MSN 5600L Case Studies Endocarditis Acute Conditions Soap Note Paper

MSN 5600L Case Studies Endocarditis Acute Conditions Soap Note Paper

MSN 5600L Case Studies Endocarditis Acute Conditions Soap Note Sample Paper

PATIENT INFORMATION
Name: Mr. W.S.
Age: 65-year-old
Sex: Male
Source: Patient
Allergies: None
Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime
PMH: Hypercholesterolemia
Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.
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 Hx: No smoking history or illicit drug use, occasional alcoholic beverage consumption on
social celebrations. Retired, widow, he lives alone.
SUBJECTIVE:
Chief complain: “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.
ROS:
CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss.

NEUROLOGIC: Headache and dizzeness 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

CONSTITUTIONAL: 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 0/10.

General appearance: 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

Musculoskeletal: No pain to palpation. Active and passive ROM within normal limits, no stiffness.

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

Assessment 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.

Differential diagnosis:

➢ Renal artery stenosis (ICD10 I70.1)

➢ Chronic kidney disease (ICD10 I12.9)

➢ Hyperthyroidism (ICD10 E05.90) Plan 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. These basic laboratory tests are:

• CMP

• Complete blood count

• Lipid profile

• Thyroid-stimulating hormone

• Urinalysis

• Electrocardiogram

➢ Pharmacological treatment: The treatment of choice in this case would be: Thiazide-like diuretic and/or a CCB

• Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once 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.

• Provide with nutrition/dietary information.

• Daily blood pressure monitoring at home twice a day for 7 days, keep a record, Education 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

• Evaluation with PCP in 1 weeks for managing blood pressure and to evaluate current hypotensive therapy. Urgent Care visit prn.

• 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 … Purchase answer to see full attachment

You must use this template for Soap note 1 and 2. Use the information provided in the PDF as an “EXAMPLE”. You must use the word temple file and tailor it to your patient and their diagnosis. Using this template will make it very easy to learn the things needed in the note and help you not forget to put something or lose points due to incorrect format or missing information.

The Chief Complaint, Patient info, HPI, Plan section, and references must all be of your own work and no copy-paste.

The Main Areas of Focus that will be checked for plagiarism is Chief Complain, History of Present Illness (HPI), Assessment with Rationale and Explanation, and the Plan. All of this should be in your own words and not copy-pasted from a past note or website or book. There should be minimum likeness noted by turn it in software in these areas.

The Objective and Subjective information can be from a template (Standard Documentation) and will only be looked at for content and not for plagiarism. So if you are past 50% and the above main areas of focus sections are clear and minimum then you are ok. You can resubmit as many times but after 3 it takes up to 24 hours to get turn it in a score.

This is a made-up patient, so review your diagnosis and have the patient have the standard presentation, objective and subjective symptoms that would typically present and adjust them.