SOAP note for a Nurse Practitioner program

This is a SOAP note for a Nurse Practitioner program. I am attaching a template and my patient’s information (my SOAP note).
Running head: SOAP #1 1 Soap Note #1 Student’s Name University NUR 6041 – Advanced Nurse Practicum September 26, 2019 SOAP NOTE #1 2 Demographic Information: Patient initials: F.R. DOB: 10/11/1981 Age: 37 Y/O Gender: Male Race: Hispanic Religion: Catholic Occupation: Catholic Priest Date of Visit: 09/18/19 Subjective Data: Reason for Visit: “My chest has been feeling so tight the past few days, it has been making me short of breath and wheeze, and I have this dry cough that is annoying.” History of Present Illness: F.R. is a 37-year-old Hispanic male that presents to the office with a 7-day history of chest tightness, shortness of breath (SOB), wheezing and a dry cough. Reports that the symptoms started 7 days ago when he left his house to go to work, and it was “really” cold outside. Patient reports that he has experienced these symptoms before; usually at the start of the winter months. Patient reports the chest tightness as rapid onset, and occurs intermittently 2-3x per week, and is aggravated by exposure to cold weather and activity. Describes his SOB and wheezing to occur after the tightness begins, and is alleviated with rest and use of his. Patient reports that he has been using his albuterol sulfate and Advair Diskus since the symptoms started with some improvement. Patient reports that he does not use his Advair as ordered every day because he is nervous of the steroid in the inhaler will make his sugars go high. Additional reports a 3-day history of a dry cough that is intermittent, non-productive that is relieved with OTC cough drops. Patient denies any active chest pain, shortness of breath, sore throat or fatigue. Patient presents to the office because his symptoms only minorly improved, and he wants to get back to work. Past Medical History: Asthma, diabetes mellitus II, gastroesophageal reflux disease obstructive sleep apnea, hypertension, and hyperlipidemia. Past Surgical History: Cholecystectomy (2009) Active Medications: Albuterol Sulfate 90mcg 2 puffs QID PRN Insulin Aspart – Sliding Scale Dexlansoprazole 30mg PO BID Losartan 50mg PO QD Fenofibrate 120mg PO QD Nebivolol Hydrochloride 10mg PO QD Fluticasone/Salmetrol 100mcg/50mcg 1x puff BID Rosuvastatin Calcium 10mg PO QD SOAP NOTE #1 3 Allergies: No known drug or food allergies. Pertinent Family History: Mother: 64 Y/O – History of HTN controlled with medications. Father: 66 Y/O- History of DM controlled with medications. Social History: Patient reports that he is single, and lives in an apartment. He is a Catholic Priest at a nearby church. Denies having any pets. Intimate Partner Violence: Patient denies any emotionally or physical abuse at home. Exercise: Reports working out 2-3x per week at his local gym. He performs 20 minutes of walking on the treadmill at 2mph 1-2x/week and taking fitness classes 2x/week. Diet: Patient states that he eats a “good” diet. 24- Hour diet recall includes: Breakfast: coffee with a piece of bread and butter, lunch: a ham and cheese sandwich with a can of diet- Pepsi, and dinner: grilled chicken salad with a glass of wine. Sleep: Reports getting an average of 5-6 hours a sleep per night. Tobacco and/or Drug Use: Denies tobacco or drug use. Alcohol: Occasional social drinker, reports a 1-2 glasses of wine per week. Occupational Health: Catholic Priest at a nearby church. Works 30-40x per week, denies any occupational health hazards. Health Maintenance Regular Wellness Exam: January 2019 Flu Vaccine: Sept 2018 – Refused flu vaccination until his signs and symptoms improve. Dental Exam: December 2018 Eye Exam: December 2018 Review of Systems: General: Denies fever, fatigue, body aches. EENT: Patient denies any visual difficulty, pain, double vision, redness, swelling, or discharge to eyes. Denies any earaches, ear discharge, hearing loss or changes, tinnitus, or vertigo. Denies any frequent colds, sinus pain, nasal congestion, trauma to nose, nosebleeds or altered smell. Denies any sores or lesions, sore throats, bleeding gums, toothaches, difficulty swallowing, or altered taste. Respiratory: Reports a 7-day history of chest tightness, SOB and wheezing. Patient reports that the chest tightness occurs when he is outside in the cold weather and with exertion. Reports using albuterol inhaler and Advair Diskus as a treatment with some improvement. Reports a 3- day history of an intermittent, dry non-productive cough that is relived with OTC cough drops. Denies sputum production, hemopytsis, shortness of breath with rest and chest pain when SOAP NOTE #1 4 breathing. Denies history of frequent or severe colds, allergies or tuberculosis. Reports history asthma, and only is compliant with inhaler use during winter months. Denies history of smoking, secondhand smoke exposure, or home oxygen use. Cardiovascular: Reports a 7-day history of chest tightness, SOB, wheezing. Denies any chest pain with rest or activity, dyspnea, orthopnea, fatigue, edema, and nocturia. Denies any lower extremity edema or skin changes, orthopnea, or leg cramps with rest and exertion. Reports history of HTN treated with medication, diet and exercise. Denies any other cardiovascular or deep vein thrombosis history. Reports a negative stress test from 09/2019 as a part of his bariatric surgery workup. Objective Data: Vital Signs: BP 128/90 HR: 80 RR: 18 T: 98.0°F SpO2: 98% on Room Air Height: 5’8” Weight: 250 pounds BMI: 38 General: Patient is calm and cooperative, answering questions appropriately; sitting upright in examination room dressed according to the season. Gait is steady, face is symmetric, speech is clear and no weakness noted. Patient is awake, alert and orientated, in no acute distress. EENT: Normal confrontation, bilateral corneal light reflex symmetric, EOMs intact. Bilateral conjunctiva and sclera are clear, and pink, no redness noted. PERRLA. Bilateral external and internal ear canals are clear with no redness, lesions, foreign bodies, or discharge. Bilateral tympanic membranes are pearly gray without perforation with light reflex and landmark intact. Bilateral turbinates appear pale-pink, no lesion or foreign bodies noted with clear discharge. Frontal and maxillary sinus non-tender upon palpitation. Bilateral lips appear symmetric and moist, no redness, lesions, or cracking noted. Mucosa and gums are pink and smooth, no bleeding noted. Tongue is pink, and moist, with saliva present, no patches, nodules or lesions noted. Uvula rise midline. Tonsils are pink, and 2+ with no evidence of exudates or white patches. Cough and gag reflex intact. No odor noted. Neck is symmetric, supple with full active ROM. Bilateral non-palpable and non-tender lymph nodes, no lymphadenopathy or masses Respiratory: Thorax and chest expansion is symmetric, skin color appropriate for ethnicity. No tenderness on palpitation. Bilateral equal tactile fremitus, and resonant percussed over lung fields. On auscultation, bilateral upper lobes clear, and lower lobes noted with a mild expiratory wheeze. Cardiovascular: Bilateral upper and lower extremity pink, no cyanosis, clubbing, or edema noted, capillary refill ❤, warm to touch. Bilateral carotid, brachial, and radial pulses are 2+. JVD not noted. Rhythm regular, S1S2 present, no extra heart sounds or murmurs noted. SOAP NOTE #1 5 Differential Diagnosis: ICD-10 CM J20.9 Acute bronchitis Acute bronchitis is an acute inflammation of the bronchioles, bronchi and trachea caused by bacterial, viral and fungal infections (Hollier, 2018, p. 659). It has a high prevalence in the fall and winter. Some common signs and symptoms are cough lasting 2-3 weeks, with/without sputum production, shortness of breath, nasal congestion, post-nasal drip, headache, low-grade fever, sub-sternal pain when coughing (Kinkade & Long, 2016). On physical examination, patients may present with wheezing, decreased breath sounds, increased tactile fremitus (Kinkade & Long, 2016). F.R. is a 37-year-old male that presented to the office with a 7-day history of chest tightness with SOB and wheezing, and a dry, non-productive cough. On examination, patient noted with clear bilateral upper lobes, and expiratory wheeze in the lower lobes. Benign EENT and cardiovascular exam. Based off of history and physical, acute bronchitis was ruled out because the patient’s symptoms were <7 days, patient was negative for sputum production, nasal congestion, post-nasal drip, and fever. ICD-10 CM J18.9 Pneumonia Pneumonia is an acute infection affected the lung(s) that can include the parenchyma, alveolar space or interstitial tissue where the area becomes consolidated with bacteria, cellular debris, fluid and blood cell which decrease surface space causing hypoxia (Jarvis, 2016). Signs and symptoms include cough, fever >100.4F, chills, fatigue, chest pain, sputum production, diminished breath signs, shortness of breath, consolidation on percussion, and increased tactile fremitus. Patients who do not display any abnormal vital signs and lung examination is unlikely to have pneumonia (Kinkade & Long, 2016). F.R. is a 37-year-old male that presented to the office with a 7-day history of chest tightness with SOB and wheezing, and a dry, non-productive cough. On examination, patient noted with clear bilateral upper lobes, and expiratory wheeze in the lower lobes. Benign EENT and cardiovascular exam. Based off of history and physical, pneumonia was ruled out because the patient’s respiratory exam is not as significant as one should expect with pneumonia, patient negative for fever, chills, fatigue, chest pain, diminished breath signs, consolidation on percussion, and increased tactile fremitus. Assessment: J45.21 Mild intermittent asthma with acute exacerbation Asthma is a respiratory disorder that causes airway constriction and bronchial hyperresponsiveness (Hollier, 2018, p. 662). Acute exacerbations are episodes of worsening asthma symptoms that can be cause by triggers such as a viral upper respiratory infection, exposure to allergens, non-compliance with controller medications (Fanta, 2019). Some signs and symptoms of an acute exacerbation includes chest tightness, cough, shortness of breath, SOAP NOTE #1 6 wheezing, dyspnea (Hollier, 2018, p. 663). F.R. is a 37-year-old male that presented to the office with a 7-day history of chest tightness with SOB and wheezing, and a dry, non-productive cough. On examination, patient noted with clear bilateral upper lobes, and expiratory wheeze in the lower lobes. Benign EENT and cardiovascular exam. A diagnosis of an acute asthma exacerbation was made because the patient has a known history of asthma, noncompliance with controller medications, change in weather with allergens associated with the patient’s symptoms of chest tightness, SOB and wheezing, which improved with use of a rescue inhaler. Plan: Treatment Goals: Monitor respiratory status to ensure adequate treatment, and avoidance of worsen exacerbation. Treatment: Diagnostics/Laboratory Testing: Diagnosis can be made of history and physical exam. Non-pharmacological: 1. Maintain rest and hydration 2. OTC throat lozenges to alleviate cough 3. Tea with honey Pharmacological: 1. Ipratropium bromide/albuterol sulfate 0.5mg/2.5mg 3mL Sig: 3mL via nebulizer Q6H Refills: 1x 2. Methylprednisolone Dosepak 4mg Sig: As directed on pack Refills: None 3. Azithromycin Z-Pak Sig: As directed on pack Refills: None *Current guidelines recommend the use of inhaled short-acting beta agonists, inhaled corticosteroids, and systemic glucocorticoids as treatment for an acute exacerbation. Antibiotics are currently not listed as a recommended guideline, however this patient was prescribed Azithromycin Z-Pak because of his history of asthma, OSA, and DM as per the precepting physician. SOAP NOTE #1 7 Referrals: None Education: 1. Education about asthma, and how to identify and avoid asthma triggers (Hollier, 2018, p.663). 2. Development of a personalized action plan of preplanned medication plan for exacerbations (Hollier, 2018, p.663). 3. Recognize the signs and symptoms of a worsen exacerbation and when to seek help 4. Compliance with controller medications to avoid exacerbations (Fanta, 2019). 5. Inhaler techniques, and proper administration method (Hollier, 2018, p.663). 6. Patient’s should be advised side effects of medications prescribed. a. DuoNeb: Headaches b. Medrol Pack: Hypertension, increased appetite, gastric irritation, hyperglycemia c. Z-Pak: Abdominal pain, nausea, vomiting, and diarrhea Follow Up: Follow up in one-week w/ PMD if signs and symptoms do not improve, or worsen. Patient should seek emergency treatment if the patient develops any respiratory difficulties or chest pain. SOAP NOTE #1 8 References Fanta, C. H. (2019, February 28). Acute exacerbations of asthma in adults: Home and office management. Retrieved from https://www.uptodate.com/…/acute-exacerbations-ofasthma… exacerbation&source=search_result&selectedTitle=1~150&usage_type=default&display _rank=1#H23099126 Hollier, A. (2018). Clinical guidelines in primary care (3rd ed.). Scott, LA: Advanced Practice Education Associates. Jarvis, C. (2016). Physical examination & health assessment (7th ed.). St. Louis, MO: Elsevier. Kinkade, S., & Long, N. A. (2016, October 01). Acute Bronchitis. Retrieved September 20, 2019, from https://www.aafp.org/afp/2016/1001/p560.html Sexton, D. J., & McClain , M. T. (2018, February 22). The common cold in adults: Diagnosis and clinical features. Retrieved from https://www.uptodate.com/…/the-common-coldin-adults… respiratory infection&source=search_result&selectedTitle=1~150&usage_type=default&display_ran k=1

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