NSG 6020 Wk9 Soap Note Lumbar Herniated Disk

Name: Mr. D	Date: May 25,	Time: 1300
	Age: 52 years old	Sex: Male
SUBJECTIVE
CC: “I experience back pains that I have never felt before”.
HPI: Seen and examined Mr. D., a 52-year old Italian male, presented in the clinic with complaints of experiencing unusual back pains. (5/10) Reports to have started one week ago, isolated on lower back, usually worsens when lifting and prolonged walking, usually relieved by rest and by lying down. He denies taking any pharmacological treatments. Had history of cholecystectomy 4 years ago, has chronic diagnosis of HTN, and recently diagnosed with Type II DM (non-insulin).
Medications:


ROS
General 52 years old, Italian male, alert and oriented x 3, able to make needs known and alert during interview	Cardiovascular Denies experiencing chest pains, palpitations and lightheadedness.

Skin Denies delayed healing or bruising. Skin color is appropriate for ethnicity. Denies any changes in moles.	Respiratory Denies wheezing, shortness of breath or history of TB.
Eyes Denies wearing any corrective lense glasses. Denies having exudates and discharges from eyes	Gastrointestinal Denies abdominal pain, nausea and vomiting, ulcers, black tarry stools.Reports no problems moving bowels.
Ears Denies Ear pain, hearing loss, ringing in ears, and any discharges.	Genitourinary/Gynecological Denies urgency, frequency burning, change in color of urine. Denies hx of STI’s.

Nose/Mouth/Throat Denies having any lesions, masses and tenderness. Also denies diﬃculty of hearing, vertigo and throat pain.	Musculoskeletal Complains isolated aching low back pain (5/10)
Breast Denies rashes, bruising, sores, lumps, dryness and color changes.	Neurological Denies numbness and tingling, tremors.
Heme/Lymph/Endo Denies easy bruising and bleeding, Denies heat or cold intolerance, and denies having swollen lymph nodes.	Psychiatric Denies anxiety, depression, diﬃculty sleeping and suicidal ideation.
OBJECTIVE

Weight 185 lbs BMI 28.13

Temp 98.1

BP 132/72

Height 5’8”	Pulse 52 years old	Resp 16
General Appearance Seen and examined Mr. D. 52-year old Italian male. Appears to be pleasant, mobile, and active. He has worked as a truck driver for 15 years. Alert and oriented x 3, answers all questions appropriately and very cooperative.
Skin Intact, warm to touch and dry with no bruising, lesions, rashes or discoloration noted. No cyanosis or clubbing noted. No visible scars observed.

HEENT · Normocephalic · Conjunctiva pink, sclerae white, no jaundice, free from drainage, PERRLA. · Ears non-tender, no swelling and free from drainage · Nose: nasal mucosa moist without drainage, septum midline, free from swelling and lesions· Throat: free from lesions and not enlarged · Neck: Trachea is midline, non-palpable thyroid and lymph nodes, neck supple with no masses or tenderness.

Cardiovascular S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refills 2 seconds. Pulses 3+ throughout. Localized edema on B/L LE

Respiratory Symmetrical chest expansion. Respirations even and unlabored, breath sounds clear upon auscultation bilaterally. No wheezing, rhonchi, or stridor noted. No increased tactile fremitus.

Gastrointestinal Abdomen ﬂat, soft, non-distended, Bowel sounds present on all quadrants. Abdomen tympanic with percussion, Non-tender when palpated and no hepatosplenomegaly.

Breast -Normal, symmetrical – No visible or nipple abnormalities -No spontaneous or expressed nipple discharge or blood

Genitourinary -Normal external genitalia

Musculoskeletal Complains isolated aching low back pain (5/10)

Neurological CNII-XII intact. Good coordination and body posture observed. Romberg and heel to toe were deferred at this time.

Psychiatric AAO x 3. Appropriate affect. Mr. D. is neatly dressed, maintains eye contact and answers all questions accordingly and appropriately.

Lab Tests CBC, CMP – pending Lumbosacral X Ray

Special Tests None

Diagnosis

Differential Diagnoses.

Plan/Therapeutics

o Plan:

Evaluation of patient encounter

References:

Mayo Clinic (2018) Herniated Disk retrieved from https://www.mayoclinic.org/diseases-conditions/herniated-disk/diagnosis-treatment/dr c-20354101

Mayo Clinic (2018) High Blood Pressure retrieved from https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/diagnosis-treatm ent/drc-20373417

NSG 6020 Wk9 Soap Note – Lumbar Herniated Disk

NSG 6020 Week 8 SOAP Note – MS Patient Allergic To Sulfonamides

MS Patient Allergic to Sulfonamides

Allergies: sulfonamides cause extreme rash and hives Temp: 97.8

BP: deferred as the patient was allowing more than she was comfortable with by seeing us both.

CC: none today other than “my catheter is having issues”

HPI: simple well check, however had occasion to check the catheter placement as they feel that it’s leaking.

Subjective: 61 year old female with MS that is progressing. She has an appointment with urology on 10/01/2018 (ﬁrst available) about the leaking catheter. Patient denies any unusual pain or discomfort, at the moment. Patients have a long and signiﬁcant history if UTI’s so we will need to be cautious and observant.

Head: denies issues with headache or otherwise; with exception of the dry skin throughout the scalp due to seborrhea. Eyes: clear, follows gaze text (CM) uses corrective lenses Ears: denies pain and or hearing loss; Nose: pink mucosa, clear and dry; Throat/Mouth: Pink oral mucosa, teeth are inadequate repair, swallows well, soft spoken; Neck: Denies complaints; Heart: denies Respiratory: denies GI: denies GU: suprapubic catheter was recently placed, but leakage is noted; Hematology: none; MSK: denies any trouble beyond normative paralysis; Neuro: no sensitivity in hands and, for the most part, feet. Denies seizures or headaches.

NSG 6020 Wk8 SOAP Note – MS Patient Allergic To Sulfonamides Current Medications:

PMHx:

Allergies: NKA/NKDA

Chronic or major illnesses: Hospitalizations/Surgeries: Family Hx:

Social Hx: ROS:

General:

Skin:

Eyes:

Ears:

Nose/Throat/Mouth:

Breast:

Heme/Lymph/Endocrine: Cardiovascular:

Respiratory:

GI GU MSK

Psychiatric:

OBJECTIVE DATA:

Wgt. BMI BP P RR Gen Appear: Orientation:

HHEENT:

Cardiovascular:

Respiratory:

GI:

Breast:

MSK

NEURO PSYCH

Labs;

Rights of Medication Administration

● Right patient

■ Check the name on the order and the patient.

■ Use 2 identiﬁers.

■ Ask the patient to identify himself/herself.

■ When available, use technology (for example, bar-code system).

● Right medication

■ Check the medication label.

■ Check the order.

● Right dose

■ Check the order. NSG 6020 Wk8 SOAP Note – MS Patient Allergic to Sulfonamides.

■ Conﬁrm appropriateness of the dose using a current drug reference.

■ If necessary, calculate the dose and have another nurse calculate the dose as well.

NSG 6020 Wk8 Soap Note – Chronic HTN And HLD

Name: Mr. G

Date: 05/22/2018 Time: 10:30 AM

Age: 56 years old Sex: Male

SUBJECTIVE CC:

“ I have urgent and frequent problems when urinating. Also, at night I have observed that I need to wake up a couple of times to urinate. Normally, I would wake up once through the night but now I have to wake up 2-3 times and sometimes more.”

HPI:

Seen Mr. F, 56 years old Caucasian male with past medical history of Chronic HTN and HLD presented to the clinic complaining of urinary frequency, urgency and nocturia, had a history of appendicitis and

appendectomy 5 years ago. Denies pain or any discomfort at this time or when urinating.

Medications:

Lisinopril 20 mg once daily for Hypertension

Atorvastatin 10 mg once daily at bedtime for Hyperlipidemia Vitamin D3 1000 units as supplement

Vitamin C 500mg daily as supplement

NSG 6020 Wk8 Soap Note – Chronic HTN And HLD

PMH

Allergies:

No known Drug or Food allergies

Medication Intolerances:

No known Medication intolerance Chronic Illnesses/Major traumas Hypertension (I10) – 20 years ago

Hyperlipidemia (E78.5) – 10 years ago Hospitalizations/Surgeries Appendectomy – 5 years ago

Family History

Mother – Hypertension, Type II DM Father – Hypertension, HLD

Sibling – 1 elder sister who has Hypertension Indicates Patient

Living Male

Living Female PP

HEENT · Normocephalic · Conjunctiva normal in color, free from drainage, PERRLA, (-) · Ears non-tender, no swelling and free from drainage · Nose: free from swelling, lesions and discharges · Throat: free from lesions and not enlarged · Neck: Trachea is midline, non-palpable thyroid and lymph nodes, neck supple with no masses or tenderness. NSG 6020 Wk8 Soap Note – Chronic HTN and HLD

Cardiovascular S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refills 2 seconds. Pulses 3+ throughout. No edema.

Respiratory Symmetrical chest expansion. Respirations even and unlabored, breath sounds clear upon auscultation bilaterally. No wheezing, rhonchi, or stridor noted. No increased tactile fremitus.

Gastrointestinal

Abdomen ﬂat, soft, non-distended, Bowel sounds present on all quadrants. Abdomen tympanic with percussion, Non-tender when palpated and no hepatosplenomegaly.

NSG 6020 Soap Note – Hypothyroidism And Hyperglycemia

SOAP NOTE

Name:

J K

7/15/2016

Time: 9:00 am

Age: 43

Sex: Female SUBJECTIVE CC:

“I’m here to follow up after having an ear infection and to talk about my lab results and why I’m so tired all the time”. HPI:

Mrs. Keenan is 23 year old female patient presenting to the oﬃce today for a follow up after being treated with for an ear infection and complaints of constant fatigue. Her last visit consisted of an evaluation and lab work to determine the cause of fatigue. She denies any fever, shortness of breath or pain.

Medications:

Ciprodex 0.3-0.1% suspension. 4 gtts twice daily

Levothyroxine Sodium-250 mcg daily (ran out of medications 3 weeks ago) Lasix-40 mg 1 tab daily

PMH

Allergies: NKA

Medication Intolerances: None listed Chronic Illnesses/Major traumas

Iron Deﬁciency Anemia (IDA)
Hypothyroidism
Hyperglycemia
Vitamin D deﬁciency

Chronic Health Problems:

1. Iron Deﬁciency Anemia (IDA) (D50.9)

2. Hypothyroidism (E03.9)

3. Vitamin D Deﬁciency (E55.9)

4. Hyperglycemia (R73.9) Hospitalizations/Surgeries

Gallbladder surgery in 2003
Breast biopsy in 2003 Other:

Immunizations:

Received ﬂu vaccine in November 2015 and plans to receive it again when it’s time. Environmental hazards:

Denies any environmental hazards. Lives at home with husband in a clean home. Able to perform ADLs without diﬃculty.

Safety measures:

Stated “I always put my seatbelt on”.

NSG 6020 Soap Note – Hypothyroidism and Hyperglycemia

Rights Of Medication Administration

Right time

■ Check the frequency of the ordered medication.

■ Double-check that you are giving the ordered dose at the correct time.

■ Conﬁrm when the last dose was given.

Right documentation

■ Document administration AFTER giving the ordered medication.

■ Chart the time, route, and any other speciﬁc information as necessary. For

for example, the site of an injection or any laboratory value or vital sign that needed to be checked before giving the drug.

Right reason

■ Conﬁrm the rationale for the ordered medication. What is the patient’s history?

NSG 6020 SOAP Note Assignments Week 5 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 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

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.

Week 6 Physical Exam Video and Write Up Assignment

Complete Health History and Physical Assessment Write-Up Presentation

This assignment consists of complete head to toe physical while being videoed. You will also need to complete a written assignment of your ﬁndings. Review the Expanded rubric to note how you will be graded on this assignment.

Week 7 SOAP Note Assignment

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_W7_A3_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 8 SOAP Note Assignment

SOAP Note

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_W8_A3_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 9 SOAP Note Assignment

SOAP NOTE

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_W9_A3_LastName_FirstInitial.doc. Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date assigned.

NSG 6020 Wk9 Soap Note Lumbar Herniated Disk