender, non-distended, no masses, no hernia, no ascites, positive BS all 4 quadrants. No abdominal guarding. Liver: not enlarged. Spleen not enlarged. Musculoskeletal: Neck and all 4 extremities with full ROM, no pain. No tenderness of vertebral column, no deformity or curvature. Muscle strength - able to maintain flexion against resistance and without tenderness. Neurologic: cranial nerves intact, appearance, behavior, and speech appropriate, AA&Ox3, CNS grossly intact ASSESSMENT Diarrhea Irritable Bowel Syndrome K58.0 PLAN 1. Irritable Bowel Syndrome  Rx: Eluxadoline 100mg PO BID  Diet: Avoid or limit alcohol and caffeine, avoid foods that are known to make you gassy/induce diarrhea (such as beans, spicy food, cabbage, broccoli, cauliflower, raw fruit juices and fruits) or that make symptoms worse such a greasy/fatty foods.  Decrease stress which also causes exacerbations 2. Medications reviewed with patient, prescription risks and side effects discussed, expected course of both diagnoses discussed, the patient verbalized understanding and agrees with plan as discussed. Return in two weeks or if symptoms do not improve or with increasing signs or symptoms Research Irritable Bowel Syndrome (IBS) with diarrhea is a common gastrointestinal disorder that is characterized by recurring abdominal pain, bloating, and/or loose frequent stools in the absence of any structural, inflammatory, or biochemical abnormities. According to Lembo (2016), effective and safe treatments are needed for patients who have irritable bowel syndrome with diarrhea. Initial therapies include dietary and lifestyle modifications along with antidiarrheal agents; these therapies are frequently unsuccessful. Two Phase 3 clinical trials were conducted to assess the efficacy and safety of eluxadoline, a new oral agent with mixed opioid effects in patients with IBS with diarrhea. For twelve weeks, more patients in the eluxadoline groups (75 mg and 100 mg) than in the placebo group experienced decreased episodes of diarrhea. The studies concluded that eluxadoline is a new therapeutic agent that reduces symptoms of IBS with diarrhea. It further states the eluxadoline offers sustained efficacy over 6 months in patients who received the 100-mg dose twice daily. IBS with diarrhea is associated with impairment in healthrelated quality of life. Current treatment options are limited and therefore based on the research it was reasonable to offer the patient a trial of medication in hopes of symptom reduction. Ethical/Legal/Professional

As the advanced practice nurse, the use of online libraries to research current evidence based practice is essential. I was able to confidently diagnose conditions and prescribe medications with these resources. QSEN 1. 2.

3. 4. 5. 6.

Patient Centered: Discussed the importance diet modification and life style changes as a primary plan of care to improve quality of life. Teamwork/Collaboration: My preceptor is extremely open to questions and offers me time and patience. He gives me feedback regarding my assessment and treatment while encouraging my critical thinking. EBP: I am able to provide comprehensive, up-to-date, evidenced based, clinical decisions by utilizing research on my treatment plan. QA: The addition of eluxaoline will improve symptoms of diarrhea. Safety: The patient has no drug-to drug interactions or contraindications for this medication and the patient denies any drug allergies. Information Technology: I purchased the Epocrates application on my iphone and it has become very useful in verifying dosages and drug interactions with patients on multiple medications. The use of the PC to electronically order prescriptions is also time-efficient and convenient.

Self Reflection I am comfortable with my assessment skills and management of diarrhea as this is very common complaint in cancer patients. I was very comfortable assessing this patient, identifying the symptoms and making a diagnosis. Since the patient has had diagnostic testing including lab work, stool sampling, colonscopy and endoscopy it seemed reasonable to diagnosis the patient with Irritable Bowel Syndrome and prescribe an agent to treat the cause. The patient also complained of high levels of stress, which can induce IBS symptoms, including diarrhea, so this diagnosis is reasonable. I was comfortable recommending dietary changes and life style modifications. I was not familiar with medication treatment plans for maintenance of Irritable Bowel Syndrome. I typically see with diarrhea in the setting of oncology, so I was happy to learn more about other causes and potential treatment options. With time, I will learn. I am comfortable looking up medications in Epocrates to assist with dosages. Reference Lembo, A., Lacy, B., Zuckerman, M., Schey, R., Dove, L., Andrae, D., Davenport, M., McIntyre, G., Lopez, R., Turner, L. & Covington, P. Eluxadoline for Irritable Bowel Syndrome with Diarrhea (2016). New England Journal of Medicine, 374, 242-253

CC: Left knee pain starting about 1 week ago. Patient reports “feels like a sharp pain in my knee and dull pain around it” HPI: Patient presents today with left knee pain starting about one week ago. Initially it began as dull pain surrounding the joint and has progressed to a sharp pain with dullness surrounding the knee area infiltrating the lower thigh and upper shin. Patient reports taking Alleve with some relief. Patient reports symptoms are worse in the morning and improve with walking and physical movement throughout the day. Physical assessment reveals small effusion at left knee. Rates current pain level 1/10. PMHx: gout, arthritis, hypertension, hernia Family Hx: Mother deceased 72, pulmonary embolism, Father deceased 66, MI, one brother alive, one sister alive Social Hx: non-smoker, drinks alcohol socially Personal Hx: white, retired. Vaccinations UTD Occupational Saftey: negative Meds: Losartan Potassium-HCTZ 50-12.5mg tablet Verapamil HCl CR 240mg extended release Labs: None Allergies: NKDA, denies food allergies VS: Temp 98.5, HR 78/min, BP 124/76 mm Hg, Ht 72 in, Wt 190 lbs Review of Systems (ROS) Constitutional symptoms Denies fever Denies chills Denies night sweats Denies weight gain Denies fatigue Eyes Denies acute vision change Denies eye pain Denies photophobia Ears, Nose, Mouth, Throat Denies ear pain Denies vertigo Denies tinnitus Denies hearing loss Denies runny nose Denies sinus pressure Denies nasal congestion

Denies nasal discharge Denies sore throat Denies tooth pain Cardiovascular Denies chest tightness Denies palpitations Denies orthopnea Denies syncope Respiratory Denies shortness of breath Denies cough Gastrointestinal Denies abdominal pain Denies bloating Denies flatulence Denies nausea Denies diarrhea Denies bloody stools Denies urinary complaints Denies hematuria Musculoskeletal Positive pain left knee Positive swelling left knee Denies weakness Neurological Denies parenthesis Denies headache OBJECTIVE Constitutional: Appears comfortable, appearance consistent with age, Well developed, no acute distress. Skin: Pink, warm, dry, intact, turgor good, no edema. No lesions, birthmarks, edema noted. Hair is normally distributed, no pest or inhabitants noted. No biting of nails, no clubbing noted. Nail beds pink and firm with cap refill < 2 sec. Head, Face: normocephalic, no lesions, lumps, scaling, parasites or tenderness noted. Face symmetric, no facial swelling, no erythema, no tenderness over maxillary sinus Eyes: Conjuctiva clear, sclera white, no lesions, redness, or discharge. PERRLA Ears: Pinna reveals no mass, lesions, scaling, discharge, or tenderness to palpation. Canals are clear, OD tympanic membrane pearly gray, OS bulging tympanic membrane, no perforations Nose, Throat: No deformities, no enlargement of nasal turbinates noted, no purulent nasal discharge noted, no halitosis, neck is supple with full ROM, tracheal ML, no lymphadenopathy, mucosa and gingivae pink, no exudates, uvula rises midline, tonsils 0, gag reflex is present, thyroid is non-palpable and non-tender, no JVD. Cardiac: S1S2 (-) m/r/g (-) bruits Respiratory: Respiratory effort even and unlabored, lungs clear bilaterally. No wheezing, no

rhonchi, no rales/crackles were heard. Abdomen: soft, non-tender, non-distended, no masses, no hernia, no ascites, positive BS all 4 quadrants. No abdominal guarding. Liver: not enlarged. Spleen not enlarged. Musculoskeletal: Neck and all 4 extremities with full ROM, no pain. No tenderness of vertebral column, no deformity or curvature. Muscle strength - able to maintain flexion against resistance and without tenderness. Swelling at left knee. Neurologic: cranial nerves intact, appearance, behavior, and speech appropriate, AA&Ox3, CNS grossly intact ASSESSMENT Left knee effusion M25.462 PLAN Start Diclofenac Potassium Tablet, 50mg 1 tablet orally twice day prn Return in two weeks or if symptoms do not improve or with increasing signs or symptoms Ethical/Legal/Professional As the advanced practice nurse, the use of online libraries to research current evidence based practice is essential. I was able to confidently diagnose conditions and prescribe medications with these resources. QSEN 1. 2.

3. 4. 5. 6.

Patient Centered: Discussed ways to alleviate knee pain including ice and rest. Teamwork/Collaboration: My preceptor is extremely open to questions and offers me time and patience. He gives me feedback regarding my assessment and treatment while encouraging my critical thinking. EBP: I am able to provide comprehensive, up-to-date, evidenced based, clinical decisions by utilizing research on my treatment plan. QA: The addition of Zorvolex will improve symptoms of pain and inflammation. Safety: The patient has no drug-to drug interactions or contraindications for this medication and the patient denies any drug allergies. Information Technology: I purchased the Epocrates application on my iphone and it has become very useful in verifying dosages and drug interactions with patients on multiple medications. The use of the PC to electronically order prescriptions is also time-efficient and convenient.

Self Reflection I am comfortable with my assessment skills and management of pain. I was very comfortable assessing this patient, identifying the symptoms and making a diagnosis. The patient reported that he has taken Vioxx in the past with relief of pain symptoms and therefore I am hopeful that the addition of Zorvolex will also help to relieve the pain and inflammation....