Nr 509 Week 4 Soap Notes Template

S: Subjective Information the patient or patient representative told you. Initials: BF Age: 58 years old Gender: Male Height: 5’11” Weight: 197lbs BP: 146/90 HR: 104 Temp: 19 SPO2: 98% Pain (1-10): 0/10 Allergies Medication: Codeine—Nausea and vomiting Food: No Known Food Allergies Environment: No Known Environmental Allergies 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): Chest Pain/Tightness Onset: 1 month Location: Center of my chest” Duration: “It lasts 2-3 minutes when it happens” Characteristics: “Intermittent tightness and discomfort” Aggravating Factors: Activity, yard work, climbing stairs Relieving Factors: Rest Treatment: No medication treatments, seeking medical treatment today Current Medications Medication Dosage Frequency Length of Time Used Reason for Use Metoprolol 100mg Daily 1 year Hypertension Atorvastatin 20mg Daily at bedtime 1 year High cholesterol Omega 3 Fish Oil 1200mg Twice Daily 1 year High cholesterol 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. Mr. Foster had a Tdap in October 2014 and has received the influenza vaccine for this season. He reports a codeine allergy which caused nausea and vomiting. He denies any history of major illness, hospitalizations, or surgeries. He denied any history of diabetes, coronary artery disease, or peripheral vascular disease. His only reported medical diagnoses are hypertension and high cholesterol. He also reports an approximate weight gain of 20 pounds over the past two years. 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. Mr. Foster is married and works full-time as an engineer at a civil engineering firm. He denies any history of smoking tobacco or any illicit drugs, including marijuana, cocaine, or heroin. He avoids soda, and reports that his only alcohol intake is 2-3 beers on the weekends “if I’m grilling”. He likes to ride bicycles but reports his last one was stolen. He intends to purchase another bicycle soon so that he can start riding again. Mr. Foster enjoys fishing, watching sports (including his sons body building competitions), and doing repairs on small electronics. 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. Mr. Foster denies any known family history of stroke, DVT or pulmonary embolism. He reports that his father died of colon cancer at the age of 75 years and had a history of hypertension, hyperlipidemia, obesity. Mr. Fosters mother is 80 years old and has hypertension and diabetes type II. He reports that his brother died at the age of 24 years from a motor vehicle accident. His sister is 52 years old and has hypertension and diabetes type II. Mr. Fosters maternal grandfather died of a heart attack at 54 years of age, and his maternal grandmother died of breast cancer at 65 years of age. Mr. Fosters paternal grandfather died of “old age” at 85 years of age, and his paternal grandmother died of pneumonia at 78 years of age. Mr. Foster has a healthy 26-year-old son and a 19-year-old daughter with asthma. 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 Fatigue Weakness Fever/Chills x Weight Changes 20 pound weight gain over 2 year period Trouble Sleeping Night Sweats Other Skin If patient denies all symptoms for this system, check here: Denies all symptoms for this system Check the box next to each reported symptom and provide additional details. Check if Positive Symptom Details Itching Rashes Nail Skin Color Other HEENT If patient denies all symptoms for this system, check here: Denies all symptoms for this system Check the box next to each reported symptom and provide additional details. Check if Positive Symptom Details Diplopia Eye Pain Eye redness Vision changes 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 all symptoms for this system 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: Denies all symptoms for this system Check the box next to each reported symptom and provide additional details. Check if Positive Symptom Details Syncope or Lightheadedness Headache 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 x Chest pain Intermittent tightness and discomfort with activity SOB Exercise Intolerance Orthopnea Edema Murmurs Palpitations Faintness Occlusions Claudications PND Other MSK If patient denies all symptoms for this system, check here: Denies all symptoms for this system Check the box next to each reported symptom and provide additional details. Check if Positive Symptom Details Pain Stiffness Crepitus Limited ROM RUE LUE RLE LLE Redness Misalignment Other GI If patient denies all symptoms for this system, check here: Denies all symptoms for this system 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: Denies all symptoms for this system Check the box next to each reported symptom and provide additional details. Check if Positive Symptom Details Urgency Dysuria Burning Hematuria Polyuria Nocturia Incontinence Other PSYCH If patient denies all symptoms for this system, check here: Denies all symptoms for this system 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: Denies all symptoms for this system Check the box next to each reported symptom and provide additional details. Check if Positive Symptom Details Rash Discharge Itching Irregular Menses Dysmenorrhea Foul Odor Amenorrhea LMP Contraception Other: Hematology/Lymphatics If patient denies all symptoms for this system, check here: Denies all symptoms for this system 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: Denies all symptoms for this system Check the box next to each reported symptom and provide additional details. Check if Positive Symptom Details Abnormal growth Increased appetite Increased thirst Thyroid disorder Heat/cold intolerance Excessive sweating Diabetes Other: Body System Positive Findings Negative Findings General Alert and oriented to person/place/time/situation, well nourished, well groomed, dressed appropriately, has adequate hygiene, and interacts appropriately. Skin Skin in warm, dry and intact without rashes or lesions. Appropriate color for ethnicity. Nailbeds pink with no cyanosis or clubbing. HEENT Head: The head is normo- cephalic and atraumatic without tenderness, visible or palpable masses, depressions, or scarring. Hair is of normal texture and evenly distributed. Face: No visible abnormal findings at this time. Eyes: No visual acuity performed at this time. Conjunctivae are clear without exudates or hemorrhage. Sclera is non- icteric. EOM are intact, PERRLA. Fundi appear normal including optic discs and vessels. No signs of nystagmus. Eyelids are normal in appearance without swelling or lesions. Ears: Assessment not performed at this time. Nose: Assessment not performed at this time. Throat: Assessment not performed at this time. Neck: The neck is supple without adenopathy. Trachea appears to be midline. Thyroid gland appears to be normal without masses. Right carotid artery exhibits a bruit and thrill with 3+ amplitude. Left carotid artery exhibits no bruit or thrill with a 2+ amplitude. Height of jugular venous pressure is 4cm or less above the sternal angle, no JVD noted at this time. Respiratory The chest wall is symmetric and without deformity. No signs of trauma. Chest wall is non-tender. No signs of respiratory distress. Breath sounds are clear throughout all lung fields with exception of fine crackles to the bilateral, posterior lower lobes. Neuro AAOx4, converses appropriately, and able to control movements appropriately. Complete neuro exam not performed at this time. Cardiovascular The external chest is normal in appearance without lifts, heaves, or thrills. PMI is not visible and is displaced laterally (less than 3cm) suggestive of a mildly enlarged heart and exhibits a brisk and tapping amplitude. Tachycardia noted during assessment and on the Ekg. S1, S2, and S3 are heard with gallops present. Intermittent chest pain reports over past month, denies presence of active chest pain or tightness at this time. Palpation: Bilateral brachial arteries: • No thrill with 2+ amplitude Bilateral radial arteries: • No thrill with 2+ amplitude Bilateral femoral arteries: • No thrill with 2+ amplitude Bilateral popliteal arteries: • No thrill with 1+ amplitude Bilateral tibial arteries: • No thrill with 1+ amplitude Bilateral dorsalis pedis arteries: • No thrill with 1+ amplitude Musculoskeletal Upper and lower extremities are atraumatic in appearance without tenderness or deformity. No swelling or erythema. Full range of motion is noted to all joints. Muscle strength is 5/5 bilaterally. Tendon function is normal. Capillary refill is less than 3 seconds in all extremities. Pulses palpable. No edema in bilateral lower extremities. Bilateral hands: • No visible abnormal findings (redness, moles, skin tags, masses, freckles, birthmark, discoloration, excessive dry or flaky skin, purpura, scarring, laceration/lesion/wound, bruising, or rash) Bilateral fingers: • No visible abnormal findings (pallor, cyanosis, splinter hemorrhages, or clubbing) Bilateral lower extremities: • No visible abnormal findings (visible distortion or swelling, brownish pigmentation, skin thickening, ulceration, or varicose veins) Bilateral toes: • No visible abnormal findings (pallor, cyanosis, splinter hemorrhages, or clubbing) Gastrointestinal Abdomen is soft, symmetric, and non-tender without distention. There are no visible lesions or scars. The aorta is midline without bruit or visible pulsation. Umbilicus is midline without herniation. Bowel sounds are present and normoactive in all four quadrants. Abdomen is generally tympanic upon percussion. No masses or splenomegaly are noted. No friction rub noted to the liver which is palpated between 6 and 12cm. Genitourinary No assessment at this time. Psychiatric Mild anxiety regarding potential causes for chest pain episodes. Gynecological Not applicable Hematology/Lymphatic No assessment at this time. Endocrine No assessment at this time. Problem List Order Item 1 Acute chest pain 2 Tachycardia 3 Coronary artery disease 4 Cardiomegaly 5 Hepatomegaly 6 Unintentional weight gain 7 Activity intolerance 8 Hypertension 9 Hyperlipidemia 10 Right carotid bruit 11 Diminished pulses lower extremities 12 Bibasilar crackles Diagnosis ICD-10 Code Pertinent Findings Angina pectoris, unspecified I20.9 Intermittent chest pains with exertion Tachycardia, unspecified R00.0 Exhibits resting heart rate 100bpm Peripheral vascular disease, unspecified I73.9 Exhibits generally diminished arterial amplitude to bilateral lower extremities Diagnostics: List tests you will order this visit. None at this time: Test Rationale/Citation Lab tests including: CBC with differential, CMP, Cardiac enzymes including troponin, BNP, Lipid panel, CRP Chest pain in a 58 year old male with Hypertension and Hyperlipidemia Chest xray Chest pain in a 58 year old male with Hypertension and Hyperlipidemia Chest CT Undiagnosed PMI displacement laterally 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 Hydrochlorothiazide 25mg Daily in the morning Start now Signs of CHF—crackles in bilateral lower lung fields without evidence of respiratory complaints Metoprolol 100mg Daily Continued Beta blockers work to treat HTN, CHF, and tachycardias/arrhythmias Atorvastatin 20mg Daily Continued Treating diagnosed hyperlipidemia Omega 3 Fish Oil 1200mg BID Continued Assist in treating hyperlipidemia Aspirin 81mg Daily Start now Decrease risk of heart attack Referral/Consults: None at this time: Referral/Consults: Rationale/Citation Cardiologist and vascular surgeon Chest pain in a 58 year old male with Hypertension and Hyperlipidemia, signs of cardiomegaly, hepatomegaly, and heart failure Education: None at this time: Education Rationale/Citation --Mr. Foster will be educated regarding exercise, diet, and lifestyle modifications --Mr. Foster will be educated to seek immediate medical attention if chest pain returns, gets worse, and is associated with radiation, diaphoresis, shortness of breath, nausea/vomiting, or dizziness/faintness --Home monitoring of blood pressure --Education on signs and symptoms of myocardial infarction and when to seek emergent care --Educate on the importance of monitoring daily weights - Diet and exercise helps to reduce the risk of cardiovascular damage or the occurrence of worsening symptoms of a heart disease. - monitoring blood pressure and weight measurements helps the patient to be aware of worsening disease state - Educating patient of signs of a myocardial infarction helps in early identification, early presentation to the hospital, and thus, early intervention to reduce the severity of disease (Paterick, Patel, Tajik, & Chandrasekaran 2017) 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 Make appointment with cardiology as soon as possible Make appointment with vascular surgeon Follow up with PCP in 1 month or PRN for symptoms --For evaluation, echocardiogram, exercise stress Test. --For carotid evaluation and bilateral carotid doppler --Health maintenance and monitoring 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: Paterick, P., Patel, N., Tajik, J. & Chandrasekaran, K. (2017). Improving health outcomes through patient education and partnerships with patients. Retrieved from