NSG 6020 WK5 Soap Assignment2 Infectious Colitis Or Diverticulitis
Week 5 SOAP Note Assignment
Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template.
The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.
Submission Details:
By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.
- Name your SOAP note document SU_NSG 6020_W5_A2_LastName_FirstInitial.doc.
- Include the reference number from CORE in your document.
- Submit your document to the Submissions Area by the due date assigned
Week 6 SOAP Note Assignment
SOAP Note
Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the
- Submission Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.
Submission Details:
- By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.
- Name your SOAP note document SU_NSG 6020_W6_A4_LastName_FirstInitial.doc.
- Include the reference number from CORE in your document.
- Submit your document to the Submissions Area by the due date assigned
| Name: DR | Date: 09/13/2018 | Time: 1630 |
| Age: 58 years | Sex: Female | |
| SUBJECTIVE |
SAMPLE SOLUTION
| CC:“I have had nausea, vomiting, abdominal pain, and diarrhea since yesterday.” |
| HPI:This is a 58 y/o female with PMH of multiple myeloma, depression, and DVT history presenting with complaints of nausea, vomiting, abdominal pain, and diarrhea. Symptoms started yesterday. She vomited twice today, unable to keep anything down. She has a feeling of something stuck at the lower esophagus for quite some time and would like to be scoped during this admission. She has had 8-10 loose bowel movements today, which is watery and associated with abdominal pain. Patients reported abdominal pain as a constant, sharp and cramping in nature, 6/10 in severity, associated with nausea, vomiting, and diarrhea. Patient has been on antiemetic at home that is not helpful in relieving the symptom. Patient denies fever, fatigue, wt. loss, dizziness, and blood in stool. She has been admitted multiple times for abdominal pain associated with nausea and diarrhea. |
| Medications:Fluoxetine 20 mg PO daily for DepressionDocusate Sodium 100 mg PO TID for ConstipationPantoprazole 40 mg PO daily for prophylaxis of acute stress ulcerBortezomib (Velcade) 1.3 mg/m²/dose IV twice weekly for 2 weeks (days 1, 4, 8, 11) followed by a 10-day rest period (days 12 to 21) for six 3-week cycles; may continue for 8 cycles if response is first seen at cycle 6Acyclovir 400 mg PO BID to prevent the herpes zoster in myeloma patients. Morphine SR 30 mg PO BID For pain due to multiple myelomaEnoxaparin 80 mg SUBQ Q 12 H for prophylaxis of DVTLoperamide 2 mg PO Q6H PRN for diarrheaOndansetron ODT 4 mg PO Q4H PRN for nauseaPromethazine Topical 25 mg topical Q6H PRN for nausea and vomiting PMH |
| Multiple myelomaLLE DVTDepressionPatients deny diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis except depression.Allergies: NKAMedication Intolerances: no known medication intoleranceChronic Illnesses/Major traumasMultiple MyelomaDepressionHospitalizations/SurgeriesHip replacement on 1/5/18Tunneled Catheter placement | |
| Family History: Does your mother, father or siblings have any medical or psychiatric illnesses?Father had diabetes and died due to cancerMother diet due to breast cancerBrother died due to cancer -Daughter has diabetes. | |
| Social HistoryPatient denies smoking, alcohol and illicit drugs use | |
| ROS | |
| GeneralWNL. Patient is active, alert, and oriented with no acute distress. Denies weight change, fatigue, fever, chills, night sweats, decrease energy level. | CardiovascularDenies chest pain, palpitations, PND, orthopnea, edema. |
| SkinDenies rashes, bruising, bleeding or skin discolorations, itching, dryness, and any changes in lesions or moles. | RespiratoryTB test negative. Denies cough, wheezing, hemoptysis, dyspnea, pneumonia. |
| EyesPatient uses reading glasses. Denies blurring, diplopia, discharge, vision loss. | GastrointestinalReports nausea, vomiting, abdominal pain, and diarrhea. Denies melena, and hematochezia. |
| EarsDenies ear pain, hearing loss, ringing in ears, discharge. | Genitourinary/GynecologicalDenies dysuria, hematuria, urgency, frequency, burning sensation, changes in color of urinePatient is menopausal, sexually active. Denies vaginal discharge, use of contraception, and h/o STDSLast pap was negative 2 years backMammogram done a year ago with normal finding. |
| Nose/Mouth/ThroatDenies sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain. | MusculoskeletalReported back pain on exertion. Denies joint swelling, stiffness or pain, and hx, osteoporosis or fracture. |
| BreastDenies SBE, lumps, bumps or changes. | NeurologicalDenies seizures, syncope, and tremors, transient paralysis, weakness, paresthesias, and black out spells |
| Heme/Lymph/EndoNegative HIV status, denies bruising, blood transfusion hx, night sweats, swollen glands, increased thirst, increased hunger, cold or heat intolerance. | PsychiatricReport depression at the age of 33. Denies confusion, delusions, anxiety, sleeping difficulties, suicidal ideation/attempts. |
| OBJECTIVE | |
| Weight 168 lbs(76.3kg) BMI 28.8 | Temp 36.5BP 134/85 |
| Height 5.4 feet | Pulse 82Resp 16 |
| General AppearancePatient is an adult female in no acute distress. Alert and oriented; answers questions appropriately. | |
| SkinSkin is white, warm, dry, clean and intact with multiple brown age spots all over her body. No rashes or lesions noted. | |
| HEENTHead is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation.Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules.Oral mucosa is pink and moist. Pharynx is non-erythematous and without exudate. Teeth are in good repair. | |
| Cardiovascular S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema. | |
