Soap notes will be uploaded to Moodle and put through


  

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. 

Example:

PATIENT INFORMATION

Name: Mr. W.S.

Age: 65-year-old

Sex: Male

Source: Patient

Allergies: None

Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime

PMH: Hypercholesterolemia

Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.

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 Hx: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.

SUBJECTIVE:

Chief complain: “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.

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

dyspnea.

Gastrointestinal: 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

CONSTITUTIONAL: 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 0/10.

General appearance: 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 reboundno distention or organomegaly noted on palpation

Musculoskeletal:No pain to palpation. Active and passive ROM within normal limits, no stiffness.

Integumentary:intact, no lesions or rashes, no cyanosis or jaundice.

Assessment

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.

Differential diagnosis:

Ø Renal artery stenosis(ICD10 I70.1)

Ø Chronic kidney disease(ICD10 I12.9)

Ø Hyperthyroidism (ICD10 E05.90)

Plan

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.

These basic laboratory tests are:

· CMP

· Complete blood count

· Lipid profile

· Thyroid-stimulating hormone

· Urinalysis

· Electrocardiogram

Ø Pharmacological treatment: 

The treatment of choice in this case would be:

Thiazide-like diuretic and/or a CCB

· Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily. 

Ø Non-Pharmacologic treatment:  

· Weight loss

· Healthy diet (DASH dietary pattern): Diet rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced content of saturated and trans l fat

· Reduced intake of dietary sodium: <1,500 mg/d is optimal goal but at least 1,000 mg/d reduction in most adults

· Enhanced intake of dietary potassium

· Regular physical activity (Aerobic): 90–150 min/wk

· Tobacco cessation

· Measures to release stress and effective coping mechanisms.

Education

· Provide with nutrition/dietary information.

· Daily blood pressure monitoring at home twice a day for 7 days, keep a record, bring the record on the next visit with her PCP

· Instruction about medication intake compliance. 

· Education of possible complications such as stroke, heart attack, and other problems.

· Patient was educated on course of hypertension, as well as warning signs and symptoms, which could indicate the need to attend the E.R/U.C. Answered all pt. questions/concerns. Pt verbalizes understanding to all

Follow-ups/Referrals

· Evaluation with PCP in 1 weeks for managing blood pressure and to evaluate current hypotensive therapy. Urgent Care visit prn.

· No referrals needed at this time.

References

Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Clinical Consult 2017 (25th ed.). Print (The 5-Minute Consult Series).

Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.). ISBN 978-0-8261-3424-0



Source link

Share This Post

Email
WhatsApp
Facebook
Twitter
LinkedIn
Pinterest
Reddit

Order a Similar Paper and get 15% Discount on your First Order

Related Questions

Task 2: Argumentative Research Paper- Organic foods verses GMOs

Writing a research paper gives you an opportunity to explore a topic of special interest, research that topic, and organize your research findings in writing for an academic audience.   Through your preparation work, you have established an argumentative thesis statement and have planned a clear organization of your main

The decision in Williams v Roffey Bros signals that the courts in

The decision in Williams v Roffey Bros signals that the courts in deciding whether or not to enforce a promise, may be guided less by technical questions of consideration than by questions of fairness, reasonableness and commercial utility.   The assignment will be in accordance with the following criteria: •

Management and Organizational Behavior.

Description Exercise 17: Read Annual Pay Raises (W-68-69). This is located in the color-coded workbook section in the back of your book. ( Uhl-Bien, M., Osborn, R. N., & Schermerhorn, J. R. (2014).) Organizational Behavior. Hoboken, NJ: Wiley. ISBN:9781118517376 Review the exercise and complete steps 1 and 2. For this

HEPATITIS C USING APRI SCORE

Determination of Human Subjects Research Form and my project proposal. please, research about IRB. write the Description. Referencing the Determination Checklist on Page 2, briefly describe project objectives, the subject population and types of data/specimens to be collected and analyzed, how the data/specimens will be obtained, and why you determined

Company Description and SWOT

Non Alcoholic Beverage company!!!! n this assignment, you will conduct a SWOT (Strength, Weakness, Opportunity, and Threat) analysis for the type of beverage you have selected, and for your company overall. As you work on the assignment, consider why you have chosen one type of non-alcoholic beverage over another and

Effective Resource Allocation

 The discussion assignment for this week includes a review of the Key Assignment Outline completed by one of your classmates, as well as a substantial response to at least one other student. Primary Task Response: Your first task is to post your own Key Assignment Outline to the discussion area

Ethics Case Study

A student’s analysis of the ethic case must use the following written structural framework, which can be written as a memorandum to the file. Without the bullet points – these indicate required headings for each of the four sections. The following the description heading below to form a memorandum to

What is the overall impact in Muslim communities who have been exposed

 Research in the field of addiction studies has important implications for individuals, groups, organizations, the government, and society at large.Develop and hone your empirical question/issue, search the literature, read and analyze the literature, and form conclusions regarding your research question/issue based on the scientific articles. Number of references: Your paper

Poverty in the classroom

A four-unit research paper in APA formatting centered around the effects of poverty in education. The first unit needs to be about the effects poverty has on students in the classroom and needs to be 8-10 pages. Second unit is on the effects of substance abuse on students in the

Causes of America’s War in Vietnam

Description Formatting 12 font or smaller, standard script (e.g. Calibri, New Times Roman), 1.00-1.25 margins maximum, double spaced, clean appearance, etc. Basic organization is simple— don’t make it difficult Title— choose one that reflects your views on the topic to inform and engage your reader from the start, do not

Information Systems-Decision Making

 1. Identify one cyberattack that occurred in the last 2 years. What caused the cyberattack? How did the cyberattack impact data loss, financial loss, cleanup cost, and the loss of reputation? If you were the manager of this company, what are some key steps you would have taken to prevent

Describe a system

 Describe a system (object, situation, etc.) whose dynamics could reasonably be modeled as a harmonic oscillator, i.e., by using a second order, constant coefficient ordinary differential equation (with or without some “damping”). In your description, be sure to include the following: a. Convince the reader why the dynamics can be

Crime and punishment in modern society

 Description Students are required to complete two essays of 1,250 words each. You must submit an electronic file containing both pieces of work to turnitin by the hand in date of Friday 5th April 2019. Choose two from the following: How have Marxist ideas been applied to understandings of crime

Healthcare administration

 Description Submit the name of the country you will be studying as required for your final assignment for instructor approval. Provide 3-5 relevant facts about the country you have chosen. Remember you will need to post a power point of your findings as well as submitting a paper 10-12 pages

Crisis in Journalism

Description 1. Critically assess the extent to which there is a ‘crisis’ in contemporary journalism (100 marks) Essay should be 2,500 words. Bibliography and quotes are NOT included in the word count ,USE the following criteria: Structure and Argument Demonstrates an effective structure (introduction, main body, conclusion, referencing in Harvard 6

Climate Change *In South Florida*

 Description Requirements: No less than 1400 words of text, not counting title and reference pages, in APA style. No less than six unique references on the scientific content (Please don’t use class texts, dictionaries, or encyclopedias. Also, you may cite general organizational information from the websites of your three nonprofit

Using E-Books in the Teaching and Learn

 Description Develop a template (e.g., a book report guide) for students to use to evaluate an e-book. Develop a lesson based on an e-book. Develop a template of how to evaluate an online reading program. You should keep this in your personal “toolbox” of resources for use later in the

Business Law and Ethics final

 Description Essay topic: Reflecting on the concepts you have studied in the course, research a company and discuss the legal and ethical issues surrounding it. You will need to research the company through the University library. Your essay should include the following four sections: 1) Identify and discuss two to