NR 509 WEEK 2 SOAP NOTES TEMPLATE
NR 509 WEEK 2
NR 509 WEEK 2 SOAP NOTES
S: Subjective
Information the patient or patient representative told
... [Show More] you.
Initials: JT
Age: 28 years
Gender: Female
Height: 170cm
Weight: 89kg
BP: 140/81
HR: 89
Temp: 98.5
SPO2: 97%
Pain (1-10): 0
Allergies
Medication: Penicillin
Food: No known allergy
Environment: Cats
History of Present Illness (HPI)
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
Chief Complaint (CC): Recent asthma attack which is not fully resolved
Onset: 2 days ago, while visiting cousin with cats
Location: N/A
Duration: 2 days
Characteristics: Chest tightness, worse when laying down & at night. Persistent cough x2 days
Aggravating Factors: Physical activity, laying down
Relieving Factors: Proventil inhaler, less effective than usual
Treatment: Proventil inhaler
Current Medications
Medication Dosage Frequency Length of Time Used Reason for Use
Proventil inhaler Albuterol 90mcg/spray PRN Long term Asthma
Tylenol 500mg PRN Unknown Headaches
Advil 600mg TID PRN Unknown Menstrual cramps
Metformin 500mg PO Daily 1 month Diabetes
Lisinopril 10mg PO Daily 1 month Hypertension
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 reports experiencing an asthma attack 2 days ago with ongoing shortness of breath, sleep disturbances and decreased appetite. She reports that her last hospitalization for asthma when she was in high school. She has been utilizing her Proventil inhaler more frequently. Tina reports having to use 3 puffs every 4 hours in the past couple of days and that it has not been effective.
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 is very active in church and with family, goes out occasionally with friends dancing, and enjoys bible study and volunteering with her church. She previously lived alone but moved back in with her mom and younger sister to help with finances after the death of her father. She is working on her bachelor’s degree in accounting. She does not use tobacco products or illicit drugs but reports that she tried both when younger. Ms. Jones drinks diet coke soda and drinks alcohol socially a couple times per month. She is currently single, not sexually active and not taking contraceptives but used birth control while sexually active with previous partner. She has never been married and has never been pregnant. She reports a total of three (guy) partners and denies any history of STI’s.
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.
Ms. Jones’ mom is fifty years old and has hyperlipidemia and hypertension. Her dad is deceased at fifty-eight years in age from a motor vehicle accident that occurred last year but had a history of hypertension, hyperlipidemia, and type II diabetes. Her paternal grandmother has hypertension. Her paternal grandfather (Grandpa Jones) died in his early sixties from colon cancer and had a history of type II diabetes. Ms. Jones’ maternal grandmother (Nana) died at age seventy-three from a stroke and had a history of hypertension and hyperlipidemia. Her maternal grandfather (Poppa) died at age seventy-eight from a heart attack and had a history of hypertension and hyperlipidemia. Ms. Jones has a younger sister and also has asthma. Her brother has no known medical problems, but Ms. Jones reports that he is overweight as well as most of her family. Her paternal uncle is an alcoholic.
Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis
Constitutional
If patient denies all symptoms for this system, check here:
Check the box next to each reported symptom and provide additional details.
Check if Positive Symptom Details
x Fatigue “I have been tired and cranky recently”
Weakness
Fever/Chills
x Weight Changes Reports unexpected weight loss >10 pounds
Trouble Sleeping
Night Sweats
Other
Skin
If patient denies all symptoms for this system, check here:
Check the box next to each reported symptom and provide additional details.
Check if Positive Symptom Details
Itching
Rashes
Nail
Skin Color
x Other Open, draining wound to right foot, plantar aspect
HEENT
If patient denies all symptoms for this system, check here:
Check the box next to each reported symptom and provide additional details.
Check if Positive Symptom Details
Diplopia
Eye Pain
Eye redness
x Vision changes Blurry vision when studying or reading
Photophobia
Eye discharge
Eye discharge
Earache
Tinnitus
Vertigo
Hearing Changes
Hoarseness
Sore Throat
Congestion
Rhinorrhea
Other
Respiratory
If patient denies all symptoms for this system, check here:
Check the box next to each reported symptom and provide additional details.
Check if Positive Symptom Details
x Cough Persistent x2 days
Hemoptysis
x Dyspnea Persistent x2 days
Pain on Inspiration
x Other: Symptoms worse when laying down and at night Persistent x2 days
Neuro patient denies all symptoms for this system, check here:
Check the box next to each reported symptom and provide additional details.
Check if Positive Symptom Details
Syncope or Lightheadedness
x Headache Intermittent headaches when studying or reading
Numbness
Tingling
Sensation Changes RUE
LUE
RLE
LLE
Speech Deficits
Other
Cardiac and Peripheral Vascular
If patient denies all symptoms for this system, check here:
Check the box next to each reported symptom and provide additional details.
Check if Positive Symptom Details
Chest pain
x SOB Persistent asthmatic episodes x2 days
x Exercise Intolerance Chronic
x Orthopnea Troubles breathing while lying flat
Edema
Murmurs
Palpitations
Faintness
Occlusions
Claudications
PND
Other
MSK
If patient denies all symptoms for this system, check here:
Check the box next to each reported symptom and provide additional details.
Check if Positive Symptom Details
x Pain Improved right foot pain
Stiffness
Crepitus
Limited ROM RUE
LUE
RLE
LLE
x Redness Improved right foot redness
Misalignment
Other
GI
If patient denies all symptoms for this system, check here: Denies symptoms
Check the box next to each reported symptom and provide additional details.
Check if Positive Symptom Details
Nausea/Vomiting
Dysphasia
Diarrhea
x Appetite Change Unintentional weight loss over past several months
Heartburn
Blood in Stool
Abdominal Pain
Excessive Flatus
Food Intolerance
Rectal Bleeding
Other
GU
If patient denies all symptoms for this system, check here:
Check the box next to each reported symptom and provide additional details.
Check if Positive Symptom Details
Urgency
Dysuria
Burning
Hematuria
Polyuria
x Nocturia Reports increased thirst
Incontinence
x Other: Urinary frequency Reports increased thirst
PSYCH
If patient denies all symptoms for this system, check here: Denies all symptoms
Check the box next to each reported symptom and provide additional details.
Check if Positive Symptom Details
Stress
Anxiety
Depression
Suicidal/Homicidal Ideation
Memory Deficits
Mood Changes
Trouble Concentrating
Other:
GYN
If patient denies all symptoms for this system, check here:
Check the box next to each reported symptom and provide additional details.
Check if Positive Symptom Details
Rash
Discharge
Itching
x Irregular Menses Reports irregular, heavy, painful cycles
x Dysmenorrhea Heavy, painful cycles
Foul Odor
Amenorrhea
x LMP In past 4 weeks
Contraception
Other:
Hematology/Lymphatics
If patient denies all symptoms for this system, check here: Denies symptoms
Check the box next to each reported symptom and provide additional details.
Check if Positive Symptom Details
Anemia
Easy bruising/bleeding
Past Transfusions
Enlarged/tender lymph node(s)
Blood or lymph disorder
Other:
Endocrine
If patient denies all symptoms for this system, check here:
Check the box next to each reported symptom and provide additional details.
Check if Positive Symptom Details
Abnormal growth
Increased appetite
x Increased thirst “I have been very thirsty lately”
Thyroid disorder
Heat/cold intolerance
Excessive sweating
x Diabetes “I have diabetes, but I don’t take medications now”
Other:
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.
Body System Positive Findings Negative Findings
General
Alert and oriented, well nourished, well groomed, dressed appropriately, has adequate hygiene, and interacts appropriately. She exhibits signs and symptoms of intermittent shortness of breath. Reports non-compliance with necessary health maintenance options
Skin
Ongoing healing wound of right foot—plantar aspect, breakouts of acne
HEENT
Intermittent headaches with blurry vision when reading or studying which cause throbbing behind her eyes. Head injury or trauma, neck pain or trauma, runny nose, eye discharge or pain, ear discharge, ringing, or pain, glasses or contacts, cataracts, dentures, broken or chipped teeth
Respiratory
Recent asthma attack with ongoing, intermittent shortness of breath & wheezing Chest pain
Neuro
Headaches with blurry vision when studying for long periods Dizziness, memory concerns, balance or sensation changes
Cardiovascular
Hypertension Chest pain, tightness, shortness of breath, dyspnea
Musculoskeletal
Healing wound of right foot-plantar aspect Amputations or prosthetics
Gastrointestinal
Abdominal pain, nausea/vomiting, constipation or diarrhea, heartburn
Genitourinary
Recent reports of nocturia, urinary frequency Pain, itching, discharge, foul odor
Psychiatric
Situational sadness related to father’s death Depression, anxiety, suicidal or homicidal thoughts, psychosis
Gynecological
Irregular, heavy, painful menstrual cycles Pregnancy, miscarriage, STI’s, current sexual activity
Hematology/Lymphatic
Anemia, easy bruising/bleeding, transfusions, enlarged/tender lymph node(s), blood or lymph disorder
Endocrine
Diabetes Type II, random blood sugar 224, recently started on Metformin Medication compliance, health maintenance compliance
Problem List
Order Item
1 Asthma exacerbation
2 Asthma—Moderate persistent
3 Sleep disturbance related to breathing difficulties
4 Type II Diabetes
5 Hypertension
6 Dysmenorrhea
7 Menorrhagia
8 Oligimenorrhea
9 Obesity
10 Polycystic Ovarian Disease
11 Abnormal Uterine Bleeding
12 Tension Headaches
13 Local infection of skin and subcutaneous tissue of right foot—medication initiated in past week
14
15
16
A: Assessment
Medical Diagnoses. Provide 3 differential diagnoses which may provide an etiology for the CC. The first diagnosis (presumptive diagnosis) is the diagnosis from which the interventions on the Plan of Care (POC) is written.
.
Diagnosis ICD-10 Code Pertinent Findings
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, select “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.
None at this time:
Test Rationale/Citation
Pulmonary function tests
Test lung function related to chronic, long term asthma history
Medication/Treatment: List medications/treatments including OTC drugs you will order and “continue previous meds” if pertinent.
None at this time:
Continue previous meds:
Drug Dosage Length of Treatment Rationale/Citation
Proventil Albuterol 90mcg/spray MDI Continue previous meds Asthma regimen
Tylenol Recommended dose Continue previous meds Tension headache regimen
Advil 2 tablets Continue previous meds Pain regimen
Metformin 500mg PO Daily 1 month Tx uncontrolled diabetes type II, requires frequent follow-up (Mayo Clinic, 2019)
Lisinopril 10mg PO Daily 1 month Tx hypertension (drugs.com, 2019)
Singulair 10mg PO Daily Start taking now Tx moderate persistent asthma (Hollier, 2018)
Advair Diskus 250/50 1 puff daily Start taking now Tx moderate persistent asthma (Hollier, 2018)
Referral/Consults:
None at this time:
Referral/Consults: Rationale/Citation
Pulmonologist Management of moderate persistent asthma with recent exacerbation
Education:
None at this time:
Education Rationale/Citation
Nonpharmacologic management of asthma—peak flow monitoring, avoidance of triggers, ongoing education related to disease process, utilization of asthma action plan (Hollier, 2018)
Lifestyle alterations (eating, exercise, weight loss, heart disease, travel, work stress, etcetera) Better understanding leads to increased compliance (Johns Hopkins Medicine, n.d.)
Diabetic diet options Better understanding leads to increased compliance (Johns Hopkins Medicine, n.d.)
DASH diet for hypertension Better understanding leads to increased compliance (Johns Hopkins Medicine, n.d.)
Compliance with treatment regimen (compliance with inhalers & oral asthma regimen, logging asthma symptoms daily, glucose & blood pressure monitoring, nutrition & hydration, meal planning, food log, alcohol, effects of illness, benefits of completing medication regimens, etcetera) Better understanding leads to increased compliance (Johns Hopkins Medicine, n.d.)
Ongoing education related to the effects of diabetes & hypertension (increased risk of severe infection, heart disease, vascular disease, neuropathy, renal disease, eye disease, sleep apnea, etcetera) Better understanding leads to increased compliance (Johns Hopkins Medicine, n.d.)
Education for all medications prescribed Better understanding leads to increased compliance (Johns Hopkins Medicine, n.d.)
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.
None at this time:
Follow-Up Rationale/Citation
Follow up 3-6 months
Ensure appropriate treatment results and patient compliance for disease stability
References (Include at least one evidence-based peer-reviewed journal article which relates to this case. Use the correct APA 6th edition formatting.)
List references below:
Acetaminophen-Hydrocodone. (2018). Acetaminophen-hydrocodone, oral tablet. Retrieved from https://www.healthline.com/health/acetaminophen-hydocodone-oral-tablet
Hollier, A. (2018). Clinical guidelines in primary care, 3rd Edition. Advanced Practice Education Association, Inc. Lafayette, LA.
Lisinopril. (2019). Lisinopril dosage. Retrieved from https://www.drugs.com/dosage/lisinopril.html
Johns Hopkins Medicine. (n.d.). Diabetes self management patient education materials. Retrieved from https://www.hokinsmedicine.org/gim/core_resources/patient%20handouts/index.html
Metformin. (2019). Metformin (oral route). Retrieved from https://www.mayoclinic.org/drugs-supplements/metformin-oral-route/proper-use/drg-20067074 [Show Less]