NR 509 Week 1 Health History SOAP Note (GRADED A)

SOAP Note Template S: Subjective Information the patient or patient representative told you Initials: T.J. Age: 28 Gender: Female Height Weight BP HR RR Temp SPO2 Pain Allergies 170 cm 90 kg 142/ 82 86 19 101.1 99 ...

SOAP Note Template S: Subjective Information the patient or patient representative told you Initials: T.J. Age: 28 Gender: Female Height Weight BP HR RR Temp SPO2 Pain Allergies 170 cm 90 kg 142/ 82 86 19 101.1 99% Medication: Penicillin- rash/hives Food: no known food allergies Environment: Cat dander- sneezes, pruritus, asthma flare-up History of Present Illness (HPI) Chief Complaint (CC) Infected wound to foot 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 Wound occurred a week go with pain getting worse 2 days ago Location Plantar aspect of right foot Duration 1 week Characteristics Red, swollen, pus, warm to touch Aggravating Factors Walking and weight bearing Relieving Factors Pain medications and resting Treatment Cleans with soap and water twice a day, uses Neosporin twice a day, covers with a bandage 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 Tramadol 50 mg Three times a day (TID) 2 days Pain Metformin unknown Twice a day (BID) 3 years ago Diabetes Albuterol Inhaler 90 mcg PRN (2-3 times a week) 3 days ago Asthma Advil 600 mg PRN TID unknown Menstrual Cycle Cramps 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. Asthma, Type 2 Diabetic 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. Single Denies tobacco use Use to use illicit drugs-Marijuanna- last used 3 years ago Social alcohol use (2 times a month) 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- HTN, Hyperlipidemia Father- HTN, Hyperlipidemia, Type 2 Diabetic Paternal Grandmother- HTN, Hyperlipidemia 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 ☐ Fatigue Click or tap here ☐ Itching Click or tap ☐ Diplopia Click or tap ☐ Earache Click or tap here ☐ Hoarseness Click or tap here to enter text. here to enter text. here to enter text. to enter text. to enter text. ☐ Weakness Click or tap ☐ Rashes Click or tap ☐ Eye Pain Click or tap ☐ Tinnitus Click or tap here ☐ Oral Ulcers Click or tap here here to enter text. here to enter text. here to enter text. to enter text. to enter text. ☐ Fever/Chills Click or tap ☐ Nail Changes Click ☐ Eye redness Click or ☐ Epistaxis Click or tap ☐ Sore Throat Click or tap here here to enter text. or tap here to enter tap here to enter text. here to enter text. to enter text. ☐ Weight Gain Click or tap text. ☐ Vision changes Click or ☐ Vertigo Click or tap here ☐ Congestion Click or tap here here to enter text. ☐ Skin Color Changes tap here to enter text. to enter text. to enter text. ☐ Weight Loss Click or tap Click or tap here to ☐ Photophobia Click or ☐ Hearing Changes Click ☐ Rhinorrhea Click or tap here here to enter text. ☐ Trouble Sleeping Click or enter text. ☒Other: tap here to enter text. ☐ Eye discharge Click or or tap here to enter text. to enter text. ☐ Other: tap here to enter text. Wound to right plantar tap here to enter text. Click or tap here to enter text. ☐ Night Sweats Click or tap aspect of foot here to enter text. ☐ Other: Click or tap here to enter text. Respiratory Neuro Cardiovascular ☐ Cough Click or tap here to enter text. ☐ 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: Asthma- induced when around cats ☐ Syncope or Lightheadedness Click or tap 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. ☐ Chest pain Click or tap here to enter text. ☐ 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 Click or tap here to enter text. ☐ Murmurs Click or tap here to enter text. ☐ Palpitations Click or tap here to enter text. ☐ Faintness Click or tap here to enter text. ☐ OC Changes Click or tap here to enter text. ☐ Claudications Click or tap here to enter text. ☐ PND Click or tap here to enter text. ☒Other: elevated blood pressure- family history MSK GI GU PSYCH ☒Pain 7/10 at right foot ☐ Stiffness Click or tap here to enter text. ☐ Crepitus Click or tap here to enter text. ☒Swelling at wound on right plantar aspect of foot ☐ Limited ROM ☒Redness at wound on right plantar aspect of foot ☐ Misalignment Click or tap here to enter text. ☒Other: unable to bear weight to right foot ☐ 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. ☐ 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. ☐ 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. ☐ Excessive Flatus 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: Click or tap here to enter text. ☐ Other: Click or tap here to enter text. ☐ Other: Click or tap here to enter text. GYN ☐ 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 c/o having menstrual cycles needing to change a super tampon every 2-3 hours ☒Dysmenorrhea c/o cramps ☐ 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:use to take oral contraceptive but has taken herself off it Body System Positive Findings Negative Findings General Appears kept Overweight Skin No noticeable discoloration noted. Wound to plantar aspect of right foot. HEENT No visual or hearing apparatuses needed. Respiratory Does not appear short of breath. Neuro Alert and oriented x3 Pain upon walking or bearing weight to right foot. Cardiovascular Pulse within normal limits. Presents with elevated blood pressure Musculoskeletal Unable to bear weight to right foot Gastrointestinal Genitourinary This stuPdsy ysocurhceiawtars idcownloaded by 100000849840424 from CourseHero.com on 11-16-2022 07:48:01 GMT -06:00 Patient appears calms and presents herself appropriately. Frustrated with the effects the wound on right foot is causing to Problem List 1. Acute pain 6 Dysmenorrhea 11 2 Localized infection to right foot 7 Menorrhagia 12 3 Uncontrolled Type 2 Diabetic 8 13 4 Asthma 9 14 5 Hypertension 10 15 A: Assessment Medical Diagnoses. Provide 3 differential diagnoses 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 Acute pain G89.11 Patient c/o of pain 7/10. Unable to bear weight to right foot. Local infection of the skin and subcutaneous tissue L08.9 Wound is red, warm to touch, and has pus draining from wound. Uncontrolled Type 2 Diabetes E11.9 Blood sugar 238 mg/dl. Noncompliant with diabetic medication regimen. 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 Wound Culture To know what the wound is growing in order to prescribe the correct antibiotic Hemoglobin A1C To obtain baseline of glucose level Complete Blood Count To monitor WBC as well as her H&H Lipid Panel To maintain baseline due to patient’s family history 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 previous meds” if pertinent. Drug Dosage Length of Treatment Rationale/Citation Metformin 250 mg Twice a daily (BID) 30 days Lower dose due to patient complaining of feeling sick and gassy when taking full dose in the past (Woo &Robinson, 2016). Clindamycin 300 mg Three times a day (TID) 10 days To aid in treating the infection caused by the wound until the wound cultures come back showing which antibiotic would be best to treat the infection (Woo & Robinson, 2016). NuvaRing 15 mcg 3 weeks To aid in irregular menses and gives patient some freedom from taking medications since she has a history of being noncompliant with taking oral medications (Woo & Robinson, 2016). Tramadol 50 mg As needed for pain To aid with pain in right foot. Acetaminophen 500 mg As need for breakthrough pain For breakthrough pain. Beclomethasone dipropionate 40 mcg 30 days To use daily to prevent asthma flare-ups to aid in the prevention of bronchospasm due to allergens. Albuterol Inhaler 90 mcg 30 days To be used in addition to Qvar to aid in asthma maintenance and to be used during an asthma attack. Referral/Consults: OB/Gyn Rationale/Citation Dysmenorrhea and menorrhagia Education: Diabetic Education to include nutrition education Rationale/Citation Patient is overweight and is noncompliant with previous treatment. Will benefit from proper nutritional education to help with weight loss and diabetic management. Follow Up: Indicate when patient should return to clinic and provide detailed instructions indicating if the patient should return sooner than scheduled or seek attention elsewhere. Patient to return within 1 month unless symptoms in right foot become worse. If experiencing chest pain, shortness of breath, unbearable pain, or decrease in blood sugar, seek medical attention immediately. Will notify patient if new antibiotic is needed upon receiving wound culture results. Rationale/Citation Elevation of current medical treatment. Wound check. Review of current laboratory work. References Include at least one evidence-based peer-reviewed journal article which relates to this case. Use the correct APA 6th edition formatting. Woo, T. M., Robinson, M. V. (2016). Pharmacotherapeutics For Advanced Practice Nurse Prescribers. [VitalSource Bookshelf]. Retrieved from https://online.vitalsource.com/#/books/9780803658110/ Click or tap here to enter text.