NR 509> SOAP NOTE WEEK ONE | DETAILED SOLUTION

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SOAP Note Template Initials: TJ Age: Click or tap here to enter text. Gender: Click or tap here to enter text. Height Weight BP HR RR Temp SPO2 Pain Allergies 170 cm 90 Kg 142/ 82 86 19 101.... 1F 99% Medication: Penicillin - Rash Food: No known food allergies Environment: Cats: sneezing, watery eyes, chest tightness; Dust: triggers asthma History of Present Illness (HPI) Chief Complaint (CC) “Painful infected right foot wound” 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 1 week ago, with pain and drainage 2 days ago Location Plantar area of foot Duration 1 week Characteristics Edema, warmth, white/off-white drainage, sharp, throbbing pain Aggravating Factors Applied weight Relieving Factors Pain medication Treatment Cleansed and Neosporin applied twice a day with each cleaning 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 daily Two days Right foot pain Tylenol 500 mg – 1000 mg As needed As needed Headache Advil 600 mg As needed As needed Menstrual cramps Proventil MDI 90 mcg per spray 2 puffs every four hours As needed Asthma Neosporin Unknown Twice a day One week Right foot wound 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. Ms. Jones states that she tripped outside on a concrete step twisting her right ankle and scraping the ball of her right foot. She received care in the emergency room for her injuries where X-rays were taken and no fractures were found. She was prescribed tramadol for her pain and discharged from the emergency department. Ms. Jones reports cleansing the wound and applying Neosporin twice daily. She reports that over the last two days the ball of her right foot has become edematous and reddened with white drainage noted over the last 24 hours. She also reports a fever of 102 yesterday with accompanying chills. Ms. Jones has a history of diabetes mellitus type 2 and was diagnosed at the age of 24. She was originally prescribed metformin but stopped taking the medication three years ago. Ms. Jones stated the side effects were unpleasant causing flatulence and that she was unable to balance her medication regimen with glucose monitoring. The last glucose checked was in the emergency department one week ago which she has reported the test resulted high. Also, Ms. Jones has reported recent episodes of blurred vision, headaches, and a ten-pound weight loss within a month. She was diagnosed with asthma at 2 1/2 years old and stated that her last serious outbreak was in high school, except for her asthma exacerbation a few weeks ago. Ms. Jones denies any surgeries. She identifies herself as being heterosexual and has only had male sex partners. She has never been pregnant and reported that her last menstrual period was 3 weeks ago. She noted heavy bleeding for 9-10 days and painful menstrual cramps. She reports irregular cycles over the past year occurring every 4-8 weeks and last 9-10 days with heavy bleeding. She is not currently sexually active but has used contraception pills in the past. She denied the use of condoms while sexually active and was last tested for sexually transmitted infections four years ago. She reports all STI test results came back negative. Her last pap smear was 4 years ago and the result was negative for any abnormalities. Ms. Jones reports that she received her tetanus booster in the last year and believes she is current on all childhood immunizations and has not received a flu vaccine this year. Her last dental exam was a few years ago and her last eye exam was during childhood. 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. Ms. Jones reported that she is single and has never been married, and currently no children. She stated her current living condition as residing with her mother and younger sister in a single family home. She stated that there are working smoke detectors in the home. She also stated that she works a part-time supervisor at Mid-American Copy and currently attend college part-time. She denies the use of tobacco but admits to trying pot while attending high school but has not used it since because of guilt. She states she occasionally drinks alcohol on social occasions when she is out with her friends. She also admits to the safety use of seatbelt when driving. 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 50 yrs - Hypertension, high cholesterol Father 58 yrs - (Deceased) - History of hypertension, high cholesterol, type 2 diabetes Brother 25 yrs - Obesity Sister 14 - Asthma Maternal Grandmother 73yrs - (Deceased due to stroke) - Hypertension, high cholesterol Maternal Grandfather 78 yrs - (Deceased due to stroke) - Hypertension, high cholesterol Paternal Grandmother 82 yrs - Hypertension Paternal Grandfather 65 yrs - (Deceased due to colon cancer) - Type 2 diabetes Constitutional Skin HEENT ☐ Fatigue Click or tap here to enter text. ☐ Weakness Click or tap here to enter text. ☒Fever/Chills Reports fever of 102 and chills within the past 24 hrs ☐ Weight Gain Click or tap here to enter text. ☐ Weight Loss Click or tap here to enter text. ☐ Trouble Sleeping Click or tap here to enter text. ☐ Night Sweats Click or tap here to enter text. ☐ 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: Deep wound on plantar surface of right foot. Redness to wound edges and skin surrounding wound with serosanguinous drainage. No odor noted. ☐ 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 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 ☐ 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: Click or tap here to enter text. ☐ Other: Click or tap here to enter text. MSK GI GU PSYCH ☐ 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 Wound edges plantar surface of right foot ☐ Limited ROM ☒Redness Wound edges plantar surface of right foot ☐ 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. ☐ 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. ☐ 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. 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 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. https://www.coursehero.com/file/57803387/NR509-SOAP-Note-Wk-1-2docx/ Body System Positive Findings Negative Findings General Skin HEENT Click or tap here to enter text. Wound to right foot measuring 2 cm X 1.5 cm, 2.5 mm deep. Serosanguinous drainage noted. Red wound edges with mild redness surrounding the wound. No edema or odor noted. Click or tap here to enter text. Ms. Jones is alert and oriented, dressed appropriately and with good hygiene. Ms. Jones is well developed, well nourished, and appears to be in no acute distress. Click or tap here to enter text. Click or tap here to enter text. Respiratory Click or tap here to enter text. Click or tap here to enter text. Neuro Click or tap here to enter text. Click or tap here to enter text. Cardiovascular Click or tap here to enter text. Click or tap here to enter text. Musculoskeletal Ms. Jones complains of pain 7/10 when pressure is applied to right foot. Click or tap here to enter text. Gastrointestinal Click or tap here to enter text. Click or tap here to enter text. Genitourinary Click or tap here to enter text. Click or tap here to enter text. https://Pwwswy.ccohurisaehterrioc.com/file/57803387/NR509-SOAP-Note-Wk-1-2docx/ Click or tap here to enter text. 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. 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 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. P: Plan DAidadgrensossatillc5s:paLritsst otef sthtse ycoomu pwreillhoerndseivrethtriesavtmiseitnt plan. If you do not wish to order an intervention for any part of the treatment plan, write “None at this timeT” ebsut do not leave any heading blank. No intervention is self-evidentR. Patriovniadle /aCritattiionale and evidence-based in-text citation for Celaicckh oinr ttearpvehnetrioent.o 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 previous meds” if pertinent. Drug Dosage Length of Treatment 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. 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 instructions indicating if the patient should return sooner than scheduled or seek attention elsewhere. Click or tap here to enter text. Rationale/Citation Click or tap here to enter text. References Include at least one evidence-based peer-reviewed journal article which relates to this case. Use the correct APA 6th edition formatting. Okonkwo, U. A., & DiPierto, L. A. (2017). Diabetes and wound angiogenesis. International Journal of Molecular Sciences, 18(7), 1419. https://doi.org/10.3390/ijms18071419 Pop-Busui et al. (2017). Diabetic neuropathy: A position statement by the American Diabetes Association. Diabetes Care 2017, 40, 136-154. https://doi.org/10.2337/dc16-2042 [Show More]

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