Nursing soap note homework | Nursing | Homework
Nursing SOAP NOTE Homework paolaminichino03Support doing SOAP Note for assignment
- 5 months ago
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Patient Information:
Lela Snow is a 48 y/o female Accountant who presented to your urgent care facility today with complaints of severe sharp abdominal pain, especially after meals that started 3 days ago and is now constant.She ia allergic to Penicillin. Her Mother has history of Hypertension and type 2 diabetes and is aliveShe has Type 2 Diabetes and Hypertension and talks lisinopril 10mg daily and metformin 500mg twice a day. She doesn’t smoke, drinks occasional wine on the weekends, denies using illicit drugs She is married and has 2 children by c-section. LMP August 12th She denies pain or joint swelling. She states she took Pepcid and motrin for the pain without relief. Her father has a history of Type2 diabetes and is still alive. She appears in moderate distress. Her heart rate and rhythm with normal S1,S2 noted and no ectopy. Her abdomen has tenderness in the right upper quadrant, positive Murphy’s sign. She denies Dizziness, weakness or numbness. She denies and pain with urination, frequency or blood in her urine.
Her Vital Signs:
o Blood Pressure: 150/90 mmHg o Heart Rate: 88 bpm o Respiratory Rate: 18 breaths per minute o Temperature: 98.6°F o Oxygen Saturation: 98% on room air o Height: 5’5" o Weight: 180 lbs o BMI: 30.0 She reports feeling fatigue, but denies any weight loss or fever. Her lung sounds are clear to auscultation bilaterally. Her skin is warm and dry to touch. She denies having any headaches, vision changes or hearing loss. She denies chest pain, palpitations or edema
o Her Lab values are as follows: CBC:
WBC: 7.5 x 10^3/µL Hemoglobin: 13.5 g/dL Hematocrit: 40.2% Platelets: 250 x 10^3/µL
Chem 7:
Sodium: 140 mmol/L Potassium: 4.2 mmol/L Chloride: 102 mmol/L Bicarbonate: 24 mmol/L BUN: 15 mg/dL Creatinine: 0.9 mg/dL Glucose: 110 mg/dL
o Liver Panel:
AST: 45 U/L (elevated) ALT: 50 U/L (elevated)
ALP: 120 U/L
Total Bilirubin: 1.2 mg/dL Albumin: 4.0 g/dL o Ultrasound: Gallstones present in the gallbladder, no signs of cholecystitis. She denies and cough. Her neck is supple, no lymphadenopathy. Her head is normocephalic, atraumatic, PERRLA, EOMI. She denies any rash, lesions, or Shortness of breath. She denies any cough, denies diarrhea or constipation. Her extremities are non-edematous with pulses +2 Bilaterally. She denies any History of anxiety or depression. She has a past Surgical History of an appendectomy The above is scrambled information which will make up the “S” and “O” portions of the SOAP note. Read the narrative and place the information in the appropriate category/location. Write the SOAP note exam using the information provided. You could find a sample format to help guide your write up in your course document section of If the above narrative does not provide information for your ROS or PE then assume these bullets or categories are normal and fill in those blanks with what is normal for those sections. DO NOT LEAVE THEM BLANK. This is to be a comprehensive SOAP note. If you feel there are other diagnostic exams necessary for this case, then indicate them in your treatment plan with the rationale. Continue your SOAP note with your “A” making sure to include at least (3) differentials for your case. Lastly, include all the pertinent information in your “P” Plan including (if applicable) follow up, treatment plan, referral and teaching/ education plan. Remember to consider health promotion and disease prevention. Patient Demographics
Age:
90+ years
Biological Sex:
Female
Race:
White, Non Hispanic
Insurance:
Medicaid
Referral:
No referral Clinical Information
Time with Patient:
20 minutes
Consult with Preceptor:
Type of Decision-Making:
Low complexity
Student Participation:
Less than shared
Reason for Visit:
Episodic
Chief Complaint:
physical
Encounter #:
Type of HP:
Problem Focused
Social Problems Addressed:
Procedures/Skills (Observed/Assisted/Done) (Critical in Bold) ICD-10 Diagnosis Codes #1 - Z00.00 - ENCNTR FOR GENERAL ADULT MEDICAL EXAM W/O ABNORMAL FINDINGS #2 - Z76.0 - ENCOUNTER FOR ISSUE OF REPEAT PRESCRIPTION #3 - Z68.1 - BODY MASS INDEX (BMI) 19.9 OR LESS, ADULT CPT Billing Codes #1 - 99213 - OFFICE/OP VISIT, EST PT, MEDICALLY APPROPRIATE HX/EXAM; LOW LEVEL MED DECISION; 20-29 MIN Medications
# OTC Drugs taken regularly:
# Prescriptions currently prescribed:
# New/Refilled Prescriptions This Visit:
Types of New/Refilled Prescriptions This Visit:
Adherence Issues with Medications:
Other Questions About This Case
Patient choice of language:
English
Patient is unable verbalize / speak:
Patient is verbal and cooperative:
Patient does not speak English:
Patient comatose / unresponsive:
Patient is ambulatory:
Maintains NP-patient relationship :
Participates in NP role :
Manages health care deliverysystems:
Proves culturally competent care:
Incorporates NP role into care:
Indirect :
Clinical Notes Sex: FeMale
DOB: 11/11/1928
Age: 94 Yrs
CHIEF COMPLAINT:PHYSICAL W.L
HISTORY OF PRESENT ILLNESS:Pleasant 94 year old female presents with daughter for a followup appointment and medication refill. Patient has no complaints or concerns for today's visit. States she lives alone, but near family (daughters). Patient states she walks daily using cane and right hip is feeling strong following hip surgery that took place one year ago. Denies recent illness and states her appetite is very good. She states she is compliant with her medications, Norvasc and ASA, and they are working well for her. Patient states she notices bilateral peripheral edema at the end of the day, but she elevates legs and sees improvement. She uses a walker and cane for ambulation. MEDICAL HISTORY:Common: Essential Hypertension
SOCIAL HISTORY:
· Alcohol: Denies alcohol use · Illicit Drugs: Caffeine usage 1 cup /day · Smoking: Does not actively smoke tobacco and has never smoked · Marital Status: She is widowed · Working Status: She is currently unemployed ACTIVE MEDICATIONS: Medication Reviewed/ Reconciled Amlodipine Besylate 10mg Tablets Take 1 Tablet By Mouth Every Day Aspirin 81MG Tablet Chewable 1 Po Q D Norvasc 10MG Tablet 1 Po Q D
ALLERGIES:
· No Known Drug Allergies. · No Known Food Allergies. · No Known Environmental Allergies.
VITALS:
Weight: 107 lbs / 48.53 kg Height: 5.4 ft BMI: 18.4BSA: 1.5
BP: 140/70
Pulse Rate: 86 BPMResp. Rate: 16 RPM Temp: 97.5 F Pain Scale: 0 ROS:Refer to HPI. The patient was also asked about all other systems. All other systems were reviewed and are negative
PHYSICAL EXAM:
Gen: Pt. is alert, oriented to place, person and time, NAD HEENT: Normocephalic, extraocular movements intact, pupils equal and reactive to light, normal moist mucosa of nose and throat. Chest: CTAB, no wheezes, rales and rhonchi CVS: RRR, s1/s2 Abd: positive for BS, soft, NT/ND Ext: no pedal edema, cyanosis/clubbing. Neuro: II-XII cranial nerves intact, moving all four extremities, FROM, sensory/ motor intact