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NR509_SOAP_Note_NEURO. SOAP Note Template Initials: BF Age: 58 Gender: Male Height Weight BP HR RR Temp SPO2 Pain Allergies Click or tap here to enter text. Click or tap here to enter text... . 146/ 90 104 19 36.7 98 Medica tion: Codeine – causes nausea and vomiting Food: None Environment: none History of Present Illness (HPI) Chief Complaint (CC) Claims he has been experiencing “troubling pain in my chest now and then for the past month” that “starts out of nowhere” “and it makes me anxious when it doesn’t subside” 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 Earlier this month Location Middle of chest Duration Lasts “several minutes” with 3 occurences with last episode on Friday Characteristics “Tight” and “uncomfortable”, pain 5/10 without radiation to arms, shoulders, legs, jaw or neck; currently no pain Aggravating Factors Physical activity, first episode was after working in yard, second episode happened after climbing five flights of stairs at work, last, and most recent occurrence (Last Friday) he was also utilizing the stairs Relieving Factors “lying still” or sitting down to rest Treatment No medications or medical treatment prior to this visit 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 Metoprolol (Lopressor) 100mg Daily 1 year hypertension Atorvastatin (Lipitor) 20mg HS daily 1 year hyperlipidemia Omega-3 fish oil 1200mg BID 1 year “To help lower cholesterol” Ibuprofen 200 mg PRN 3-4 times monthly “aches and pains” Tylenol 325 mg PRN 3-4 times a month “aches and pains” 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. No previous surgeries or hospitalizations; never had rheumatic fever; no history of childhood illnesses; diagnosed with hyperlipedema and stage 2 hypertension 1 year ago, last Tdap 2014, flu vaccine this season, up-to-date on all childhood immunizations 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. No past or present tobacco use, occasional drinker of 2-3 alcoholic beverages per week, admits to using illegal drugs in youth, but denies any illicit drug use in 30 years, Married for 27 “glorious” years, lives with wife and daughter, works as a civil engineer; enjoys fishing and small electronic repair; has not exercised regularly in several years since his bike was stolen; always wears his seatbelt. 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. Father is living: hypertension, hyperlipidemia, obesity, colon cancer, 75 years old; Mother is living: type 2 diabetes, hypertension, 80 years old; Sister is living: type 2 diabetes, hypertension, 52 years old; Brother is deceased at age 24, MVA; Maternal Grandmother died age 65, breast cancer; Maternal Grandfather died of heart attack, age 54; Paternal Grandmother died of pneumonia, age 78; Paternal Grandfather died natural causes, age 85; Son is healthy, age 26, Daughter has asthma, age 19, Wife (Maria) is healthy, age 51 Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive symptom and provide additional details. Constitutional Skin HEENT ☐ Fatigue Click or tap here ☐ Itching Click or tap ☐ Diplopia Click or tap ☐ Earache Click or tap here ☐ Hoarseness Click or tap here to enter text. here to enter text. here to enter text. to enter text. to enter text. ☐ Weakness Click or tap ☐ Rashes Click or tap ☐ Eye Pain Click or tap ☐ Tinnitus Click or tap here ☐ Oral Ulcers Click or tap here here to enter text. here to enter text. here to enter text. to enter text. to enter text. ☐ Fever/Chills Click or tap ☐ Nail Changes Click ☐ Eye redness Click or ☐ Epistaxis Click or tap ☐ Sore Throat Click or tap here here to enter text. or tap here to enter tap here to enter text. here to enter text. to enter text. ☒Weight Gain has gained text. ☐ Vision changes Click or ☐ Vertigo Click or tap here ☐ Congestion Click or tap here 20 lbs over last few years ☐ Skin Color Changes tap here to enter text. to enter text. 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. Click or tap here to enter text. ☐ Other: Click or tap here to enter text. ☐ Photophobia Click or tap here to enter text. ☐ Eye discharge Click or tap here to enter text. ☐ Hearing Changes 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 ☒Other: fine crackles heard in posterior lower lobes bilaterally ☐ 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 tightness and discomfort with exertion ☐ 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. MSK GI GU PSYCH ☒Pain in chest 5/10 at worst, currently 0/10 ☐ Stiffness Click or tap here to enter text. ☐ Crepitus Click or tap here to enter ☐ Nausea/Vomiting Click or tap here to enter text. ☐ Dysphasia Click or tap here to enter text. ☐ Diarrhea Click or tap here to enter ☐ Urgency Click or tap here to enter text. ☐ Dysuria Click or tap here to enter text. ☐ Burning Click or tap here to ☐ Stress Click or tap here to enter text. ☒Anxiety when chest pain does not subside ☐ Depression Click or tap here text. ☐ Swelling Click or tap here to enter text. ☐ Limited ROM ☐ Redness Click or tap here to enter text. ☐ Misalignment Click or tap here to enter text. ☐ Other: Click or tap here to enter text. 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. 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. 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. Body System Positive Findings Negative Findings General Skin Brian is a pleasant 58-year-old white male who is concerned about recurrent episodes of chest pain (x3) upon exertion over the last month. BP 146/90, HR 104 RR 19, SpO2 98%, oral temperature 36.7C Warm, dry, intact, normal color for race, no lesions or scarring, no tenting or bruises noted HEENT Respiratory Click or tap here to enter text. Fine crackles can be heard in posterior lower lobes bilaterally Denies vision changes, denies headaches, denies tinnitus, denies nasal drainage or stuffiness, denies sore throat or difficulty swallowing Reports no shortness of breath, denies orthopnea, no sputum production Neuro Click or tap here to enter text. Denies any sensory changes Cardiovascular Musculoskeletal PMI laterally displaced, right carotid artery has a +3 thrill with a bruit present; decreased amplitude of +1 in popliteal, tibial, and dorsalis pedis arteries bilaterally; atrial gallop and S3 heart sounds auscultated Click or tap here to enter text. JVP 3 cm above the sternal angle; PMI <3 cm, brisk and tapping; capillary refill <3 seconds on hands and feet bilaterally; left carotid artery has no bruit or thrill with +2; no bruit ascultated in abdominal, iliac or femoral arteries; Denies muscle weakness and muscle cramps Gastrointestinal Genitourinary Click or tap here to enter text. Click or tap here to enter text. Denies any changes in bowel habits; denies periods of indigestion; denies any nausea or vomiting; liver palpable 1 cm below the right costal margn and percussed a span of 7 cm at the midclavicular line Denies problems with full bladder emptying or control This stuPdsy ysocurhceiawtarsidcownloaded by 100000879074711 from CourseHero.com on 02-01-2024 13:35:00 GMT -06:00 Anxiety with chest pain Denies episodes of depression, denies changes in sleep habits Problem List 1. Chest pain 6 Click or tap here to enter text. 11 Click or tap here to enter text. 2 Hypertension 7 Click or tap here to enter text. 12 Click or tap here to enter text. 3 Tachycardia with S3 gallop 8 Click or tap here to enter text. 13 Click or tap here to enter text. 4 Hyperlipidemia 9 Click or tap here to enter text. 14 Click or tap here to enter text. 5 Anxiety 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 Acute systolic congestive heart failure I50.21 New onset of chest pain, bibasilar crackles, HTN, S3 with gallop, right carotid bruit +3 thrill, decreased peripheral pulses Stable angina I20.9 Chest pain with exertion/relief with rest, bruit with +3 thrill Acute Myocardial Infarction I21.9 Recurrent sudden chest pain and pressure, anxiety 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 Ceoarcohnianrtyeravnegnitoiognra. phy or intravascular ultrasound Coronary angiography is the “gold standard “ used to determine the presence, extent and severity of heart disease and intravascular US is an acceptable alternative diagnostic tool (Finh et al., 2015). Troponin levels Increased troponin levels may indicate injury to cardiac muscles Chest xray To evaluate for an enlarged heart and evidence of pulmonary edema BNP levels,12-lead EGC, & Doppler studies To confirm presence & severity of heart failure (Hollier, 2018) Lipid profile To determine if current medication regimen is adequately treating the patient’s hyperlipidemia Medications: List medications/treatments including OTC drugs you will order and “continue previous meds” if pertinent. Drug Dosage Length of Treatment Rationale/Citation Captopril (Capoten) 25 mg TID 2 weeks, then titrate to 50 mg TID in 2 weeks To reduce vasocontriction and sodium retention (Hollier, 2018) Furosemide (Lasix) 40 mg BID Continuous Diuretics provide fast relief of fluid retention (Hollier, 2018). Continue previous meds Click or tap here to enter text. Click or tap here to enter text. Fish oil and Lipitor will aid in decreasing LDL, Lopressor reduces blood pressure by dilating blood vessels 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: Cardiologist Rationale/Citation Adequate monitoring by a specialist increases positive patient outcomes. Education: Daily home BP and weight monitoring Exercise 3 times a week and rest as needed Dietary modifications including adding more vegetables, fruits and lean meats and less fatty meats and processed foods; reduce salt intake to <3000 mg daily Notify provider if new symptoms occur or pain worsens or radiates Take all medications as directed and do not discontinue without discussing with a provider Rationale/Citation To identify potential fluid overload To obtain and maintain optimum body weight Reducing salt intake will decrease fluid retention and a balanced diet will aid in reducing weight For early interventions and better patient outcomes Maintain therapeutic levels increases outcomes of pharmacological therapy 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. 3 days if BP continues to remain elevated or new symptoms occur including SOB, weight gain, edema or increased pain, 1-2 weeks if weight, BP, and symptoms remain stable Rationale/Citation New onset of any heart related issue requires close monitoring and continuous medication adjustments References Include at least one evidence-based peer-reviewed journal article which relates to this case. Use the correct APA 6th edition formatting. Fihn, B. et al. (2015). 2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. The Journal of Thoracic and Cardiovascular Surgery, 149(3), e5–e23. https://doi- org.chamberlainuniversity.idm.oclc.org/10.1016/j.jtcvs.2014.11.002 Hollier, A. (2018). Clinical guidelines in primary care (3rd ed.). Advanced Practice Education Associates. [Show More]

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