NEUROLOGIC: Denies changes in LOC. Denies history of tremors or seizures

NEUROLOGIC: Denies changes in LOC. Denies history of tremors or seizures

Sample SOAP Note
PATIENT INFORMATION:
NAME: Mrs. R
AGE: 66
SEX: Female
SOURCE: Patient
ALLERGIES: Not specified
CURRENT MEDICATIONS: Ibuprofen 200-800 mg prn for hip pain
PMHX: Unremarkable. All vaccines current. Has never had a colonoscopy. Last mammogram 5 years ago. Cholecystectomy 20 years ago. Hysterectomy 10 years ago
FAMHX: Not reported
SOCHX: Has an occasional glass of wine with dinner. Does not smoke. Retired 4 years ago as an office manager and walks approximately 1 mile a day.
SUBJECTIVE:
CC: Pain on posterior left hip along lateral thigh. Pain has been getting gradually worse and is almost constant. Aggravated by walking, bending, standing and squatting. Pain constant when standing long periods of time. Patient has been taking Ibuprofen 200-800 mg prn for hip pain. Relief not specified.
ROS:
CONSTITUTIONAL: Any fever, weight loss or chills?
NEUROLOGIC: Denies changes in LOC. Denies history of tremors or seizures.
HEENT: HEAD: Denies any head injury, or change in LOC. Denies any changes in vision, diplopia or blurred vision. Denies pain in the ears. Denies loss of hearing or drainage. Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.
Respiratory: Denies any SOB, congestion or production of sputum.
Cardiovascular: Denies history of cardiac disease, abnormal EKG or chest pain. Denies dizziness or fatigue.
Gastrointestinal: Denies abdominal pain or discomfort. Denies flatulence, nausea or diarrhea.
MUSCULOSKELETAL: Denies falls, states pain when ambulating, squatting or bending down. Pain to the left hip reported when standing long periods of time. Denies history of falls or injury. Denies hearing a clicking or snapping sound. Denies discomfort with pelvic rotation. Denies noticing lengthening of the extremity.
OBJECTIVE:
CONSTITUTIONAL: blood pressure 128/84, heart rate 80 respirations 20, temperature 98.5 height 5’3”, weight 130 pounds. Reports pain 8/10 BMI 23
Neurologic: Sensation intact to bilateral upper and lower extremities; Bilateral UE/LE strength 5/5.
HEENT: Head normocephalic without evidence of masses or trauma. PERRLA, EOMs intact. Noninjected. Fundoscopic exam unremarkable. Ear canal without redness or irritation, TMs clear, pearly, bony landmarks visible. No discharge, no pain noted. Neck negative for masses. No thyromegaly. No JVD distention.
Cardiovascular: S1 and S2 RRR, no murmurs, no rubs
Respiratory: Clear to auscultation
Gastrointestinal: Soft, nontender, nondistended, bowel sounds present all 4 quadrants, no organomegaly, and no bruits
Musculoskeletal: No pain to palpation; Antalgic gait noted when patient rises from seated position to standing and begins to walk. Active and passive ROM decreased with stiffness
Integumentary: intact
ASSESSMENT:
OA (ICD10 M16.12) often referred to as degenerative joint disease that occurs to normal wear and tear. This occurs due to the cartilage between the joints break down causing pain, swelling and stiffness of the joints (Cooper, Javaid & Arden, 2014) Signs and symptoms include stiff and sore joints mostly affecting the hips, back and knees. Positive findings in Mrs. R include pain in the hip, which has progressively gotten worse occurring almost constant.
Osteoporosis (ICD10 M81.0) Osteoporosis occurs due to age, hormonal changes and deficiency of vitamin D and calcium. The bones become brittle and weak. Osteoporosis bone loss occurs more rapidly where new bone production is not sufficient. This can result in spontaneous fractures (Wright, Looker, Saag, Curtis, Delzell, Randall & Dawson‐Hughes, 2014). Signs and symptoms are not usually present until a fracture occurs. Some patients may display loss of height and pain at affected site. Positive findings in Mrs. R include pain in the hip area.
Left hip fracture (ICD 10 S72) a hip fracture can occur due to injury or osteoporosis. The fracture may occur at different areas of the hip. Fracture may occur even without injury due to patient being unaware of osteoporosis presence (Wright, Looker, Saag, Curtis, Delzell, Randall & Dawson‐Hughes, 2014). Signs and symptoms include pain at the affected site, shortening of the affected extremity, swelling and bruising. Positive findings include pain in the hip, inability to bear weight and progressive pain.
PLAN:
According to the arthritis foundation laboratory testing is not necessary to make the diagnosis however some may be helpful.
– X-ray can reveal cartilage loss by showing a narrowing of the space between the bones in the joints. There is also the presence of bone spur. There is increased density of subchondral bone (Codina, 2014).
– CBC with differential to monitor current WBC levels to check for possible infection and hbg for anemia. Lab testing rules out other causes of OA symptoms not the disease itself (Codina, 2014).
– BUN and Cr and hepatic panel for use of Cymbalta. Should not be used in hepatic impairment or CrCl <30 (Codina, 2014).

Pharmacologic treatment
NSAIDS is the most common treatment recommended for arthritic pain however it is not recommended for long term use do to inflammation being a minor contributor to the symptoms (Condina, 2014), NSAID would be more specific for mild cases of OA. She stated she is taking extra medication to provide relief that dose needs to be clarified. I would discontinue Ibuprofen at this point and begin the patient in an opioid analgesic such as tramadol used to manage moderate to severe pain. Cymbalta that has also been approved for the treatment of chronic arthritis pain (Codina, 2014).
• Cymbalta 30mg tab; SIG take 1 tablet every day. Refill 0
• Tylenol 650mg tablets; SIG 1 tablet by mouth every 6 hr. as needed for pain.
• Refill OTC medication #1

Non-Pharmacologic treatment
– Continue walking when pain is relieved. Exercise maintains joint mobility
– Keep joints moving; perform ROM exercises while at home such as straight leg raises, stretching adductors, rotator and gluteal muscles.
– Hot and cold compresses to affected area relieve pain and inflammation.
– Aerobic exercises to maintain joint function and disease progression.
– Avoid high impact exercises

Education
You have been diagnosed with OA with is a condition that causes chronic pain. Pain management, preventing further articular cartilage destruction and maintaining joint function are goals of treatment. You have been prescribed Cymbalta used to treat chronic pain as in OA. Do not crush or open capsule. Take daily as ordered. Dose may be increased in one week if symptoms do not subside. Contact practitioner does not up your own dose. Do not exceed recommended dose and do not take OTC pain relievers or herbal supplements. Consult with practitioner of any OTC or herbal medications you may be taking. Tylenol was prescribed as well to treat pain. If medication on follow up appointment is ineffective a mild opioid analgesic may be ordered. May impair judgment use caution. Report to NP any symptoms of confusion, lethargy, depression, suicidal ideations, and seizures (Goroll & Mulley, 2014)
Follow-ups/Referrals
Follow up in one week to evaluate current pain management and laboratory testing results. Referral to PT for Therapy to maintain joint function, proper ROM exercises to perform at home. Decrease pain and prevent further deterioration of joint.
No other referrals needed now.
References
Codina Leik, T. M. (2014). Family Nurse Practitioner Certification Intensive Review. New York: Springer.
Cooper, C., Javaid, M. K., & Arden, N. (2014). Epidemiology of osteoarthritis. In Atlas of Osteoarthritis (pp. 21-36). Springer Healthcare Ltd.
Wright, N. C., Looker, A. C., Saag, K. G., Curtis, J. R., Delzell, E. S., Randall, S., & Dawson‐Hughes, B. (2014). The recent prevalence of osteoporosis and low bone mass in the United States based on bone mineral density at the femoral neck or lumbar spine. Journal of Bone and Mineral Research, 29(11), 2520-2526.
Guidelines for Focused SOAP Notes
· Label each section of the SOAP note (each body part and system).
· Do not use unnecessary words or complete sentences.
· Use Standard Abbreviations
S: SUBJECTIVE DATA (information the patient/caregiver tells you).
Chief Complaint (CC): a statement describing the patient’s symptoms, problems, condition, diagnosis, physician-recommended return(s) for this patient visit. The patient’s own words should be in quotes.
History of present illness (HPI): a chronological description of the development of the patient’s chief complaint from the first symptom or from the previous encounter to the present. Include the eight variables (Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Treatment, Severity-OLDCARTS), or an update on health status since the last patient encounter.
Past Medical History (PMH): Update current medications, allergies, prior illnesses and injuries, operations and hospitalizations allergies, age-appropriate immunization status.
Family History (FH): Update significant medical information about the patient’s family (parents, siblings, and children). Include specific diseases related to problems identified in CC, HPI or ROS.
Social History(SH): An age-appropriate review of significant activities that may include information such as marital status, living arrangements, occupation, history of use of drugs, alcohol or tobacco, extent of education and sexual history.
Review of Systems (ROS). There are 14 systems for review. List positive findings and pertinent negatives in systems directly related to the systems identified in the CC and symptoms which have occurred since last visit; (1) constitutional symptoms (e.g., fever, weight loss), (2) eyes, (3) ears, nose, mouth and throat, (4) cardiovascular, (5) respiratory, (6) gastrointestinal, (7) genitourinary, (8) musculoskeletal, (9-}.integument (skin and/or breast), (10) neurological, (11) psychiatric, (12) endocrine, (13) hematological/lymphatic, {14) allergic/immunologic. The ROS should mirror the PE findings section.
0: OBJECTIVE DATA (information you observe, assessment findings, lab results).
Sufficient physical exam should be performed to evaluate areas suggested by the history and patient’s progress since last visit. Document specific abnormal and relevant negative findings. Abnormal or unexpected findings should be described. You should include only the information which was provided in the case study, do not include additional data.
Record observations for the following systems if applicable to this patient encounter (there are 12 possible systems for examination): Constitutional (e.g. vita! signs, general appearance), Eyes, ENT/mouth, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin, Neurological, Psychiatric, Hematological/lymphatic/immunologic/lab testing. The focused PE should only include systems for which you have been given data.
NOTE: Cardiovascular and Respiratory systems should be assessed on every patient regardless of the chief complaint.
Testing Results: Results of any diagnostic or lab testing ordered during that patient visit.
A: ASSESSMENT: (this is your diagnosis (es) with the appropriate ICD 10 code)
List and number the possible diagnoses (problems) you have identified. These diagnoses are the conclusions you have drawn from the subjective and objective data.
Remember: Your subjective and objective data should support your diagnoses and your therapeutic plan.
Do not write that a diagnosis is to be “ruled out” rather state the working definitions of each differential or primary diagnosis (is).
For each diagnosis provide a cited rationale for choosing this diagnosis. This rationale includes a one sentence cited definition of the diagnosis (is) the pathophysiology, the common signs and symptoms, the patients presenting signs and symptoms and the focused PE findings and tests results that support the dx. Include the interpretation of all lab data given in the case study and explain how those results support your chosen diagnosis.
P: PLAN (this is your treatment plan specific to this patient). Each step of your plan must include an EBP citation.
1. Medications write out the prescription including dispensing information and provide EBP to support ordering each medication. Be sure to include both prescription and OTC medications.
2. Additional diagnostic tests include EBP citations to support ordering additional tests
3. Education this is part of the chart and should be brief, this is not a patient education sheet and needs to have a reference.
4. Referrals include citations to support a referral
5. Follow up. Patient follow-up should be specified with time or circumstances of return. You must provide a reference for your decision on when to follow up.

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By | 2019-09-14T15:54:29+00:00 September 14th, 2019|Nursing|