The soap notes attached are ok but I need to use it for another student you need to do some changes for look different and it does not have similarity.
SOAP NOTE
Name:
R.G Date: 08/21/2019 Time: 10 AM
Age: 56 y/o Sex: Female
SUBJECTIVE
CC:
“I have been experiencing increasing shortness of breath, fatigue and problems sleeping”
HPI:
R.G, a 56 y/o African American female presents to the office with complaints of
increasing shortness of breath on exertion and mild fatigue for the past five days. The
patient reports that he has been experiencing shortness of breath after climbing stairs or
walking two to three blocks he also reports difficulty sleeping at night and states that he
often need two pillows to feel comfortable. Patient reports that 2 years ago, she suddenly
started experiencing shortness of breath after hurrying for an aeroplane. Following the
incidence, she was admitted to hospital and treated for acute pulmonary edema. After the
pulmonary edema episode, the patient reports that his blood pressure had been high
consistently. Patient denies chills, cough, chest pain, palpitations, vomiting, diarrhea
abdominal pain/distension
Medications:
Diltiazem 180 mg/d for HTN
Hydrochlorothiazide 50 mg/d for HTN and heart failure
Lopressor 25mg orally BID HTN and heart failure
Glyburide 5 mg/d for diabetes
Indomethacin 25 mg TID for pain
PMH
Allergies: No known Drug allergies
Medication Intolerances: None
Chronic Illnesses/Major traumas: Diastolic dysfunction with diastolic congestive heart
failure, Hypertension (diagnosed 5 years ago), type 2 diabetes mellitus (diagnosed 4 years
ago), arthritis (diagnosed two years ago). Denies a history of asthma
Hospitalizations/Surgeries: patient was admitted to hospital and treated for acute
pulmonary edema. Patient has no history of surgeries
Family History: Coronary heart disease, hypertension, arthritis ( father), Type 2 diabetes
mellitus ( mother), Hypertension ( older brother), other siblings and her children alive
and well.
Social History: Patient lives with her husband and youngest son. She works as a teller at
one of the local banks. Patient reports that she takes two glasses of wine after work,
reports a 6-year history of tobacco smoking but states that she quit. Denies use of illicit
drugs
ROS
General
Complains of mild fatigue and weakness.
Denies fever chills, night sweats and any
recent unexplained weight loss or gain
Cardiovascular
Patient reports dyspnea especially when
trying to sleep, which is relieved with
elevation of the head with two pillows.
Patient also reports swelling in lower limbs
and a history of HTN. Denies chest pain,
palpitations, and PND
Skin
Denies delayed healing, rashes, skin
discolorations or changes in moles or
lesions
Respiratory
Reports exertional dyspnea and wheezing
by denies cough, sputum production and
hemoptysis
Eyes
Patient is short sighted, uses corrective
lenses. Denies blurring
Gastrointestinal
Patient reports nausea and bloating but
denies abdominal pain or distension,
vomiting, diarrhea, and constipation.
Nose/Mouth/Throat
Denies sinus problems, dysphagia or sore
throat
Genitourinary
Denies frequent urination at night,
frequency burning, or changes in color of
urine.
Heme/Lymph/Endo
Denies bruising, blood transfusion,
swollen glands, increase thirst, and
increased hunger
Musculoskeletal
Patient reports a history of degenerative
joint disease and muscle weakness.
Psychiatric
Reports sleeping problems due to shortness
of breath. Denies depression, anxiety, or a
history of mental disorders
Neurological
Denies syncope, seizures, paresthesias.
Patient complains of weakness
OBJECTIVE
Weight 190lbs BMI 33.7 Temp 36.3 BP 110/50
Height 5’3” Pulse 78 Resp 24
General Appearance
Well-developed and well-nourished, dyspneic with moderate activity but in no distress
following a few minutes of rest. AAOX3, good speech and eye contact. Responds to
questions appropriately.
Skin
Skin is warm, dry and intact. No skin discolorations, lesions or rashes
HEENT
Head: Normocephalic, atraumatic. Eyes: PERRLA. Conjunctiva and EOM normal. No
scleral injection. Mouth: oral mucosa pink and moist. Pharynx is nonerythematous and
without exudate. Neck: supple, No JVD and masses.
Cardiovascular
Prominent S3 and S4 gallops. No clicks, rubs or murmurs. Bipedal oedema
Respiratory
Chest wall symmetric. Respirations are tachypneic. No use of accessory muscles. Became
more short of breath and tachypneic when in supine position. Audible expiratory wheeze
with prolonged expiratory phase. Vesicular breath sounds with reduced breath sounds at
bases, right greater than left with inspiratory rales bilaterally. No consolidation signs
Gastrointestinal
Normoactive bowel sounds in all quadrants. Moderately obese, soft, nontender abdomen.
No hepatosplenomegaly.
Musculoskeletal
Full ROM in all 4 quadrants
Neurological
Speech is clear with good tone. Posture erect with stable balance and normal gait
Psychiatric
Patient is awake and oriented X3
Lab Tests
Lab: Na 132, K 3.8, HCO3 21. BUN 17. Cr 1.1. Glucose 120 mg/dL. WBC 4.8,
hemoglobin and hematocrit 11.1 and 32.6
Special Tests
Transthoracic echocardiogram- LVEF normal but LVH and abnormal diastolic filling
patterns
EKG- reveals atrial fibrillation at the rate of 75 beats/min, normal intraventricular
conduction. QRS duration of 350 ms
Chest X-ray- reveals cardiomegaly and pleural fluid reveals pulmonary edema
Diagnosis
Differential Diagnoses
o 1-Acute on Chronic diastolic (congestive) heart failure. This is a complex condition
that results from structural and functional cardiac disorders that impair the
capability of the ventricle to eject or fill blood (Yusuf, 2019). The key signs and
symptoms of the condition include dyspnea, and fatigue, which often limit the
patients exercise tolerance and fluid retention, which is associated with pulmonary
congestion along with peripheral edema (Yusuf, 2019). Dyspnea on exertion is most
common associated with left-sided heart failure. Physical examination often reveals
tachycardia, jugular venous pressure, S4 and S3 gallop and peripheral edema
(Yusuf, 2019).
o 2-Chronic Pericarditis. This defines the inflammation of the pericardium which
starts gradually and results into accumulation of the fluid in the pericardial space.
According to Yusuf (2019), the condition is characterized by coughing, shortness of
breath and fatigue. It can also be caused by TB, heart surgery and frequent radiation
therapy to the chest. Other less causes for the condition include viral infections,
bacterial infection and mesothelioma (form of cancer caused when exposed to
asbestos).
o 2- Cardiac tamponade. A clinical syndrome caused by the accumulation of fluid in
the pericardial space. This cause a reduction in ventricular filling which is followed
by hemodynamic compromise. The condition also results into shock, pulmonary
edema and eventually death of the patient. The patient with this condition
experiences reduced arterial blood pressure, muffled heart sound and distended
neck veins (Yusuf, 2019).
Diagnosis
o Acute on Chronic diastolic (congestive) heart failure (ICD code I50.33)
Plan/Therapeutics
Further testing
None
Medication
Initiate captopril 6.25 mg orally three times daily- Captopril is an ACE inhibitor, which
are the first line treatment for patients with mild to moderate heart failure symptoms and
left ventricular dysfunction (Yusuf, 2019). ACE inhibitors reduce heart failure symptoms
including dyspnea, peripheral edema and fatigue and reduce the risk of heart attack.
Captopril was started at a lower dose given that Ponikowski et al. (2018) recommends
that patients not taking ACE inhibitor to be started at a lower dose.
Continue Lopressor 25mg orally BID- Lopressor is a beta1-adrenergic blocker at lower
doses. Ponikowski et al. (2018) state that selective beta1-adrenergic blockers such as
Lopressor are used in heart failure to reduce heart rate along with blood pressure. The
medication has been shown to reduce mortality and morbidity in patients with heart
failure. A meta-analysis by Bavishi, Chatterjee, Ather, Patel, and Messerli (2015) found
that irrespective of pretreatment heart rate, beta-blockers decreased mortality in patients
with heart failure with reduced ejection fraction in sinus rhythm
Continue Hydrochlorothiazide 50 mg PO once daily- Hydrochlorothiazide is a diuretic
which are used as an adjunct treatment in patients with fluid retention and should be
combined with an ACE inhibitor and a beta-blocker. Yancy et al. (2017) state that all
symptomatic patients with signs of congestion should receive a diuretic, irrespective of
LVEF. Diuretics produce various symptomatic benefits than other heart failure drugs.
These drugs have been shown to relieve pulmonary and peripheral edema (Rickers, et al.,
2017).
Education
Educating the patient on heart failure including the conditions disease process, signs and
symptoms, causes and possible complications. Patient was also instructed to restrict
sodium intake to at least 3 g/day (Ponikowski et al., 2018). Patient was advised to keep a
daily fluid intake/output at home and to restrict fluid intake when necessary. She was also
advised to monitor her weight daily and to increase her engagement in exercise, which is
critical in the control of blood pressure (Ponikowski et al., 2018). Additionally, she was
informed on the importance of blood pressure control and diabetes management on the
prevention of exacerbations of heart failure. Lastly, patient was educated on the
importance of continuous and close monitoring of her health and was referred to a
specialized heart failure clinic-based care (Ponikowski et al., 2018).
Non-medication treatments
Sodium restriction and fluid restriction-reducing sodium intake and fluid restriction when
necessary reduces water retention, which is associated with peripheral edema
(Ponikowski et al., 2018).
Cardiac rehabilitation and exercise training- this improves exercise tolerance, and quality
of life with reduced morbidity and mortality in patients with heart failure (Ponikowski et
al., 2018).
Evaluation of patient encounter- The patient encounter was well, and the patient was
cooperative throughout the session. The education given to the patient was well received
as she was attentive to all the guidelines and other procedures. She admitted complying
with all the guidelines. The encounter provided me with increased insight on the
evaluation and treatment of patients presenting with signs and symptoms of acute on
chronic diastolic (congestive) heart failure.
Reference:
Bavishi, C., Chatterjee, S., Ather, S., Patel, D., & Messerli, F. H. (2015). Beta-blockers in heart
failure with preserved ejection fraction: a meta-analysis. Heart failure reviews, 20(2),
193-201.
Ponikowski, P., Voors, A. A., Anker, S. D., Bueno, H., Cleland, J. G., Coats, A. J., … & Jessup,
M. (2016). 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic
heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart
failure of the European Society of Cardiology (ESC). Developed with the special
contribution of the Heart Failure Association (HFA) of the ESC. European journal of
heart failure, 18(8), 891-975.
Rickers, C., Läer, S., Diller, G. P., Janousek, J., Hoppe, U., Mir, T. S., & Weil, J. (2017).
Chronic Heart Failure. Cardiology in the Young, 27.
Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Colvin, M. M., … & Hollenberg,
S. M. (2017). 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline
for the management of heart failure: a report of the American College of
Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and
the Heart Failure Society of America. Journal of the American College of
Cardiology, 70(6), 776-803.
Yusuf, S. (2019). Chronic congestive heart failure – Symptoms, diagnosis and treatment | BMJ
Best Practice. Retrieved 22 August 2019, from http://newbp.bmj.com/topics/en-us/61
http://newbp.bmj.com/topics/en-us/61
SOAP NOTE
Name: S.S Date: 10/10/2019 Time: 12:30 p.m
Age: 70 Sex: Female
SUBJECTIVE
CC:
“My skin is turning pale and my feet and hands feel cold”
HPI:
S.S comes to the clinic with complaints of her skin turning pale and feeling cold in the
feet as well as the hands. The patient explains that she started having these symptoms
three weeks ago. She mentions that the cold feeling in her feet and hands is accompanied
by headache, chest pain, and dizziness, which go away after taking ibuprofen. She also
mentions that she cannot walk for long distances because she feels short of breath and
weak besides feeling exceedingly tired. She often rests to catch a breath. She also notes
that even though she is vegetarian, she has been having an urge to consume dirt. The
patient claims that she had been skipping meals recently since she was diagnosed with
positive H. Pylori. She denies blood in stool, states that the last colonoscopy was in 2005
with normal results.
Medications: Ibuprofen PRN for headache and chest pain
Levothyroxine 0.50 mcg/daily for hypothyroidism
PMH: Hypothyroidism diagnosed in 2013
Allergies: NKD
Medication Intolerances: None
Hospitalizations/Surgeries:
She mentions that in 2009, she underwent a breast biopsy for suspected breast cancer, but
the results were negative. Colonoscopy 2005 negative results.
Family History
Father died 20 years ago from coronary artery disease. Mother died 15 years ago from
diabetes. Brother was diagnosed with colon cancer 2 years ago. Other siblings are
healthy.
Social History
Patient holds a Bachelor’s degree in commerce. Patient worked as a bank manager before
retiring. Patient is married and lives with her husband (74 years of age) and two
grandchildren (19 years and 15 years of age). Patient does not consume alcohol, smoke or
abuse drugs. Patient mentions putting on her seatbelt on always.
ROS
General
Patient reports feeling extremely fatigued,
dizzy, and feeling weak. Denies, night
sweats, fever, chills, weight change
Cardiovascular
Patient reports dyspnea and chest pain.
Denies edema
Skin
Patient reports pale skin. Denies bruising,
Respiratory
Patient reports dyspnea and wheezing. Denies
rashes, or lesions cough, hemoptysis, hx of pneumonia or TB
Eyes
Patient wears corrective lenses, reports
blurring vision
Gastrointestinal
Denies abdominal pain, diarrhea, vomiting,
nausea, or changes in stool color or bowel
movement
Ears
Denies discharge, hearing loss, ear pain,
ringing in ears
Genitourinary/Gynecological
Denies burning, changes in color of urine,
urgency, or frequency or vaginal discharge
Nose/Mouth/Throat
Denies nose bleeds or discharge, dental
disease, sinus problems, dysphagia, throat
pain, hoarseness,
Musculoskeletal
Denies joint swelling, back pain, fracture hx,
pain or stiffness, osteoporosis
Breast
Denies SBE, bumps, tumors, or changes
Neurological
Reports feeling weak. Denies paresthesias,
syncope, black out spells, transient paralysis,
seizures
Heme/Lymph/Endo
Denies hx of blood transfusion, bruising,
swollen glands, cold or heat intolerance,
night sweats, increase hunger or thirst
Psychiatric
Patient reports being anxious. Denies sleeping
difficulties, depression, suicidal
attempts/ideation
OBJECTIVE
Weight 130 lbs BMI 21.0 Temp 98.0 BP 123/62
Height 5’6 Pulse 105 Resp 17
General Appearance
Well-nourished and well-developed, normal asthenic. Excellent attention to grooming
Skin
Skin is pale. Clear to lesion, rashes or ulcers
HEENT
Head is normocephalic/atraumatic without lesions; hair consistently dispersed. Eyes:
PERRLA. Scleral injection or Conjunctival absent. EOMs intact. Ears: Bilateral TMs
pearly grey with positive light reflex; landmarks easily visualized. Canals patent. Nose:
Normal turbinates; nasal mucosa pink. Septal deviation absent. Neck: Supple. Full ROM;
cervical lymphadenopathy and occipital nodes absent. Nodules or thyromegaly absent.
Oral mucosa moist and pink. Non erythematous pharynx without exudate. Teeth are in
excellent repair.
Cardiovascular
Regular RR. Gallops and rubs absent. JVD absent. 2+ peripheral pulses in both dorsalis
and both radialis bilaterally
Respiratory
Lungs clear to auscultation and percussion bilaterally. Wheezes, rhonchi and crackles
absent
Gastrointestinal
Abdomen soft, non-tender, non-distended; BS active X4 quadrants. No
hepatosplenomegaly
Breast
N/A
Genitourinary
N/A
Musculoskeletal
Unstable gait. Cyanosis, clubbing, pitting edema absent. Full motion range. Joint
deformities absent
Neurological
Cranial nerves II-XII within normal limits. Deep tendon reflexes 2+ in both biceps and
both knees.
Psychiatric
Excellent insight and judgment. Oriented X4. Excellent recent and remote memory.
Appropriate affect and mood.
Lab Tests
Hemoglobin 9.8 g/dL (Low)
Hematocrit 30.0 % (Low)
Mean Corpuscular Volume (MCV): 65 fL (decreased)
RDW 16.0% (increased)
Platelet, Neutrophils, Mono, Eosinophils, basophils: WNL
Serum ferritin levels: pending
Serum iron- pending
Reticulocyte count-pending
Total iron binding capacity- pending
Special Tests
None
Diagnosis
Further test: Serum ferritin levels
Serum iron
Total iron binding capacity
Differential Diagnoses
o 1-Iron Deficiency Anemia D50.9:
o 2- Cold Autoimmune Hemolytic Anemia (AIHA) D59.1
o 3- Thalassemia D56.1
Diagnosis
o Iron Deficiency Anemia (IDA) D50.9
Plan/Therapeutics
Medication
Ferrous sulfate 325 mg 1 tablet orally TID for 3 months
Vitamin C (500 units) q.d for 3 months
Education
Patient was educated on the significance of amplifying daily intake
of iron-rich foods
Patient was educated to increase vitamin C intake
Patient was advised to avoid drinking black tea.
Increase dietary fiber to prevent constipation, which is a side effects
of ferrous sulfate
Follow-up
Patient scheduled for a follow-up appointment in 4 weeks, to repeat
blood work after therapy. Patient was advised to contact the clinic if
symptoms exacerbate or do not improve
Referral
GI for colonoscopy
Discussion of Assessment and Plan
S.S is a 70 y/o Caucasian female with complaints of pale skin and cold in the feet
and hands. Based on the patient’s symptoms, physical exam, and diagnostic findings, the
primary diagnosis is iron deficiency anemia (IDA) D50.9. IDA is the most prevalent type
anemia, where there is an inadequate number of healthy blood cells (Camaschella, 2015).
As the name suggests, the condition occurs because of insufficient iron. Without
sufficient iron, the body is not able to produce adequate hemoglobin (Camaschella, 2015).
The disease is characterized by symptoms including fatigue, shortness of breath, cold feet
and hands, chest pain, fast heartbeat, and strange cravings for non-nutritive substances,
including starch, dirt, or ice (Alzaheb & Al-Amer, 2017). Risk factors include being
female and being vegetarian (Alzaheb & Al-Amer, 2017). The condition was confirmed
by a low level of hemoglobin and a low RBC volume as established by the CBC test.
According to Hennek et al. (2016), patients with IDA exhibit low levels of hemoglobin
than average (12.0-15.5 g/dL in females) and a volume of RBC lower than average (80-
96 fL/red cell in adults).
Other conditions that may present with similar symptoms include Cold
Autoimmune Hemolytic Anemia (AIHA) D59.1 and Thalassemia D56.1. Cold AIHA was
ruled out due to the absence of critical symptoms such as pain in the back of the legs,
diarrhea, and pain and blue coloring in the feet and hands, which are common in
individuals with the condition (Barcellini, 2015). Additionally, the patient does not
present with key risk factors associated with cold AIHA. Such include infections, certain
cancers, collagen-vascular diseases such as systemic lupus erythematosus, and family
history of the hemolytic disease (Barcellini, 2015). Nevertheless, confirmation of the
absence of cold AIHA will be possible once the Coombs test results are established,
which should be negative for antibodies, which may affect RBCs (Khan et al., 2017).
Thalassemia was ruled out because the patient does not present with crucial features
associated with the condition, including dark urine, facial bone deformities, abdominal
swelling, and yellowish skin (Origa, 2017). Furthermore, the condition is common in
individuals of Italian, Greek, Asian, African, or Middle Eastern descent (Origa, 2017).
The patient is Caucasian.
The patient’s treatment included iron supplements, and vitamin C. Evidence has
demonstrated that a dosage of 120 mg of elemental iron once daily can replenish iron in
the body in three months (Okam, Koch, & Tran, 2016). Moreover, vitamin C is excellent
in promoting the absorption of iron when taken with iron pills once each day (Fei, 2015).
Patient education included increasing iron and vitamin C intake and avoiding the
consumption of black tea. Notably, the patient is vegetarian, which puts her at risk of iron
deficiency. Increasing the intake of foods rich in iron such as beans, cashews, fortified
breakfast cereals, baked potatoes, and whole-grain and enriched breads can assist in
raising her iron levels (Schrier et al., 2016). Moreover, the patient was also educated on
the significance of increasing her vitamin C intake. Citrus fruits, papaya, strawberries,
and cantaloupe are rich sources of vitamin C, which can promote the absorption of iron in
the body (Fei, 2015). However, the patient was also educated to avoid the consumption of
black tea as it lessens the absorption of iron (Ahmad Fuzi et al., 2017). Follow-up was
scheduled in four weeks, and the patient was advised to contact the clinic if symptoms
exacerbate or fail to improve with therapy.
EVALUATION OF THE ENCOUNTER: The encounter with the patient went
exceedingly well. Specifically, assessment, diagnosis, as well as treatment went as
needed. The patient cooperated all through and was ready to adhere to the treatment plan.
We had a serious discussion concerning increasing iron and vitamin C intake and she was
given a list of food products, which are rich in the nutrients. I believe that all the required
history together with assessment data was gathered and nothing was left out.
Reference:
Ahmad Fuzi, S. F., Koller, D., Bruggraber, S., Pereira, D. I., Dainty, J. R., & Mushtaq, S. (2017).
A 1-h time interval between a meal containing iron and consumption of tea attenuates the
inhibitory effects on iron absorption: a controlled trial in a cohort of healthy UK women
using a stable iron isotope. The American journal of clinical nutrition, 106(6), 1413-
1421.
Alzaheb, R. A., & Al-Amer, O. (2017). The prevalence of iron deficiency anemia and its
associated risk factors among a sample of female university students in Tabuk, Saudi
Arabia. Clinical Medicine Insights: Women’s Health, 10, 1179562X17745088.
Barcellini, W. (2015). New insights in the pathogenesis of autoimmune hemolytic
anemia. Transfusion medicine and hemotherapy, 42(5), 287-293.
Camaschella, C. (2015). Iron-deficiency anemia. New England journal of medicine, 372(19),
1832-1843.
Fei, C. (2015). Iron Deficiency Anemia: A Guide to Oral Iron Supplements. Clinical Corelation
The nyu langone online journal of medicine https://www clinicalcorrelations org.
Hennek, J. W., Kumar, A. A., Wiltschko, A. B., Patton, M. R., Lee, S. Y. R., Brugnara, C., … &
Whitesides, G. M. (2016). Diagnosis of iron deficiency anemia using density-based
fractionation of red blood cells. Lab on a Chip, 16(20), 3929-3939.
Khan, U., Ali, F., Khurram, M. S., Zaka, A., & Hadid, T. (2017). Immunotherapy-associated
autoimmune hemolytic anemia. Journal for immunotherapy of cancer, 5(1), 15.
Liebman, H. A., & Weitz, I. C. (2017). Autoimmune hemolytic anemia. The Medical clinics of
North America, 101(2), 351-359.
Okam, M. M., Koch, T. A., & Tran, M. H. (2016). Iron deficiency anemia treatment response to
oral iron therapy: a pooled analysis of five randomized controlled
trials. Haematologica, 101(1), e6.
Origa, R. (2017). β-Thalassemia. Genetics in Medicine, 19(6), 609.
Schrier, S. L., Auerbach, M., Mentzer, W. C., & Tirnauer, J. S. (2016). Treatment of iron
deficiency anemia in adults. UpToDate. Waltham (MA): Wolters Kluwer.
(Student Name)
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor: Patricio Bidart MSN, APRN, FNP–C
Soap Note # ____
Main Diagnosis ______________
PATIENT INFORMATION
Name: O.R
Age: 52
Gender at Birth: Male
Gender Identity: Male
Source:
Allergies: Penicillin
Current Medications:
·
PMH: Hypercholesterolemia,
Immunizations: Updated according to the patient age.
Preventive Care:
Surgical History: None
Family History: Father- alive, 81 years old with coronary artery bypass 5 years ago, HTN
Mother- alive, 78 years old with Diabetes Mellitus, HNT
Social History: Alcoholic beverage social celebrations, ,He is currently a truck driving
Sexual Orientation: Straight
Nutrition History:
Subjective Data:
Chief Complaint: I have severe headache early morning
Symptom analysis/HPI: The patient is a 52-year-old man who complains of symptoms of hypertension, such as severe headache early morning. This patient complained of a worsening of his symptoms one week ago.. He said he recently gained weight because he is truck driving and he is no have time for practice exercise… Blood pressure was measured and increased on 3 different occasions (155/93 mmHg, 145/92 mmHg, 140/90 mmHg, respectively). This confirms that the patient has his own clinical crisis, which in this case is hypertension.
The patient is …
Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )
CONSTITUTIONAL: Denies loss of consciousness. Denies seizure, tremors. Denies change in vision /blurred vision. Pt states recently gained weight.
NEUROLOGIC: Patient states severe headache early morning. He denies seizures, tremors, loss of consciousness and change in vision /blurred vision.
HEENT: HEAD: Denies any head injury or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. No scleral icterus Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Negative for nosebleed nasal. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing. Moist mucous membranes. No cervical lymphadenopathy. EARS: Patient denies pain, tinnitus, vertigo, discharge
RESPIRATORY: Patient states shortness of breath. Patient denies cough or hemoptysis. Lungs clear to auscultation bilaterally, no accessory muscle use. Patient denies cough, sputum, hemoptysis, night sweats.
CARDIOVASCULAR: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea. Regular rate and rhythm. No murmur. No JVD, he denies edema, previous myocardial infarction, claudication, thromboses, thrombophlebitis
GASTROINTESTINAL: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or diarrhea. Abdomen soft, non-tender and non-distended. No palpable masses. Denies constipation, intolerance for any class of food, dysphagia, heartburn, hematemesis, denies any change in stool color or contents, hemorrhoids or history of ulcer.
GENITOURINARY: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence. Denies flank or suprapubic pain, denies incontinence, denies STIs.
MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound. Denies myalgia. Patient states right knee pain. Patient denies muscle weakness. Denies joints stiffness, restriction of motion, swelling, redness, heat or bony deformity
SKIN: No change of coloration such as cyanosis or jaundice, no rashes or pruritus. Denies excessive sweating or abnormal nail or hair growth.
PSYCHIATRIC: Denies depression, difficulty concentration, nervousness. Patient denies sleep disturbance. Denies suicidal thoughts, irritability.
Objective Data:
VITAL SIGNS: Temperature: 98.5 °F, Pulse: 96/min, BP: 145/92 mmHg, RR 32/min, PO2-98% on room air, Ht- 5’11”, Wt 205 lb, BMI: 28.6.
Report pain: headaches 4/10.
GENERAL APPREARANCE: The patient is alert and oriented x 3. No acute distress noted.
NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5. Deep tendon reflex response +2.
HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without lesions, Lids non-remarkable and appropriate for race.
Neck: supple without cervical lymphadenopathy, no jugular vein distention, no thyroid swelling or masses.
CARDIOVASCULAR: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary refill < 2 sec.
RESPIRATORY: Tachypnea, however, there is not contraction of accessory muscles observed or retraction of supraclavicular fossa. There is not pursed-lib breathing or a prolonged expiratory phase. There is mild retraction of intercostal muscle bilaterally. No egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on auscultation.
GASTROINTESTINAL: No mass or hernia observed. Upon auscultation, bowel sounds present in all four quadrants, no bruits over renal and aorta arteries. Abdomen soft non-tender, no guarding, no rebound no distention or organomegaly noted on palpation
MUSKULOSKELETAL: There is pain to palpation right knee. Active and passive ROM within normal limits, no stiffness. There is not effusion. There are not infection signs. Upper extremities within normal limits.
INTEGUMENTARY: intact, no lesions or rashes, no cyanosis or jaundice.
ASSESSMENT:
(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data)
Example : “Pt came in to our clinic c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and that etc.)
Main Diagnosis
(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 6th or 7th Edition.
Differential diagnosis (minimum 3)
–
–
–
PLAN:
Labs and Diagnostic Test to be ordered (if applicable)
Labs and Diagnostic Test to be ordered:
· Stress test
· Complete blood count (CBC)
· Fasting Lipid profile
· Thyroid-stimulating hormone (TSH)
· Ambulatory Blood Pressure Monitor
· Electrocardiogram (EKG 12 lead)
· Echocardiogram
· Urinalysis (Albumin Excretion)
· Chest-X-Ray
ASSESSMENT:
Main Diagnosis
· ICD10-I10). Hypertension is the term used to describe high blood pressure. Hypertension is an important public health problem and one of the leading risk factors for morbidity and mortality from cardiovascular diseases and is the most common cause of primary care visits. Hypertension among the adult population is increasing, and its complications account for 9.4 million annual deaths around the word. (Saka, M., 2020)
Hypertension however, there are different factors associated to hypertension such as increasing age, male sex, being married, low educational level, unemployment, poor economic situation, sedentary lifestyle, lack of regular physical exercise, and increasing body mass index. Secondary hypertension is caused by another pathology such as kidney problem (arteries narrowing), adrenal disease (Pheochromocytoma, primary aldosteronism or Conn’s disease, Cushing syndrome), thyroid problem (hyperthyroidism), Hyperparathyroidism and sleep apnea. (James P.A., 2015
Differential diagnosis:
· Sleep Apnea (ICD10 G47.30). Sleep apnea and Hypertension are two conditions well known associated. The association was found to be more evident in young to middle-aged men (<50 years old). Apnea is defined as the absence of inspiratory airflow for at least 10 seconds. Normal sleep is important to decrease stress and protect central nervous system and cardiovascular system. Sleep-disordered breathing or sleep apnea is a disease frequently associated with arterial hypertension. Sleep apnea has consequences that include abnormal arterial blood oxygen level decreasing parasympathetic system and increased sympathetic activity, all of which are harmful for cardiovascular system. There is also a potential role of mineralocorticoid hormones (aldosterone) produced by cortex of the adrenal gland. Its function is regulation of water and electrolytes balance in the body. Hyperaldosteronism is significantly associated with sleep apnea and Hypertension. Treatment of sleep apnea with oral appliance devices and with aldosterone antagonists decrease sympathetic activity and improve blood pressure. (Zhao, E. C., 2018) (Lombardi, G., 2018)
· E05. 80 Hyperthyroidism: Hypothyroidism and hypertension have similarity symptoms to rapid heart rate, elevated blood pressure, and
hand tremors
. You may also sweat a lot and develop a low tolerance for heat. Hyperthyroidism can cause more frequent bowel movements,
weight loss
, and, in women,
irregular menstrual cycles
. (Lights, 2019)
· I21.9 Heart Attack Chest discomfort. Most heart attacks involve discomfort in the center of the chest that lasts more than a few minutes – or it may go away and then return. It can feel like uncomfortable pressure, squeezing, fullness or pain. Discomfort in other areas of the upper body. Symptoms can include pain or discomfort in one or both arms, the back, neck, jaw or stomach. Shortness of breath. This can occur with or without chest discomfort. Other signs. Other possible signs include breaking out in a cold sweat, nausea or lightheadedness. (heart.org, n.d.)
Pharmacological treatment:
· Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg PO bid.
· Lisinopril 20mg PO qd
· Ecotrin 325mg: 1 Tab PO qd
Non-Pharmacologic treatment:
· Weight loss. BMI no more then 24.9
· Healthy diet: Implement “DASH dietary pattern”. Diet rich in fruits, vegetables, whole grains, low-fat dairy products, poultry, fish, legumes, non-tropical vegetable oils, and nuts; and limiting intake of sweets, sugar-sweetened beverages, and red meat.
· Reduced intake of dietary sodium: Limiting intake no more than 2600mg/d however <1,500 mg/d is optimal goal.
· Alcohol intake should be no more than two drinks/day for men and one drink/day for women.
· Enhanced intake of dietary potassium
· Regular moderate aerobic physical activity 3 to 4 times/week: 90–150 min/wk or 40 minutes/session.
· Measures to release stress and effective coping mechanisms.
· Patients with hypertension and obstructive sleep apnea should use continuous positive airway pressure to lower blood pressure.
Education
· Provide with nutrition/dietary information.
· Provide tobacco cessation interventions for those who use tobacco products.
· Daily self-measure blood pressure monitoring log at home twice a day for 7 days, keep a record, bring the record on the next visit with her PCP. The patient should performe this activity daily with or without additional support such as education, counseling, telemedicine, home visits, Web-based logging.
· Instruction about medication intake compliance.
· Education of possible complications such as stroke, heart attack, and other problems.
· Patient was educated on course of hypertension, as well as warning signs and symptoms, which could indicate the need to attend the E.R/U.C. Answered all pt. questions/concerns. Pt verbalizes understanding to all
· Guide the patient and family on health status (diagnosis, procedures).
· Provide family interaction according to the patient’s condition.
· Assist in using relaxation techniques and defense mechanisms.
· Offer emotional support for management of difficulty sleeping
· monitor your health condition.
· Establish and maintain adequate nurse-patient relationship to provide productive communication.
· Use of therapeutic communication techniques aimed at the patient expressing their worries and concerns.
· Offer medication and support therapy for the remission of symptoms and signs
Follow-ups/Referrals
· Follow up appointment 1 weeks for managing blood pressure and to evaluate current hypotensive therapy.
· No referrals needed at this time.
References
Codina Leik, M. T. (2018). Family Nurse Practitioner Certification Intensive Review. New York: Springer Publishing Company. ISBN 978-0-8261-3424-0
James, PA., Oparil, S., Carter, BL., et al. (2015). Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8) [published correction appears in JAMA.311(5):507–520.
Lombardi, C., Pengo, M. F., & Parati, G.(2018). Systemic hypertension in obstructive sleep apnea. Journal of Thoracic Disease, S4231-S4243.
Saka, M., Shabu, S., & Shabila, N. (2020). Prevalence of hypertension and associated risk factors in older adults. Eastern Mediterranean Health Journal, 26(3),268-275.
Valentina, L., Neal, S. (2019). Pathophysiology. The biologic basis for disease in adult and children. St.louis-Missouri: Elsevier.
Zhao, E. C. (2018). Association between Sleep Apnea Hypopnea Syndrome and the Risk of Atrial Fibrillation: A Meta-Analysis of Cohort Study. BioMed Research International.
heart.org. (n.d.). Warning Signs of a Heart Attack. Retrieved from heart.org: https://www.heart.org/en/health-topics/heart-attack/warning-signs-of-a-heart-attack
Lights, V. (2019, March 22). Hyperthyroidism. Retrieved from healthline: https://www.healthline.com/health/hyperthyroidism
Lombardi, C. (2018). Systemic hypertension in obstructive sleep apnea. Journal of Thoracic Disease, S4231-S4243.
SOAP NOTE
Name: G.P Date: 08/30/2019 Time: 1500
Age: 65 Sex: M
SUBJECTIVE
CC:
“Increased leg pain with walking and other exercises”
HPI: G.P, a 65 y/o Caucasian male presents to the clinic with complaints of increasing
leg pain with walking and other exercises. Patient reports that the pain started 2 years ago
and over the past few weeks it has become more severe. He states that the pain in his
calves starts/gets worse after walking around 200 yards and is relieved with rest. The pain
resolves within 10 minutes of rest. As a consequence, patient reports that he has become
less physically active. Patient denies rest pain. He states that the pain is worse on his right
calf compared to his left calf. Patient reports that he was diagnosed with type 2 diabetes
mellitus ten years ago which he manages using daily Metformin. He also has stable
angina, for which he takes atenolol in addition to occasional nitroglycerin. Patient denies
numbness, burning sensation, or reduced feeling in lower extremities, leg ulcers,
blackening over toes, thickening of toenails, swelling, discoloration along superficial
veins, and skin discoloration.
Medications:
Metformin 500 mg bid for type 2 diabetes mellitus
Atenolol 100 mg PO daily for Angina pectoris
Nitroglycerin 2.5 mg PO q6-8hr for Angina pectoris
PMH
Allergies: No known drug or food allergies
Medication Intolerances: None
Chronic Illnesses/Major traumas: Type 2 diabetes mellitus (diagnosed ten years ago),
Stable angina diagnosed 3 years ago, atherosclerosis (diagnosed 5 years ago)
Hospitalizations/Surgeries: Patient was hospitalized for 3 days because of chest pain 3
years ago. No history of surgeries
Family History
Father had peripheral vascular disease, type 2 diabetes mellitus, HTN, died from a stroke
at the age of 82. Mother had HTN and colon cancer, died at the age of 85. Brother had
PAD.
Social History
Patient is married and has two sons. Lives with wife and youngest son. He is a retired
mechanical engineer, currently operates car workshop/garage. Reports drinking alcohol
(1-2 beers per week). Reports smoking history (7 cigarettes per day for the past 40 years).
Reports that he tried to quit smoking after developing angina but “After nearly 30 years
of smoking, I think it’s not possible”. Denies illicit drug use
ROS
General
Denies recent weight change/loss, fever,
chills or weakness
Cardiovascular
Denies chest pain, dyspnea on exertion,
orthopnea, PND, or edema
Skin
Denies delayed healing, rashes, pallor,
Shiny/scaly skin or any skin discolorations
Respiratory
Denies dyspnea or cough
Eyes
Reports that he is short-sighted and uses
corrective lenses. Denies blurring, or
visual changes
Gastrointestinal
Denies abdominal pain, NV/D, constipation,
hepatitis, or black tarry stools
Ears
N/A
Genitourinary/Gynecological
Denies urgency, frequency burning, or
changes in urine color
Denies erectile dysfunction
Nose/Mouth/Throat
Sinus problems, dysphagia, nose bleeds or
discharge, dental disease, hoarseness,
throat pain
Musculoskeletal
Reports calf cramping with walking that is
relieved by rest. Denies back pain, joint
swelling, pain or stiffness.
Breast Neurological
N/A
Denies paralysis, paresthesia, numbness,
weakness, blackout spells, or loss of
consciousness.
Heme/Lymph/Endo
Denies bruising, swollen glands, increased
thirst and hunger, or cold or heat
intolerance
Psychiatric
Denies depression, sleeping problems, and
anxiety
OBJECTIVE
Weight: 216 lb BMI: 32.7 Temp: 97.6°F BP: 13878
Height: 68 inches Pulse: 66 Resp: 18
General Appearance
Obese adult male in no acute distress. Alert and oriented to time, place and person.
Skin
Skin warm and dry. No jaundice, or cyanosis. Negative for lesions or rashes. Skin in
lower extremities below knees cool and pale.
HEENT
N/A
Cardiovascular
S1, S2 with RRR. No murmurs, extra sounds, rubs or clicks. Radial and branchial pulse
2+ bilaterally. Posterior tibial pulses weak bilaterally (1+), weak pedal pulse (1+) on right
foot, unable to palpate on left foot; 1+ to 2+ edema both feet and ankles. Delayed
capillary refill in lower extremities nailbeds. No carotid bruit.
Respiratory
Chest wall symmetric. Respirations regular and non-labored. Lungs CTAB
Gastrointestinal
Abdomen soft, flat and non-tender. Normoactive BS in all 4 quadrants. No
hepatosplenomegaly. On percussion, no free fluid present. No dilated veins, scar or striae
Breast
N/A
Genitourinary
N/A
Musculoskeletal
Full ROM in lower extremities. Back and spine normal. Muscle wasting evident in calf
muscles of right lower limb compared to left.
Neurological
Posture erect, balance stable, gait normal. Speech is clear with a good tone
Psychiatric
Alert and oriented X3. Maintains eye contact.
Lab Tests
Complete blood count- WNL
HbA1c – 6.9 %
Total cholesterol – 205 mg/dL (Elevated)
LDL- 162 mg/dL (Elevated)
HDL- 50 mg/d
Triglycerides- 149 mg/dL
Special Tests
Ankle-brachial index (ABI): Right leg ABI – 0.83 (< 0.9), Left leg ABI – 0.81 (<0.9).
Diagnosis
Differential Diagnoses
o 1- Peripheral neuropathy. I rule out this diagnosis because patient denies
numbness, burning sensation in lower extremities. During physical examination
there are not ulcers or infections in feet (Hollier, 2018).
o 2- Deep Venous Thrombosis (DVT). Deep venous thrombosis describes the
manifestation of the venous thromboembolism (Armstrong, 2018). The primary
signs and symptoms of the DVT include leg pain, edema, tenderness, skin erythema,
and clinical symptoms of PE as the initial manifestation (Armstrong, 2018). The leg
pain is usually worse in the thigh and groin region, and it is worsened by walking,
relieved by resting or leg elevation.
o 3- Spinal Stenosis-Lumbar spondylosis refers to degenerative conditions that affect
the lumber spine (Armstrong, 2018). The condition is prevalent among individuals
aged 50 years or older and it is characterized by pain in the back, leg, thighs or
buttock that worsens with standing and relieved by position change such as sitting
or stooping forward (Armstrong, 2018). The pain can also occur in the leg with
exercise. Other symptoms include abnormality walking, muscle weakness and
cramping in addition to leg numbness, or reduced sensation on touch (Armstrong,
2018). Risk factors of the condition include age (50 years or older), previous injury
or surgery of the spine, osteoarthritis, Inflammatory spondylarthritis, Paget’s disease
and spinal tumors (Armstrong, 2018)
Diagnosis
Peripheral Artery Disease (ICD-10 code I73.9). This patient has risk factor such as Type
2 DM, atherosclerosis, smoking history, advancing age, obesity, and family history of
peripheral vascular disease. Patient reports calf cramping with walking that is relieved by
rest. During examination, skin in lower extremities is pale and cool. Posterior tibial
pulses weak bilaterally (1+), weak pedal pulse (1+) on right foot, unable to palpate on left
foot; 1+ to 2+ edema both feet and ankles. Delayed capillary refill in lower extremities
nailbeds. Muscle wasting evident in calf muscles of right lower limb compared to left.
Ankle-brachial index (ABI): Right leg ABI – 0.83 (< 0.9), Left leg ABI – 0.81 (<0.9).
Peripheral artery disease is a peripheral vascular disease that is caused by
atherosclerotic obstruction of the arteries of the lower extremities. The condition can be
symptomatic or asymptomatic. In symptomatic patients, the condition is mainly
characterized by claudication including fatigue, discomfort or pain in the leg/hip with
walking that is typically relieved by rest (Kullo & Rooke, 2016). Claudication is caused
by inadequate blood flow to the lower extremities. The signs of critical limb ischemia
may also be present including limb pain at rest, ulcers or gangrene, hair loss over the
dorsum of foot, muscle atrophy shiny/scaly skin and thickened toenails (Kullo &
Rooke, 2016). Also, acute limb ischemia may be present as characterized by pain,
paralysis, pulselessness, paresthesia, pallor, and perishing with cold (Kullo & Rooke,
2016). Physical exam findings often include diminished pulse in extremities, gangrene,
muscle atrophy, dependent rubor, and pallor with leg elevation (Aboyans et al 2017).
Risk factors of the condition include age of 65 years or older, atherosclerosis, diabetes
mellitus, smoking, hypertension, hyperlipidemia, family history of PAD or medical
history of atherosclerotic disease (Kullo & Rooke, 2016).
Plan/Therapeutics
Further testing
Color-flow Doppler ultrasound – Ordered to assess the location and degrees of stenosis.
The imaging test is highly accurate in the diagnosis of PAD (Armstrong, 2018).
Medication
Aspirin 81 mg/ day PO-Antiplatelet therapy with aspirin is the first line treatment of
claudication associated with PAD. Evidence shows that antiplatelet therapy significantly
reduces cardiovascular events in patients with claudication (Basili & Violi, 2019). Aspirin
works by inhibiting prostaglandin synthesis this preventing the formation of platelet
aggregating thromboxane A2 (Basili & Violi, 2019). This reduces thrombin generation
and formation of fibrin thus minimizing clot propagation.
Atorvastatin 40 mg PO at bedtime- The medication is a statin used to lower serum
cholesterol levels in the blood so as to prevent cardiovascular events including heart
attacks and strokes. Statins are indicated for all patients with PAD to help them achieve
LDL less than 100 mg/dL (Gerhard-Herman et al., 2017). According to Raymond et al.
(2017) lipid-lowering therapy has been shown to reduce cardiovascular events as well as
the progression of PAD.
Education
Patient was educated on peripheral artery disease including the condition’s signs and
symptoms, causes, risk factors, prognosis, and complications. Patient was also educated
regarding the importance of treatment adherence, smoking cessation, limiting alcohol
intake, diabetes control and cholesterol control (Gerhard-Herman et al., 2017). The
impacts of smoking on blood vessel was discussed with the patient and the patient was
helped to identify smoking cessation strategies including support groups and nicotine
patches. The importance of exercise in the treatment of claudication and weight
management was discussed with the patient and he was advised to walk at least 15 mins
three to four times a day, gradually increasing his duration and pace of exercise. Patient
was advised to stop exercise and rest for 3 mins if claudication develops then resume
exercising. The importance of dietary interventions for reducing the risk of cardiovascular
events including intake of low calorie, low-fat and low-cholesterol was also discussed
with the patients. An appointment with a dietitian was scheduled to help the patient
develop an ADA diet that includes the preferred foods as well as puts into consideration
usual eating patterns. Lastly, the previous foot care teaching was reinforced to help
patient prevent diabetic foot neuropathy and measures to prevent injury were also
discussed.
Non-medication treatments
Supervised exercise program for 3 months- As first-line therapy for patients with
intermittent claudication, exercise therapy in the form of supervised training program has
been shown to be effective in improving walking ability and functional outcomes in
patients with claudication (Ehrman, Lui & Treat-Jacobson, 2017). The exercise should
include walking a minimum of at least 3 times per week (30-60 min/session) for at least 3
months as recommended by AHA/ACC, and Trans-Atlantic Inter-Society Consensus
Document on Management of PAD (Gerhard-Herman et al., 2017).
Follow-up- Patient was scheduled to return to the clinic after 3 weeks for reevaluation
and to receive lab/diagnostic test results
Evaluation of patient encounter- The patient encounter went well as the patient was
cooperative throughout the session. The education given to the patient was well received
as she was attentive to all the guidelines and other procedures. The patient admitted
adhering to the treatment regimen and follow-up as instructed. The encounter provided
me with increased insight on the evaluation and treatment of patients presenting with
signs and symptoms of peripheral arterial disease (PAD).
Reference:
Aboyans, V., Ricco, J. B., Bartelink, M. L. E., Björck, M., Brodmann, M., Cohnert, T., … &
Espinola-Klein, C. (2017). 2017 ESC guidelines on the diagnosis and treatment of
peripheral arterial diseases, in collaboration with the European Society for Vascular
Surgery (ESVS) document covering atherosclerotic disease of extracranial carotid and
vertebral, mesenteric, renal, upper and lower extremity arteries endorsed by: the
European stroke organization (ESO) the task force for the diagnosis and treatment of
peripheral arterial diseases of the European Society of Cardiology (ESC) and of the
European Society for Vascular …. European heart journal, 39(9), 763-816
Armstrong, E. (2018). Peripheral arterial disease – Symptoms, diagnosis, and treatment | BMJ
Best Practice. Retrieved 28 August 2019, from
https://newbp.bmj.com/topics/en-gb/431/differentials.
Basili, S., & Violi, F. (2019). Antiplatelet Drugs in the Management of Thrombotic/Ischemic
Events in Peripheral Artery Disease. In Platelets (pp. 1059-1066). Academic Press.
Ehrman, J. K., Lui, K., & Treat-Jacobson, D. (2017). Supervised exercise training for
symptomatic peripheral artery disease. Journal of Clinical Exercise Physiology, 6(4), 78-
83.
Gerhard-Herman, M. D., Gornik, H. L., Barrett, C., Barshes, N. R., Corriere, M. A., Drachman,
D. E., … & Lookstein, R. (2017). 2016 AHA/ACC guideline on the management of
patients with lower extremity peripheral artery disease: a report of the American College
of Cardiology/American Heart Association Task Force on Clinical Practice
Guidelines. Journal of the American College of Cardiology, 69(11), e71-e126.
Hollier, A. (2018). Clinical guidelines in primary care. Scott, LA: Advanced Practice
Education Associates.
Kullo, I. J., & Rooke, T. W. (2016). Peripheral artery disease. New England Journal of
Medicine, 374(9), 861-871.
Raymond Foley, T., Singh, G. D., Kokkinidis, D. G., Choy, H. H. K., Pham, T. H., Amsterdam,
E. A., … & Laird, J. R. (2017). High‐Intensity Statin Therapy Is Associated With
Improved Survival in Patients With Peripheral Artery Disease. Journal of the American
Heart Association, 6(7), e005699.
(Student
Name)
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C
Soap Note # ____ Main Diagnosis ______________
PATIENT INFORMATION
Name:L.G
Age: 74
Gender at Birth:
Gender Identity: Female
Source:
Allergies:
Current Medications:
1-Aspirin 81 mg daily.
2-Lisinopril 20 mg daily
3
–
atorvastatin 20 mg daily,
4-fluticasone propionate/Salmeterol 250/50 inhaler 1 puff twice a day
5-ipratropium bromide/albuterol, inhaled 0.5 mg/2.5 mg/3 mL nebulizer every 6 hours as needed;
6- levalbuterol, inhaled 0.63 mg/3 mL nebulizer every 8 hours as needed.
Denies the use of herbal supplements.
PMH: Patient had significant medical history for COPD,HTN, Hearing loss
Allergies: NKDA.
Immunizations: Childhood immunizations are up to date.
Preventive Care:
Surgical History:
Family History:
Mother: 94 years old, Alive – Anxiety, GERD, CAD, Asthma
Father: Deceased – coronary artery disease (CAD) < 55 years,
Brother: Alive – HTN, DM type II, COPD (76 years old)
Son: Alive – no known health concerns (50 years old).
Social History: Currently married with one child who lives with them, they live in a single home that owned She is Christian. She every day works in the garden early in the morning, but lately is difficult to this due to increases the shortness of breath. Admitted that she smokes and she tries to cut but it is difficult, but she is the thing to quit (no guns in the home, no lead exposure)
Sexual Orientation:
Nutrition History:
Subjective Data:
Chief Complaint: “Shortness of breath.”
Symptom analysis/HPI:
The patient is … is a 74-year-old female who presents today to the clinic, complaint worsening of the shortness of breath, wheezing and increases productive cough with no changes in the sputum color. She has experiences with dyspnea in exertion, she did not report fever, night sweet or chest pain or palpitation. She had had a history of chronic obstructive pulmonary disease (COPD) exacerbation twice last year, hypertension (HTN), and cardiac Cath about 3 years ago. She had a 40 pack-year smoking history but did not report using alcohol or illicit drug. Her medication, low dose daily (81mg) aspirin (ASA), Lisinopril 20 mg daily, atorvastatin 20 mg daily, fluticasone propionate/Salmeterol 250/50 inhaler 1 puff twice a day tiotropium inhaler 18 mcg 1 cap daily, ipratropium bromide/albuterol, inhaled 0.5 mg/2.5 mg/3 mL nebulizer every 6 hours as needed; and levalbuterol, inhaled 0.63 mg/3 mL nebulizer every 8 hours as needed.
Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )
CONSTITUTIONAL Positive for fatigue, exhaustion, and lack of energy. Negative for fever, chills, malaise, night sweats, and anorexia
NEUROLOGIC: Negative for difficulty with concentration, poor balance or falls, slurred speech, headaches, numbness, or vertigo
HEENT:
Eyes: Admit her last eye exam was 3 years ago. She uses glasses all the time for vision. Denies any redness drainage or itching.
Ears: Positive for hearing the loss in the left ear corrected with hearing aids. Denies discharge, ear pain, or tinnitus.
Nose/Mouth/Throat: Negative for difficulty swallowing, hoarseness, gum diseases, and sore throat, have a superior prosthesis, inferior natural teeth.
RESPIRATORY: Positive for shortness of breath, cough, wheezing, and dyspnea on exertion that has been worse over the last couple of months and increasing exercise intolerance; denies hemoptysis or orthopnea; reports that even with the use of neb every 3-4 hours is still finding it hard to breathe well.
Breast: Deferred
CARDIOVASCULAR: Denies chest pain or palpitation
GASTROINTESTINAL: Negative for abdominal pain, nausea, vomiting, dysphagia, diarrhea, black or tarry stools, or blood in stools.
GENITOURINARY: Denies burning sensation during urination, lower abdominal pain, blood in the urine or vaginal discharge.
Last Pap Smear: 09/2020
Menarche: 11 years Menopause:52 years’ old G1P1A0
MUSCULOSKELETAL: Denies any complications with a range of motion in all four extremities, stiffness fracture as well as injuries or trauma to his head.
SKIN: Warm and dry, no rashes bruising or bleeding Exposed skin is intact. Various scattered solar lentigines. Denies any rashes, lacerations, or wounds.
PSYCHIATRIC:
Negative for anxiety, depression and suicidal ideation. Positive for sleeping disturbed.
Objective Data:
VITAL SIGNS: Weight: 196 BMI:24.5 Temp: 97.3 BP: 130/78 Height: 6.3
Pulse: 70 Resp: 20
GENERAL APPREARANCE: This 74-year-old female, ill appearance with some audible wheezing present and rapid breathing while sitting in a chair, makes eyes contact and answer the question appropriately. Well, grooming nourishment and hydrates. Dresses appropriately and cooperative with the examination
NEUROLOGIC:
HEENT: Head is normocephalic, no facial tenderness over frontal sinuses with palpation. Conjunctiva pink, sclera white without jaundice. PERRLA. Ears: External auditory canals mild cerumen. Tympanic membranes are intact. Nasal mucosa moist without drainage, septum midline. Oropharynx pink and moist with no tonsillar enlargement, lesions or exudate. Teeth superior prosthesis in place and intact. Mucus membranes are moist. Neck: Trachea is midline, thyroid not palpable. No JVD. No lymph nodes are palpable. Neck no supple with no masses or tenderness.
CARDIOVASCULAR: Regular rate and rhythm. S1 and S2 normal. No S3, S4, rubs, murmurs, clicks, snaps, or gallops noted. Peripheral Vascular: No cyanosis, clubbing, or edema. Radial pulses 3+ bilaterally
RESPIRATORY: Symmetric chest walls with decreased expansion, deformity -shaped chest. Respiration even and labored, depth normal. Lung resonant. No fremitus. Decreased breath sounds in right upper lobe (RUL) and wheezes on left, most pronounced in posterior left lower lobe (LLL) and anterior left upper lobe (LUL). Able to talk in full sentences but appears short of breath when he finishes.
GASTROINTESTINAL: Abdomen soft and depressible, non-tender, bowel sounds of normal quality in all four quadrants. No hepatosplenomegaly
GENITOURINARY: Deferred
BREAST: Deferred
MUSKULOSKELETAL: Steady gate, no limping or musculoskeletal deformities. No swelling, joint pain, crepitus, warmth or tenderness. Full ROM. Limited movement due to back pain
INTEGUMENTARY: Intact. No ulcers. Nails without clubbing or cyanosis at this time. No petechiae or ecchymosis. Various scattered solar lentigines
NEUROLOGICAL:
CNII-XII intact, Posture erects, steady gait. Speech clear.
PSYCHIATRIC: A&O&4 Pt. dressed in clean season appropriate clothes.
ASSESSMENT:
(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data)
Example : “Pt came in to our clinic c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and that etc.)
The patient is … is a 74-year-old female who presents today to the clinic, complaint worsening of the shortness of breath, wheezing and increases productive cough with no changes in the sputum color. She has experiences with dyspnea in exertion, she did not report fever, night sweet or chest pain or palpitation. She had had a history of chronic obstructive pulmonary disease (COPD) exacerbation twice last year, hypertension (HTN), and cardiac Cath about 3 years ago. She had a 40 pack-year smoking history but did not report using alcohol or illicit drug. Her medication, low dose daily (81mg) aspirin (ASA), Lisinopril 20 mg daily, atorvastatin 20 mg daily, fluticasone propionate/Salmeterol 250/50 inhaler 1 puff twice a day tiotropium inhaler 18 mcg 1 cap daily, ipratropium bromide/albuterol, inhaled 0.5 mg/2.5 mg/3 mL nebulizer every 6 hours as needed; and levalbuterol, inhaled 0.63 mg/3 mL nebulizer every 8 hours as needed.
on examination I noted Regular rate and rhythm. S1 and S2 normal. No S3, S4, rubs, murmurs, clicks, snaps, or gallops noted. Peripheral Vascular: No cyanosis, clubbing, or edema. Radial pulses 3+ bilaterally .Symmetric chest walls with decreased expansion, deformity -shaped chest. Respiration even and labored, depth normal. Lung resonant. No fremitus. Decreased breath sounds in right upper lobe (RUL) and wheezes on left, most pronounced in posterior left lower lobe (LLL) and anterior left upper lobe (LUL). Able to talk in full sentences but appears short of breath when he finishes.
Main Diagnosis
Chronic obstructive pulmonary disease with (acute) exacerbation (J44.1): Chronic Obstructive Pulmonary Disease, or COPD, refers to a group of diseases that cause blockage of the air passage. They include emphysema, bronchitis chronic and, in some cases, asthma. The common signs and symptoms of COPD are: cough persistent, or that produces a lot of mucus; This cough is often referred to as “smoker’s cough” feeling of shortness of breath, especially during physical activity wheezing or a whistle or squeak that occurs when you breathe pressure in the chest. The intensity of the symptoms will depend on the degree of lung damage. Severe COPD can cause other symptoms, such as swelling of the ankles, feet or legs, weight loss and decreased muscle capacity (Goolsby & Grubbs, 2014).
Differential diagnosis (minimum 3)
– Heart failure (I50.9): Heart failure is usually a slow process that gets worse over time. The symptoms allow determining which side of the heart does not work properly. If the left side of the heart does not work well (left heart failure), blood and mucus build up in the lungs. The patient easily loses his breath, feels very tired and has a cough (especially at night). In some cases, patients expel bloody sputum when coughing. If the right side of the heart does not work well (right heart failure), fluid builds up in the veins because the blood circulates more slowly. The feet, legs, and ankles begin to swell. This swelling is called “edema.” Sometimes the edema can spread to the lungs, liver, and stomach. Due to the accumulation of fluid, the patient has a need to urinate more frequently, especially at night. The accumulation of fluid also affects the kidneys, reducing their ability to remove salt (sodium) and water, which can lead to kidney failure (Domino, Baldor, Golding, & Stephen, 2017).
Chronic obstructive asthma (J44.9): Asthma affects people of all ages, but usually begins during childhood. In the United States, there are more than 25 million people with proven asthma. Of these people, about 7 million are children. Asthma is a chronic disease of the lungs that inflames and narrows the airways. Both asthma and COPD may cause shortness of breath and a cough. A daily morning cough that produces yellowish phlegm is characteristic of COPD. Episodes of wheezing and cough at night are more common with asthma. Other symptoms of COPD include fatigue and frequent respiratory infections (Domino et al., 2017).
Bronchogenic Carcinoma C34.90): Bronchogenic carcinoma (CB) is the most frequent neoplasm and the main cause of cancer death in the male Its incidence is increasing in the female sex. The most common symptoms of lung cancer are: A cough that does not go away or gets worse, cough with blood or sputum (saliva or phlegm) of the color of oxidized metal , chest pain that often gets worse when you take a deep breath, cough or laugh, hoarseness, weight loss and loss of appetite difficulty breathing ,tiredness or weakness, infections such as bronchitis and pneumonia that do not disappear or continue to recur, new chest whistle, (Domino, et al., 2017).
PLAN:
Labs and Diagnostic Test to be ordered (if applicable)
Lab Test: (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2017).
CBC with differential pending
CMP pending
Special Test:
Chest X-ray: Ordered for visualization of lungs due to decreased breath sounds in the right upper lobe. With smoking history and increased shortness of breath, there is a concern for lung cancer.
–
Pharmacological treatment: (Buttaro et al., 2017).
Short-Acting
Ipratropium bromide, Solution for nebulization, 500 µg/2.5 mL 3-4 times per day, separate doses by 6-8 hr.
Long-Acting:
Tiotropium DPI, 18 µg/inhalation 1 inhalation daily
Beta2-adrenergic agonists
Albuterol sulfate, Solution for nebulization, 0.5 mL of 0.5% solution, 3-4 times per day
Oral corticosteroids
Methylprednisolone 40-48 mg/day in divided doses for 3-4 days.
Non-Pharmacologic treatment:
Patients was educated on COPD including the signs and symptoms, course of exacerbations
. The use of inhalers was demonstrated to the patient
Patient was educated on the importance of risk reduction including the importance of smoking cessation
The importance of Influenza and pneumococcal vaccination was discussed with the patient. The importance of the vaccination was discussed in relation to reduce risk of exacerbations
Education (provide the most relevant ones tailored to your patient)
Follow-ups/Referrals
Referral to Pulmonary Rehabilitation: Respiratory therapist to facilitate breathing techniques and guidance for maximizing energy, which has improved both patients’ exercise tolerance and symptoms of dyspnea and fatigue.
Referral to dietitian-nutritionist: In order to instruct the patient on nutrition, exercise, upper body weight training, and eat frequent, small meals instead of a large meal; large meals cause abdominal distention, which impairs diaphragmatic function
Psychological Support: Patient may feel anxious, depressed, and fatigued. Counseling is recommended for those patients exhibiting signs and symptoms of major depression
Follow up in 72 hours and as needed if symptom no improves patient can go to the ER
References
(in APA Style)
Examples
Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).
ISBN 978-0-8261-3424-0
Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010
(25th ed.). Print (The 5-Minute Consult Series).
References
Buttaro, T. M., Trybulski, J., Polgar-Bailey, P., & Sandberg-Cook, J. (2017). Primary care: A collaborative practice. (5th ed). St. Louis, MO: Elsevier
Domino, F, J., Baldor, R. A Golding, J &, Stephen, M (2017). The 5-minute Clinical consult (25thed). Philadelphia, PA: Wolters Kluwer
Goolsby, M. J. & Grubbs, L. (2014). Advanced assessment: Interpreting findings and formulating differential diagnoses, (3rd ed.). Philadelphia, PA: F. A. Davis. ISBN: 9780803643635
ICD10. (2018). Retrieved from
https://www.icd10data.com/search
Kennedy-Malone, L., Fletcher, k. R., & Martin-Plank, L. (2014). Advanced Practice Nursing in the Care of Older Adults, (1st ed.). F. A. Davis Company. ISBN: 9780803624917
