NR509_Week_1_SOAP_Note
S: Subjective
Information the patient or patient representative told you.
Initials: JT
Age: 28 years
Gender: Female
... [Show More] Height: 170cm
Weight: 90kg
BP: 142/82
HR: 86
Temp: 101.1
SPO2: 99%
Pain (1-10): 7
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): Acute pain of right foot
Onset: 7 days prior to exam
Location: Right foot, plantar aspect
Duration: 1 week
Characteristics: Throbbing, stabbing
Aggravating Factors: Bearing weight, ambulation
Relieving Factors: Rest, elevation, pain medication
Treatment: Tramadol
Current Medications
Medication Dosage Frequency Length of Time Used Reason for Use
Proventil inhaler
Albuterol 90mcg/spray PRN Unknown Asthma
Tylenol
500mg PRN Unknown Headaches
Advil 600mg TID PRN Unknown Menstrual cramps
Tramadol 100mg TID 2 days Right foot pain
Advil 2 tablets TID Pain
Neosporin One application BID with dressing changes Unknown Skin infection
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 has uncontrolled and unmonitored type II diabetes with an open right foot wound that she sustained one week ago when she tripped on steps barefoot. She has asthma and was last hospitalized for asthma when she was in high school. She has experienced an unexpected weight loss of ten pounds and has been excessively thirsty and experiencing nocturia. Her menstrual periods are irregular and heavy, with her last menstrual cycle being three weeks ago.
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
x Fever/Chills 101.1 F during assessment
X Weight Changes Reports unexpected 10-pound weight loss
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: Denies symptoms
Check the box next to each reported symptom and provide additional details.
Check if Positive Symptom Details
Cough
Hemoptysis
Dyspnea
Dyspnea
Pain on Inspiration
Other
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: Denies symptoms
Check the box next to each reported symptom and provide additional details. .
Check if Positive Symptom Details
Chest pain
SOB
Exercise Intolerance
Orthopnea
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 Right foot pain
Stiffness
Crepitus
Limited ROM RUE
LUE
RLE
LLE
x Redness 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
Appetite Change
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:
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 3 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 being in pain. Reports non-compliance with necessary health maintenance options
Skin
Open wound of right foot—plantar aspect.
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
History of asthma Dyspnea, chest pain or tightness, shortness of breath
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
Acute right foot pain, active range of motion in all extremities Amputations or prosthetics
Gastrointestinal
Abdominal pain, nausea/vomiting, constipation or diarrhea, heartburn
Genitourinary
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, uncontrolled, random blood sugar 238 Medication compliance, health maintenance compliance
Problem List
Order Item
1 Acute pain of right foot
2 Local infection of skin and subcutaneous tissue of right foot
3 Uncontrolled Type II Diabetes
4 Hypertension
5 Asthma
6 Dysmenorrhea
7 Menorrhagia
8 Oligimenorrhea
9 Obesity
10 Polycystic Ovarian Disease
11 Abnormal Uterine Bleeding
12 Tension Headaches
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
Wound culture Assess for C&S
Hgb A1C, CBC, BMP to assess renal function, FSH, fasting serum prolactin, free androgen index, free testosterone, fasting glucose, and TSH
Metabolic monitoring baseline
Urine analysis Rule out proteinuria
Blood cultures x2 sets Ensure proper antibiotic regimen
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 BID 30 days (follow up in 1 week with possible dosing adjustment) Tx uncontrolled diabetes type II, requires frequent follow-up (Mayo Clinic, 2019)
Lisinopril 10mg PO Daily Tx hypertension (drugs.com, 2019)
Clindamycin 300mg PO Every 6 hours, 10 days Tx open wound--right foot (healthline.com, 2019)
Hydrocodone 5/325mg PO (1-2 tab) Every 4-6 hours, 3 days Pain management (healthline.com, 2018)
Referral/Consults:
None at this time:
Referral/Consults: Rationale/Citation
OB/GYN
Irregular, heavy, painful menstrual cycles, rule out PCOS
Education:
None at this time:
Education Rationale/Citation
Wound & diabetic foot care (foot care & foot care log, signs/symptoms of worsening infection, hygiene, inspection, foot soaks, etcetera) Better understanding leads to increased compliance (Johns Hopkins Medicine, n.d.)
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 (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.)
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 5-7 days for wound check and blood pressure check, follow up monthly for blood pressure and diabetes until blood pressure at goal then every three months until both under control
Open wound in diabetic patient, new medication regimens which require monitoring in a historically non-compliant patient
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
Clindamycin. (2018). Clindamycin, oral capsule. Retrieved from https://www.healthline.come/health/clindamycin-oral-capsule
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]