Week 3 Soap Note--Detailed Soap Note Completed PDF

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Summary

Week 3 soap note detailed and completed for Nur 509 case study virtual experience...

Description

Sample SOAP Note S: Subjective Information the patient or patient representative told you Initials: TJ

Age: 28

Height

Weight

BP

HR

RR

Temp

SPO2

170cm

88kg

139/ 87

82

16

98.9

99%

Gender: Female Pain Rating 3/10

Allergies (and reaction) Medication: PCN Food: No food allergies Environment: Cats

History of Present Illness (HPI) Headache with neck pain that started a few days ago after a MVA Chief Complaint (CC) 2 weeks ago and headaches started a few days ago Onset Location “Dull ache in the crown and to the back of the head” Duration

3 days

Characteristics Aggravating Factors

Dull ache in the crown of the head and the back of the head, occurs daily and last 1-2 hourse none

Relieving Factors

none

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

Treatment Tyl 650 mg PO as needed for 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 Tyelnol 650mg Once daily 3 days Headache Flovent na 2 puffs BID Daily Asthma Proventil (rescue) na As needed q3-4 hours for Four years Ashtma wheezing Metformin unknown unknown unknown Reports she has not taken in 3 years Click or tap here to enter text. Click or tap here to Click or tap here to enter Click or tap here Click or tap here to enter text. enter text. text. 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. PMH: Patient reports history of diabetes and was diagnoised at age 24 reports that she “used’ to take Metformin but does not currently take any anti diabetic medications. Blood glucose at time of assessment 117. Patient reports that she controls her blood sugar by diet controlled and avoids sweets. Typical meal includes starchy foods and a meat. Pt reports drinking 3-4 diet sodas daily. Reports that she has had increased thirst and increased urinatation with nocturia here recently but no increase in appetitie. Pt doesn’t report any changes in weight as she does not weigh herself regularly.Patient reports that she does not check her blood sugar at home. Current weight 88kg and BMI 30.5. Patient reports she tries to avoid sweets and denies increased sodum intake. Asthma- Pt reports history of asthma and that she was diagnosed in childhood. No recent hospitalzations related to asthma reports that last one was when she was 16 years of age. Pt reports using a Flovent inhaler daily and also a Proventil inhaler as needed for wheezing. Pt denies any chest tightness, shortness of air, wheezing, fever or chills at time of assessment. PCOS- Patient reports dark pigmentation around neck. Dysmenorrhea for the first two days of menstrual cycle. Reports irregular periods and states has “ 6 periods a year” LMP started yesterday. Pt reports abnormal hair growth of a “mustache” on her chin, and belly ahir. Pt reports self breast exam but not sure what to look for when examine, follow up education provided. Pt reports that menstrual cycle last 9-10 days in duration and using heavy extra absorbent tampons every 2-3 hours. Reports using a heating pad and Advil as needed for menstrual No oral contraception used, she states that she used to take the pill but does not take it at the moment since she is single and not sexual active. Report 3 sexual partners. No history of sexual transmitted infections. No pregnancies or abortions reported. Reports that last Pap Smear was five years ago. Unprotected sex reported but has not had any sexual transmitted infections. Heartburn-Reports heartburn five months ago but no current issues Strep- Reports strep throat as a child but no recent issues Secondhand smoke exposure- Reports that she has friends who smoke but she denies any current tobacco use. Allergies: Pencillin-causes rash has not taken since childhood No food allergies reported Environmental Allergies- Dust Allergic to Cats

Hypertension- Blood pressure noted to be 139/87, no reported medication to treat hypertension, increased risk with family history

Obesity- Height 170cm, weight 88 with BMI 30..5, family history of obesity in father and brother

Anxiety- Anxious after passing of father, no medications or treatment reported Depression- Pt reports some depression after the passing of her father, no medications or treatment reported.

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. Reports being a full time student in pursuit of her Bachelors degree in accounting, Full time employee. Denies any tobacco use or being around any secondhand smoke. Denies any illicit drug use. Reports alcohol intake approximately 1-2 times a week and some on weekends, no excessive intake of alcohol. She lives at home with mom and sister

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-High cholesterol and HTN Father- HTN, High cholesterol- Passed away at age 58 in MVA Maternal grandmother- HTN, High Cholesterol- Died at age 73 of a stroke Maternal grandfather-HTN, High Cholesterol- died of a heart attack unsure of age Paternal grandmother-HTN, High Cholesterol, still alive Paternal grandfather-HTN, DM, colon cancer-died at age in mid 60’s Brother-Obesity Sister-Asthma Uncle on fathers side alcohol problems

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. HEENT Skin Constitutional If patient denies all If patient denies all If patient denies all symptoms for this system, check here: ☐ symptoms for this symptoms for this system, system, check here: ☒ check here: ☒ ☐Hoarseness Denies ☐Fatigue denies ☐Itching denies ☐Diplopia Denies ☐Earache Denies ☐Weakness denies ☐Rashes denies ☐Eye Pain Denies ☐Tinnitus Denies ☐Oral Ulcers Denies ☐Fever/Chills denies ☐Nail Changes denies ☐Eye redness Denies ☐Epistaxis Denies ☐Weight Gain denies ☐Skin Color Changes- ☐Vision changes Denies ☐Vertigo Denies ☐Congestion Denies Reports dark ☐Weight Loss denies ☐Photophobia Denies ☐Hearing Changes Denies Rhinorrhea Denies pigmentation to the ☒Other: ☐Trouble Sleeping denies ☐Eye discharge Denies back of neck Click or Click or tap here to enter text. ☐Night Sweats denies tap here to 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 Denies ☐Hemoptysis Denies ☐Dyspnea Denies ☐Wheezing Denies ☐Pain on Inspiration Denies ☐Sputum Production Denies

☐Other: Click or tap here to enter text.

Neuro If patient denies all symptoms for this system, check here: ☒ ☐Syncope or Lightheadedness Denies ☐Headache Reports since two weeks ago after MVA ☐Numbness Denies ☐Tingling Denis ☐Sensation Changes Denies ☐Speech Deficits Denies ☐Other: Click or tap here to enter text.

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

☐Chest pain Denies ☐SOB Denies ☐Exercise Intolerance Denies ☐Orthopnea Denies ☐Edema Denies ☐Murmurs Denies

☐Palpitations Denies ☐Faintness Denies ☐Claudications Denies ☐PND Denies ☐Other: Denies

MSK If patient denies all symptoms for this system, check here: ☒ ☐Pain Reports pain to neck upon movement since MVA two weeks ago ☐Stiffness Denies ☐Crepitus Denies ☐Swelling Denies ☐Limited ROM Denies ☐Redness Denies ☐Misalignment Denies ☐Other: Click or tap here to enter text.

GI If patient denies all symptoms for this system, check here: ☒ ☐Nausea/Vomiting Denies ☐Dysphasia Denies ☐Diarrhea Denies ☐Appetite Change Denies ☐Heartburn Denies ☐Blood in Stool Denies ☐Abdominal Pain Denies ☐Excessive Flatus Denies ☐Food Intolerance Denies ☐Rectal Bleeding Denies ☐Other:

GYN If patient denies all symptoms for this system, check here: ☒ ☐Rash Denies ☐Discharge Denies ☐Itching Denies ☐Irregular Menses Reports irregular periods with a period every 2 months ‘6 periods a year” ☐Dysmenorrhea Cramping the first couple of days of menstrual cycle ☐Foul Odor Click or tap here to enter text. ☐Amenorrhea Reports not having a menstrual cycle every month ☐LMP: Began a few days ago ☐Contraception Reports no contraception use at this time. Last sexual partner 3 years ago. Did not use condoms

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

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

☐Urgency Nocturia reported at night ☐Dysuria Denies ☐Burning Denies ☐Hematuria Denies ☐Polyuria Denies ☐Nocturia Reports ☐Incontinence Denies ☐Other: Click or tap here to enter text.

☐Stress Denies ☐Anxiety Denies ☐Depression Denies ☐Suicidal/Homicidal Ideation Denies ☐Memory Deficits Denies ☐Mood Changes Denies ☐Trouble Concentrating Denies ☐Other: Click or tap here to enter text.

Hematology/Lymphatics If patient denies all symptoms for this system, check here: ☒ ☐Anemia Denies ☐ Easy bruising/bleeding Denies ☐ Past Transfusions Denies ☐ Enlarged/Tender lymph node(s) Denies ☐ Blood or lymph disorder Denies ☐ Other Denies

Endocrine If patient denies all symptoms for this system, check here: ☒ ☐ Abnormal growth Denies ☐ Increased appetite Denies ☐ Increased thirst Reports for the last couple of weeks ☐ Thyroid disorder Denies ☐ Heat/cold intolerance Denies ☐ Excessive sweating Denies ☐ Diabetes Reports diagnosis of DM ☐ Other Click or tap here to enter text. Abnormal hair growth to chin, and belly patient describes a “mustache”

☐Other:Reports menstrual cycle last for 910 days in duration. Heavy flow with using extra absorbent tampons every 2-3 hours. Reports menstrual flow is heavy the first five days.

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 Blood glucose 117 BP-139/87

Skin

Dark pigmentation to posterior aspect of neck. Acne present on face

HEENT None noted

Alert and oriented, pleasant and cooperative, 28 year old African American Female , seated on the exam table without acute physical distress. Skin warm, dry and intact without rashes or skin lesions to face, upper chest or back.

Head normocephalic. Eyes PERRLA. TMs pearly gray without effusion. Nares patent. Turbinates pink. Frontal and maxillary sinuses nontender bilaterally. Teeth without dental caries. Tongue midline. Gums and oral mucosa intact without lesions. No petechiae on hard or soft palate. No cobblestoning. Uvula midline and non-edematous. Tonsils +2. 1.0 cm mobile, mildly tender, left anterior cervical lymph node. Neck is full and supple

Respiratory None noted

Chest symmetrical. No use of accessory muscles. Unlabored. Lungs clear to auscultation bilaterally.

Decreased sensation to right foot Decreased sensation to left foot Reports of Headache

No syncope or lightheadedness reported. No reports of numbness or tingling to any extremity. Speech with in normal limits, no slurred speech or aphasia noted. Patient able to have abstract sthinking. Attention span accurate. Able to follow instructions. General knowledge questions correct. Memory intact and accurate. Complexity of vocabulary expected complex for patient’s age, education level and general ablilty. No observed problems with pronunciation or expression. Olfactory nerve intact and symmetrical. Visual acuity right eye 20/20, Visual Acuity left eye 20/30.

Click or tap here to enter text.

Chest wall symmetrical, equal expansion on inspiration. No injuries or areas of concern observed.

Click or tap here to enter text.

Gait is steady, no balance issues observed, able to perform all task without loosing balance,

Click or tap here to enter text.

Unable to assess

Neuro

Cardiovascular

Musculoskeletal

Gastrointestinal

Problem List 1. Pain

6. Hypertension 7. Polycystic Ovarian Syndrome 8. Obesity 9. Family history of Hypertension 10. Family history of High Cholesterol

controlled 3.Asthma 4. Oligomenorrhea 5. Medication Non Compliance

11. Dysmenorrhea 12. Menorrhagia 13. Amenorrhea 14. Family history of Diabetes 15. Disease Management Education

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. Acute Pain

G89.1

Dullache from crown to back of head daily lasting 1-2 hours in duration

Uncontrolled Diabetes

R73.9

Polydipsia, Polyuria, Polyphagia, blood glucose 224, no med

Hypertension

401.0

Blood pressure 140/81, family history of HTN, diabetes treatment, does not check glucose at home

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 Rationale/Citation CT Scan of head Evaluate for possible brain bleed or other injuries CBC Evaluate for markers of inflammation or possible infection BMP Evaluate electrolytes and renal function 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 Ibuprofen 800 mg Every 8 hours for 7 days. May Pain control (source) alternate with Tylenol. Tylenol 650 mg Every 6 hours for 7 days. May Pain control (source) alternate with Ibuprofen. Metformin 500mg PO BID with meals AC and Continuous Uncontrolled Diabetes and no HS current medication 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. 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.

Referral/Consults: OBGYN

Polycystic Ovarian Syndrome

Dysmenorrhea, Menorrhagia, Oligmenorrhea. Last Pap smear five years ago

Education: Diabetes Education on medication compliance, managing diabetes, risk of wound infection in diabetic wounds, support groups for managing diabetes.

Patient has uncontrolled type 2 Comfort measure (Kalra et al., diabetes, she is currently not 2020) medicated for. Patient needs education on the importance of medication compliance with Education on hypertension with the diagnosis of diabetes, managing diabetes, diet control hypertension, risk of hypertension with family history, diet to prevent Importance of adhering to hypertension. medication regime to prevent further complications from disease. 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 1 week to reassess asthma exacerbation and if One week follow up will allotted medication prescribed is effective. Patient needs to return to the office time for pain medication to be in if experiencing any chest pain, increased shortness of breath at rest or effect of treating asthma exertion, increase wheezing and difficulty breathing, any fever greater exacerbation. than 101.1, Productive cough (green/yellow in color). Any nausea, Will readdress compliance and vomiting, diarrhea, blurred vision, increase in severity of headaches or effectiveness of Metformin in any new onset confusion controlling blood sugars. Assess any possible side effects of medications and any concerns

References Include at least one evidence-based peer-reviewed journal article which relates to this case. Use the correct current APA edition formatting. Miles, L.(2019). Diabetes Insipidus. British Medical Journal, 36(81), 321-343. Doi: 10/175683 Schug,S.(2016). Acute pain management:Scientific evidence.Medical Journal of Australia,67(19), 114-122. Doi.org/10.5694/mja16.00133...