NR 602 Week 3 iHuman SOAP

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NR 602 Week 3 iHuman SOAP SOAP Note Template Initials: J Age: 65 YO Gender: F Height Weight BP HR RR Temp SPO2 Pain Rating Allergies (and reaction) 5’5” 126 Click or tap here to ente r... text. Clic k or tap here to ente r text. Clic k or tap her e to ent er text. Click or tap here to enter text. Click or tap here to enter text. Medication: KNA Food: Click or tap here to enter text. Environment: Click or tap here to enter text. History of Present Illness (HPI) Chief Complaint (CC) Trouble sleeping and increase in fatigue 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 Onset A few months ago, intermittent. Now several times a week Location Click or tap here to enter text. Duration Several months and several times a week Characteristics Gittery and nervous and losing weight. Difficulty falling asleep and awakening early. Difficulty getting back to sleep. Light sleeping and hearing everything. Can fall back asleep but it takes awhile. Aggravating Factors Denies Relieving Factors denies Treatment Has tried a glass of milk. Retired and denies pressure or anxiety. Gets up to do housework and goes back to bed later. Unsure of how frequently she’s waking up and hasn’t kept track of what times she awakens. Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. Medication (Rx, OTC, or Homeopathic) Dosage Frequency Length of Time Used Reason for Use Multivitamin daily 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. Calcium daily Click or tap here to Click or tap here to enter Click or tap here Click or tap here to enter text. S: Subjective Information the patient or patient representative told youenter text. text. to enter text. Metamucil daily 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. 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. 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. Denies current or past medical problems. Occasional headaches. Occasional GERD. Chronic constipation. Hospitalized during the birth of her two children. Childhood illnesses: mumps, measles, rubella Immunizations: tetanus within the last 10 years, varicella 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. Mother of two children. Normal American Diet Exercises – plays tennis on weekends. Colonscopy at age 58 normal. Yearly mammograms all negative with dense breast tissue. Non-smoker (smoked occasionally in college). Drinks alcohol socially (1-2x per month; goes out with girlfriends). Denies recreational drug use. Married, monogamous, no history of STDS or herpes. Retired high school science teacher. 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. Father: deceased at 90 from pneumonia, history of asthma and osteoarthritis Mother: died in hit and run car accident at age 71. Maternal grandmother: deceased and died of a stroke, history of being “nervous” and was told it was her thyroid Maternal grandfather: died in war, no medical problems Paternal grandmother: died of breast cancer Paternal grandfather: died of prostate cancer No siblingsReview 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 If patient denies all symptoms for this system, check here: ☐ Skin If patient denies all symptoms for this system, check here: ☐ HEENT If patient denies all symptoms for this system, check here: ☐ ☒Fatigue Click or tap here to enter text. ☐Weakness Click or tap here to enter text. ☐Fever/Chills Click or tap here to enter text. ☐Weight Gain denies ☒Weight Loss Click or tap here to enter text. ☒Trouble Sleeping Click or tap here to enter text. ☐Night Sweats denies ☐Other: Click or tap here to enter text. ☐Itching Click or tap here to enter text. ☐Rashes Click or tap here to enter text. ☒Nail Changes Click or tap here to enter text. ☐Skin Color Changes Click or tap here to enter text. ☒Other: Hair thinning ☐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. ☐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. Respiratory If patient denies all symptoms for this system, check here: ☐ Neuro If patient denies all symptoms for this system, check here: ☐ Cardiac and Peripheral Vascular If patient denies all symptoms for this system, check here: ☐ ☐Cough Click or tap here to enter text. ☐Syncope or Lightheadedness Click or tap ☐Chest pain Click or tap here to enter text. ☒Palpitations over the past few years☐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 ☐Other: Click or tap here to enter text. here to enter text. ☒Headache Click or tap here to enter text. ☐Numbness Click or tap here to enter text. ☐Tingling Click or tap here to enter text. ☐Sensation Changes ☐Speech Deficits Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☒SOB breathing harder and heart beats faster with ☒Exercise Intolerance exhausted with weekly tennis ☐Orthopnea Click or tap here to enter text. ☐Edema Click or tap here to enter text. ☐Murmurs Click or tap here to enter text. ☒Faintness struggles with heat ☐Claudications Click or tap here to enter text. ☐PND Click or tap here to enter text. ☐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 ☐Redness Click or tap here to enter text. ☐Misalignment Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☐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. ☐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 Click or tap here to enter text. ☐Anxiety Click or tap here to enter text. ☐Depression Click or tap here to enter text. ☐Suicidal/Homicidal Ideation Click or tap here to enter text. ☐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.☐Food Intolerance Click or tap here to enter text. ☐Rectal Bleeding Click or tap here to enter text. ☐Other: GYN If patient denies all symptoms for this system, check here: ☒ Hematology/Lymphatics If patient denies all symptoms for this system, check here: ☒ Endocrine If patient denies all symptoms for this 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 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. ☐Other:Click or tap here to enter text. ☐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. ☐ Abnormal growth Click or tap here to enter text. ☐ Increased appetite Click or tap here to enter text. ☐ Increased thirst denies ☐ Thyroid disorder Click or tap here to enter text. ☐ Heat/cold intolerance heat intolerant ☐ 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.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 Pleasant 65-year-old female appropriately dressed and appropriate responses to questions Click or tap here to enter text. Skin Warm and dry. Palms moist. No obvious skin lesions seen. Normal skin turgor. Hair is dry but typical for age. Normal thickness and distribution pattern for patient gender. Eyebrows: sparse; missing lateral aspect. No swelling of extremities or deformities. No cyanosis, clubbing or edema. Click or tap here to enter text. HEENT Eyes: no erythema or swelling; positive for lid retraction and mild lid lag; no proptosis. Conjunctivae: pink, no discharge. Sclerae: anicteric. Orbital area: no edema, redness, tenderness or lesions noted. Lateral outside third of eyebrow is missing bilaterally. Neck has no visible scars, deformities or other lesions and trachea is midline. Thyroid is soft, 45gm in size. Isthmus ropey, easily palpable, slight bilateral asymmetry R>L, no nodules palpated. Thyroid moves with swallowing and no nodules are felt. Click or tap here to enter text. Respiratory Chest is symmetrical and the anterior-posterior diameter is normal. The excursion with respiration is symmetrical and there are no abnormal retractions or use of accessory muscles. No distention, scars, masses or rashes. Click or tap here to enter text. Neuro No fasiculations. Slightly coarse tremor in extended hand. Hyperreflexia of biceps and brachioradialis tendons. Click or tap here to enter text. Cardiovascular PMI is in the 5th intercostal space at the mid-clavicular line. RRR. Click or tap here to enter text. Musculoskeletal Normal muscle bulk and tone. Click or tap here to enter text. Gastrointestinal Abdomen is flat and symmetric with no scars, deformities, striae or lesions. Hyperactive bowel sounds. Click or tap here to enter text.Problem List 1. Click or tap here to enter text. 6. Click or tap here to enter text. 11. Click or tap here to enter text. 2. Click or tap here to enter text. 7. Click or tap here to enter text. 12. Click or tap here to enter text. 3. Click or tap here to enter text. 8. Click or tap here to enter text. 13. Click or tap here to enter text. 4. Click or tap here to enter text. 9. Click or tap here to enter text. 14. Click or tap here to enter text. 5. Click or tap here to enter text. 10. Click or tap here to enter text. 15. Click or tap here to enter text. Diagnosis ICD-10 Code Pertinent Findings 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. 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.Diagnostics: List tests you will order this visit Test Rationale/Citation 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. 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 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.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. 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. 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: Click or tap here to enter text. Rationale/Citation Click or tap here to enter text. Education: Click or tap here to enter text. Rationale/Citation Click or tap here to enter text. Follow Up: Indicate when patient should return to clinic and provide detailed symptomatology indicating if the patient should return sooner than [Show More]

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