TITLE: NASAL FRACTURE

EXAMPLE: SOAP NOTE

  

Soap Note # Main Diagnosis ( Exp: H&P Note #3 DX: Hypertension)

Student Name

Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor: Dr. Rafael Camejo

  

Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension)

PATIENT INFORMATION

Name: Mr. DT

Age: 68-year-old

Gender at Birth: Male

Gender Identity: Male

Source: Patient

Allergies: PCN, Iodine

Current Medications: 

· Atorvastatin tab 20 mg, 1-tab PO at bedtime

· ASA 81mg po daily

· Multi-Vitamin Centrum Silver

PMH: Hypercholesterolemia

Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.

Preventive Care: Coloscopy 5 years ago (Negative) 

Surgical History: Appendectomy 47 years ago.

Family History: Father- died 81 does not report information

 Mother-alive, 88 years old, Diabetes Mellitus, HTN

Daughter-alive, 34 years old, healthy

Social History: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.

Sexual Orientation: Straight

Nutrition History: Diets off and on, Does not each seafood 

Subjective Data:

Chief Complaint: “headaches” that started two weeks ago

Symptom analysis/HPI:

The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month. Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.

Review of Systems (ROS)

CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures. 

HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.

RESPIRATORY: Patient denies shortness of breath, cough or hemoptysis.

CARDIOVASCULAR: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal

dyspnea.

GASTROINTESTINAL: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or

diarrhea.

GENITOURINARY: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.

MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound.

SKIN: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.

Objective Data:

VITAL SIGNS: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 2/10.

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.

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: No dyspnea or use of accessory muscles observed. 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: No pain to palpation. Active and passive ROM within normal limits, no stiffness.

INTEGUMENTARY: intact, no lesions or rashes, no cyanosis or jaundice.

ASSESSMENT:

Main Diagnosis

Essential (Primary) Hypertension (ICD10 I10): Given the symptoms and high blood pressure (156/92 mmhg), classified as stage 2. Once the organic cause of hypertension has been ruled out, such as renal, adrenal or thyroid, this diagnosis is confirmed (Codina Leik, 2015). Diagnosis is based on the clinical evaluation through history, physical examination, and routine laboratory tests to assess risk factors, reveal identifiable causes and detect target-organ damage, including evidence of cardiovascular disease (Domino et al,. 2017).

Differential diagnosis:

Ø Renal artery stenosis (ICD10 I70.1)

Ø Chronic kidney disease (ICD10 I12.9)

Ø Hyperthyroidism (ICD10 E05.90)

PLAN:

Labs and Diagnostic Test to be ordered:

· CMP

· Complete blood count (CBC)

· Lipid profile

· Thyroid-stimulating hormone (TSH)

· Urinalysis with Micro

· Electrocardiogram (EKG 12 lead)

Pharmacological treatment: 

· Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily. 

· Lisinopril 10mg PO Daily

Non-Pharmacologic treatment: 

· Weight loss

· Healthy diet (DASH dietary pattern): Diet rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced content of saturated and trans l fat

· Reduced intake of dietary sodium: <1,500 mg/d is optimal goal but at least 1,000 mg/d reduction in most adults

· Enhanced intake of dietary potassium

· Regular physical activity (Aerobic): 90–150 min/wk

· Tobacco cessation

· Measures to release stress and effective coping mechanisms.

Education

· Provide with nutrition/dietary information.

· Daily 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

· 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

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

Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Clinical Consult 2017

(25th ed.). Print (The 5-Minute Consult Series).

Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.). 

ISBN 978-0-8261-3424-0

NOTE: PLEASE APA FORMAT OF THE REFERENCE, AND ORIGINAL

  

To do a comment to each post below in APA style with citation, needs 2 credible reference from 2013 and above.

Post 1

Episodic/Focused SOAP Note 

Patient Information: Lily, 20-year-old, Female S. CC: “Sore throat” HPI: The patient is a 20-year-old female who developed a sore throat 3 days ago Location: Throat Onset: 3 days ago Character: sore Associated signs and symptoms: decreased appetite, headache and pain with swallowing Timing: Would ask Exacerbating/ relieving factors: Would ask Severity: Would ask Current Medications: Unknown Allergies: Unknown PMHx: Unknown Soc Hx: Student at the local college. Fam Hx: Unknown ROS: HEENT: Eyes: Ears, nose and throat: Negative for congestion. Positive for runny nose and sore throat, pain with swallowing. GASTROINTESTINAL: Positive for decreased appetite NEUROLOGICAL: Positive for headache O. HEENT: Eyes: Ears, nose and throat: Patient has runny nose, does not sound congested. Patient has slight hoarseness in voice. Diagnostic results: Full vital signs – to include temperature Through mouth and throat exam – specifically looking for puss or enlarged tonsils Rapid influenza test – One study tested 3782 subjects that presented with a fever greater than 38degrees Celsius and either a cough or sore throat. Of these subjects the influenza PCR tested positive 33% of the time and negative 67% of the time. This study showed that the influenza PCR is better at ruling out influenza (Anderson et al., 2018). Monospot test A. Differential Diagnoses Airway Reflux: Acid reflux and sometimes reach higher areas up into the throat. This can create a sore throat and typically leads to a hoarse voice (Adams, 2017). Other symptoms to address include a feeling of a lump in the throat and waking up at night gasping for air (Adams, 2017). Upper Respiratory Infection: Viral upper respiratory infections can create vocal cord inflammation which could be why Lily has a hoarse voice (Dains, Baumann & Scheibel, 2016, p. 9714). Pharyngitis: Bacterial infections can lead to a sore throat and a headache (Dains, Baumann & Scheibel, 2016, p. 9137). Epiglottitis: An infection with H influenza type B, typically presents with sore throat and pain while swallowing (Dains, Baumann & Scheibel, 2016, p. 14434). Mononucleosis: Typically presents with a gradual onset, mild sore throat, malaise and fatigue (Dains, Baumann & Scheibel, 2016, p. 14459). P. References Adams, J. U. (2017). Sore throat and hoarseness might not be just a cold. The Washington Post. Anderson, K. B., Simasathien, S., Watanaveeradej, V., Weg, A. L., Ellison, D. W., Suwanpakdee, D., & Jarman, R. G. (2018). Clinical and laboratory predictors of influenza infection among individuals with influenza-like illness presenting to an urban Thai hospital over a five-year period. Plos ONE, 13(3), 1. doi:10.1371/journal.pone.0193050 Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

Post 2

Episodic/Focused SOAP Note Template

Patient Information:

J, 11, Male, XX (Race) 

S.

CC: “Mild ear ache”

HPI: The patient is 11 year old XX male who presented himself with a mild right ear ache, which started two days ago. Associated symptom include possible fever, right ear pain, difficulty hearing from the right ear. Associated symptom are exacerbated with sleep. 

Current Medications: Inquire if patient is currently taking any medications, rule out earring loss related to medication toxicity. 

Allergies: Inquire about allergies. 

PMH: Inquire if patient has a history of acute otitis media or underlying hearing loss. Inquire if patient has had tonsillectomy or an adenoidectomy in the past.
SH: Spends time in pool during summer. 

FH: Inquire if family members have history of hearing loss. 

ROS:

• GENERAL: Possible fever. Inquire      about patient’s swimming habits and ask if ear plugs used. Determine      method of cleaning ear. 
• HEENT: Right ear pain. Inquire if      patient has tinnitus, discharge from ear, vertigo, or itchiness. Inquire      if patient has a history of acute otitis media, hearing loss, vertigo,      tinnitus, discharge from ear canal.
• RESPIRATORY: Inquire if patient      has had post nasal discharge or sputum production and ask about color of      mucous. 
• ALLERGIES:  Unknown 

O.

Physical exam:

• HEENT— Assess outer ear and note      surrounding tissue, shape, color, and any lesions. Assess the external ear      for discharge or any odor. Assess for the placement of a foreign object in      ear. Assess for tenderness on the outer ear near the auricle and mastoid.      Tenderness could indicate a possible infection. Use otoscope to assess      external and middle ear. At this time, assess for erythema, lesions, and      discharge. Inspect tympanic membrane for perforations. Assess the frontal      and maxillary sinuses for swelling. No tenderness or swelling over the      soft tissue should be present. Assess tonsils and inside of mouth for      lesions, erythema, and swelling. 
• RESPIRATORY: Determine if upper      respiratory infection is present, assess for clear lungs. 

Diagnostic results: 

• Whispered Voice- Determines if      patient is able to hear whispering. If they do not pass this test, hearing      loss could be assumed. (Ball, Dains, Flynn, Solomon, Stewart, et al.,      2015, p. 241). 
• Weber Test- Determines unilateral      hearing loss (Ball et al., 2015, p. 241). 
• Rinne Test- Determines if the      patient conducts sound better through bone or air. The patient should hear      the sound conducted through the air twice as long (Ball et al., 2015, p.      241)
• Culture of ear fluid (Attlmayr,      2015). 

Differential Diagnoses

• Otitis externa  
  • Often seen with individuals that       swim. This infection is located on the outer ear. Pain is worse when an       otoscope is inserted because sensitivity is on the outer ear. The outer       portion of the ear is often inlamted and tender to touch. When inspecting       the ear, the ear canal would appear narrow. Because of the narrowing,       fluid is unable to drain from the ear (Rosenfeld et al., 2014). 
• Otitis media 
  • Otitis media is a middle ear       infection that usually presents unilaterally, hearing loss is present,       and tympanic membrane is pink. Pus often forms inside the ear, which       could cause perforation of the tympanic membrane. Ear pain, fever,       difficulty hearing, irritability, and lethargy can also accompany this       diagnosis. While examining the ear with the otoscope, erythema, dullness,       decrease light reflex, and bulging of the tympanic membrane (Nash,       2013). 
• Eustachian catarrh  
  • Often results after an upper       respiratory infection. It would be essential to determine if the patient       has has a recent upper respiratory tract infection. Fluid collects in the       eustachian tube, which causes pain and trouble hearing (Nash,       2013). 
• Cholesteatoma  
  • The growth of a skin tag inside       the ear, behind the ear drum. The patient could be born with it or it can       develop after several ear infections. It would be essential to determine       if the patient has had frequent ear infections in the past (Chawla, Ezhil       Bosco, Lim, Shenoy, & Krishnan, 2015). 
• Mastoiditis 
  • Mastoiditis is a common       complication of acute otitis media. Pain, erythema, and tenderness are       typically present alone the mastoid process (Attlmayr, 2015). 

P.  NA

Reference

Attlmayr, B., Zaman, S., Scott, J., Derbyshire, S. G., Clarke, R. W., & De, S. (2015). 

Paediatric acute mastoiditis, then and   now: Is it more of a problem now?. The Journal 

Of Laryngology And Otology, 129(10), 955-959. doi:10.1017/S0022215115002078

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S.,   Stewart, R. W. (2015). Seidel’s guide to physical 

examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Chawla, A., Ezhil Bosco, J. I., Lim, T. C., Shenoy, J. N., & Krishnan, V. (2015). Computed tomography 

features of external auditory canal cholesteatoma: A pictorial review. Current Problems In 

Diagnostic Radiology, 44(6), 511-516. doi:10.1067/j.cpradiol.2015.05.001

Nash, L. (2013). A case study on prescribing for an acute ear infection in a child. Nurse Prescribing, 

11(4), 179-184.

Rosenfeld, R. M., Schwartz, S. R., Cannon, C. R., Roland, P. S., Simon, G. R., Kumar, K. A., & … 

Robertson, P. J. (2014). Clinical practice guideline: Acute otitis externa. Otolaryngology-Head & 

Neck Surgery, 150S1-S24. doi:10.1177/0194599813517083

Discussion board questions:

500 word APA FORMAT 

1.  Think about the ethical theories and approaches in this Chapter 4 and the moral conflicts you have experienced in the past.  Have you used one of these approaches to resolve a conflict?  Which theory or approach have you used?

2. Has there ever been a time when you have experienced the dilemma of having to make a choice that you know will affect the well-being of another individual? Have you ever experienced moral suffering?

  Please check the grading criteria(Browse File)

 In this assignment, you will assess a current semi-direct or indirect nursing situation that is in need of change. Observe a healthcare environment, focusing on areas of the nursing process that are inefficient, unsafe, or problematic in nature. Diagnose the problem and choose a nursing change theory that suits the change(s) you want to make. Propose a detailed plan based on your chosen change theory, explaining how to implement change. Develop criteria to evaluate the effectiveness of the plan and include a timeline for your change proposal. Finally, reflect on how your change affects the nursing profession. 

 

You plan to take a 1554​-mile
trip in your​ car, which averages 28
miles per gallon. How many gallons of gasoline should you expect to​ use? Would a car that has only half the gas mileage require twice as much gasoline for the same​trip? Explain.

You should expect to use about How many
gallons of gasoline? ​(Type an integer or a​ decimal.)

Would a car that has only half the gas mileage ​(14
miles per​ gallon) require twice as much gasoline for the same​ trip? 

Select the correct choice below and fill in the answer box to complete your choice.
​(Type an integer or a​ decimal.)
A.
​No; the car would use ______
​gallons, which is not twice as many gallons.
B.
​Yes; the car would use ____
​gallons, which is twice as many gallons.