Soap note pediatrics Nur507

Health Medical

NUR507

florida international

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I'm working on a nursing project and need guidance to help me study.

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I need assistance with a SOAP note for advance FNP children and family. the pediatric patient must be 8 years old

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Encounter date: 10/19/2020 Subjective Data Patient Initials: MJ Gender: Male Age: 71 Race/Ethnicity: African American Reason for Seeking Health Care: “I have abdominal pain and pain with passing urine and fever for the past 3 days.” HPI: 71-year-old African American male presents to the clinic complaining of intermittent, nonradiating right and left lower quadrant (RLQ and LLQ) abdominal pain associated with chills, low grade fever, and dysuria and foul-smelling urine nausea, nocturia, urinary frequency, urgency, and dribbling started 3 days ago and progressively getting worse with urination. The patient states that he was sitting down watching television when the pain started. He describes the pain as dull and burning and reports the pain level as a 7 on a scale 0 to 10. The patient states that he has been taking ibuprofen 400mg orally for the pain every 6 hours as needed for the past 48 hours with no relief. The reports having similar symptoms previously for which he was treated for kidney stones and UTI. However, this time the patient reports that he is experiencing nocturia, what seems to hematuria, and painful ejaculation. The patient reports that he is sexually active and is in a monogamous relationship. He denies history of STIs and his wife has no symptoms of STIs. He denies penile discharge or bleeding, back or flank pain, and vomiting. Allergies: The patient denies allergies to drugs, food, environmental factors, herbal supplements and latex Current Perception of Health: Excellent Good Fair Poor Past Medical History • Major/Chronic Illnesses: Atherosclerotic cardiovascular disease (ASCVD), cardiomyopathy, hyperlipidemia, kidney stones, BPH and HTN, 1989, all active; heart failure (HF) and myocardial infarction (MI) in 1995 • Trauma/Injury: The patient denies trauma or injury. • Hospitalizations: The patient states that he was hospitalized in 1995 twice due to MI and HF, in 2009 for coronary artery bypass graft (CABG), and in 2011 for automated implantable cardioverter defibrillator (AICD) placement. Past Surgical History Appendectomy at age 18 for perforated appendicitis CABG in 2009 with stent placement for triple coronary vessel occlusion AICD placement in 2011 for severe cardiomyopathy Joseph, M. (2020) Older Adult SOAP Note Sample © 1 Medications Aspirin 81 mg oral daily for ASCVD, last dose this morning Plavix 75 mg oral daily for ASCVD, last dose this morning Carvedilol 25mg oral daily for HFrEF, ASCVD last dose yesterday Lisinopril 40 mg oral daily for HFrEF, HTN, last dose this morning Simvastatin 40 mg oral at bedtime for hyperlipidemia, last dose yesterday Spironolactone 12.5 mg oral daily for HTN, HFrEF, last dose yesterday Norvasc 5 mg oral daily for HTN, last dose yesterday Ibuprofen 200 mg 2 tablets every 6 hours as needed for pain, last dose (last night). Family History The patient reports that he is the only child. He has no siblings. His paternal and maternal grandparents all died of natural causes. His father died at age 45 from myocardial infarction and his mother died at age 63 from complication of colon cancer. The patient denies family history of glaucoma, pulmonary disease, congenital abnormalities, diabetes, tuberculosis, kidney disease, epilepsy, or mental illness. Social History Lifestyle: The patient reports that he lives in a one-story single-family home with his spouse. He reports that he has family, friends and strong social support; enjoys daily walks and family visits. Marital Status: married at age 20, has three living children in their 30’s and six grandchildren with no health problems Occupation: Retired police officer Education: graduated high school Religion: Catholic Tobacco: The patient reports smoking 1 pack of cigarettes per day for 20 years. However, he stopped smoking 10 years ago. ETOH/Drugs: Denies alcohol and illicit drug. Sexual orientation: The patient reports that she is heterosexual and is sexually active with her husband. She denies use of contraception when she is having sexual activity. Family Composition: Has three living children and spouse. All children are married. Health Maintenance/Screening Tests Last colonoscopy, 10/2010, normal Fecal occult blood test (FOBT), 2019, normal Prostate specific antigen (PSA), 2018, 52 Immunization History: Influenza 2019, Pneumococcal vaccination 2019, Tdap 2015, Varicella Zoster 2016. Safety: The patient reports that he uses seat belt and sunblock regularly. Medications are kept in an unlocked medicine cabinet. Cleaning solutions in unlocked cabinet below sink. Shotgun and box of shells are kept in unlocked closet upstairs. Review of Systems Joseph, M. (2020) Older Adult SOAP Note Sample © 2 General: Reports chills and low-grade fever, unknown temperature. Denies unintentional weight loss, weight gain or changes. Denies fatigue and weakness. Dermatology: Denies rash, pruritis, dryness, skin cancer, lesion, bruises, or discoloration. HEENT Eyes: Reports that he wears glasses for reading, last eye exam in 2019, normal. Denies use of contact lenses, changes in vision, poor eyesight, eye pain, discharge or excessive tearing. Ears: Denies loss of hearing, changes in hearing, ear pain, or tinnitus. Nose: Denies changes or loss of sense of smell, runny nose, nasal congestion sinus problems, itching, sneezing, or nose bleeds. Mouth: Admits to using dentures and cleaning them daily. Denies dental disease, ulceration, or lesions in the tongue or gingivitis, last dental visit 02/2020. Throat: Denies throat pain, hoarseness or dysphagia. Lungs: Denies cough, dyspnea, hemoptysis or wheezing. Cardiovascular: Denies chest pain, palpitations, orthopnea, dyspnea on exertion or swelling. Breast: Denies lumps, bumps, nipple discharges, or changes. GI: Reports 7/10 intermittent, non-radiating lower abdominal pain, described as dull, associated with nausea. Denies vomiting, reflux, heartburn, diarrhea, constipation, melena or hematochezia. Reports last BM yesterday, but states that stools are more formed than usual and normal routine is to have a BM every morning. Male/female genital: Denies penile discharge, bleeding, itching, vaginal dryness, or dyspareunia. Denies history of STIs. Reports being sexually active with spouse. Denies use of condoms during sexual intercourse. GU: Reports nocturia, dysuria upon urination, urinary urgency, frequency onset 3 days (Refer to HPI), dribbling, and week stream. Admits to history of multiple episodes kidney stones. Denies hematuria. Musculoskeletal: Denies stiffness, trauma, back pain, joint swelling, or fracture. Denies changes in ROM. Neuro: Denies headaches, memory loss, syncope, seizures, tremors, weakness or paresthesia Psychologic: Denies mood changes or swing, anxiety, nervousness, depression or psychiatric disorders Integumentary: Denies any changes in skin, hair or nails Joseph, M. (2020) Older Adult SOAP Note Sample © 3 Endocrine: Denies cold or heat temperature intolerance, denies polydipsia, polyphagia, polyuria, and/or changes in skin, hair, or nails Hematologic/Lymphatic: Denies anemia, history of blood transfusions, easy bruising, fatigue, swollen or tender glands. Allergic/Immunologic: Denies allergies and use of steroids Activity & Exercise: Reports daily walking Nutrition: Reports diet high in carbohydrates and fat. Denies anorexia or bulimia Sleep/Rest: Reports 7 to 8 hours of sleep per night. Denies insomnia LMP: Not applicable Objective Data Physical Examination BP: 138/72, right arm, sitting Temp: 100.2oF, oral HR: 94 RR:18 Ht.: 5’8” (175.26 cm) Wt.: 202 lbs. (91.8 kg) BMI: 30 Pain: 7/10. General: Mr. MJ is 71-year-old African American man who is obese, cooperative, pleasant and responds to questions appropriately. He is well-nourished and well groomed. Dermatology: Skin is warm, dry and intact. Skin color is good and evenly pigmentated for ethnicity. No rashes or lesions noted. HEENT. Head: Normocephalic and atraumatic (NC/AT), scalp without lesions. Hair is dark, of average texture, and evenly distributed. Eyes: Conjunctiva pink, sclera white. Pupils 4mm constricting to 3 mm, round, regular, equally reactive to light and accommodation (PERRLA). Extraocular movements (EOMs) intact. Disc margins sharp, without hemorrhages or exudates. No arteriolar narrowing or A-V nicking. Vision 20/30 bilaterally. Visual fields full by confrontation. Ears: Tympanic membranes (TM pearly gray with good cone of light. Acuity good to whispered voice. Weber midline. AC > BC. Nose: Mucosa pink, septum midline. No sinus tenderness. Mouth: Oral mucosa moist and pink. Dentition good. Tongue midline, no ulcerated areas noted. Tonsils absent. Pharynx without exudates. Neck: Supple. Trachea midline. Thyroid isthmus barely palpable, lobes not felt. No lymphadenopathy. Joseph, M. (2020) Older Adult SOAP Note Sample © 4 Pulmonary: Thorax symmetric with good excursion. Lungs resonant to percussion. Breath sounds clear to auscultation bilaterally with no adventitious breath sounds. Diaphragms descend 4 cm bilaterally. Cardiovascular: Regular rate and rhythm, audible S1 and S2, no S3, S4, clicks, rubs, or murmurs. No jugular venous distention (JVD) present. Carotid upstrokes brisk, without bruits. Apical impulse discrete and tapping, barely palpable in the 4th left intercostal space midclavicular line. Capillary refill 2 seconds. Radial, posterior tibial and dorsalis pedis pulses 2+ bilaterally. No edema observed. Last EKG 2019 reviewed, NSR. Breasts: Pendulous, symmetric. No masses; nipples without discharge. GI: Protuberant. Well-healed scar, right lower quadrant noted on inspection. No evidence of hernia or mass. Normoactive bowel sounds X4 quadrants on auscultation. Soft, non-distended, no masses palpated, mild to moderate RLQ and LLQ tenderness on palpation. Liver span 8 cm in right midclavicular line; edge smooth, palpable 1 cm below right costal margin (RCM). Spleen and kidneys not felt. Presence of costovertebral angle tenderness (CVAT). No guarding or rebound tenderness. Male/female genital: External genitalia without lesions and discharge. Rectal: Digital rectal exam (DRE) is deferred this visit to avoid interference with PSA serum level. GU: Suprapubic area is non-distended. Musculoskeletal: No tenderness to palpation. No joint deformities. Good range of motion in hands, wrists, elbows, shoulders, spine, hips, knees, ankles. Neurologic. Mental Status: Alert and cooperative. Speech clear. Thought coherent. Oriented to person, place, time and situation. Cranial Nerves: II-XII intact. Motor: Good muscle bulk and tone. Strength 5/5 in all extremities. Cerebellar: Posture erect, gait steady. Rapid alternating movements (RAMs), point-to-point movements intact. Sensory: Pinprick, light touch, position sense, vibration, and stereognosis intact. Romberg negative. Reflexes: Biceps, brachioradialis and patellar reflexes 2+ bilaterally. Psych: Pleasant. Depression screening- PHQ-2 was negative for depression. Geriatric depression scale: total points = 4 which indicates no depression Laboratory/Imaging Data: No recent labs or diagnostic studies to review Significant/Contributing Data: Age, history of multiple episodes of kidney stones, Abdominal pain, low-grade fever, chills, dysuria, urinary frequency, urgency Urinalysis dipstick in the office positive for leukocyte esterase, nitrite, and tea colored Joseph, M. (2020) Older Adult SOAP Note Sample © 5 Assessment Differential Diagnoses 1. Prostatitis - due to lower abdominal pain, dysuria, weak stream, slight fever, and nausea 2. Pyelonephritis - due to CVAT, intermittent lower abdominal pain, slight fever, and nausea 3. Nephrolithiasis - due to intermittent lower abdominal pain (location of pain) and nausea Primary Diagnoses 1. 2. 3. 4. 5. Acute prostatitis Pyelonephritis Nephrolithiasis Obesity ASCVD Plan Diagnosis #1, 2, 3: Acute prostatitis, pyelonephritis, nephrolithiasis Laboratory/Diagnostic Tests • UA with micro and urine culture CBC with Diff, CRP, CMP, serum PSA CT scan of abdomen and pelvis without contrast • Pap smear done today, awaiting result. Therapeutic • Prescribed Pharmacological Therapy: Cipro 500 mg orally twice daily for 14 days. Indication: To treat common bacterial infections associated with prostatitis, urinary infections MOA: inhibition of enzymes which are required for bacterial DNA replication, transcription, repair, and recombination. Usual dosage: 500mg PO every12 hr for 28 days Available as name brand, generic or both: Both Cost of med: CVS – 20 tabs $26.19, 60 tabs $72.99 Walmart – 20 tabs $4.00, 60 tabs $10.00 Ibuprofen 400 mg oral every 6 hour as needed for pain/fever • • Drink plenty of fluids. No bathtub, no douching. Frequent urination. Education Joseph, M. (2020) Older Adult SOAP Note Sample © 6 Pt. counseled regarding disease process, medications, activity limitations and symptomatic treatment. • Drink plenty of liquids, especially water. • Urinate frequently. If you feel the urge to urinate, do not delay using the toilet. • PSA is elevated secondary to acute prostatitis. Follow up to Have PSA checked regularly and follow up with urologist. Follow-up: Return to clinic in 3 days, sooner if worsening of symptoms or allergic reaction to the antibiotic. Repeat PSA in 2 months Referrals: Urologist tomorrow Diagnosis # 4, 5: ASCVD, Obesity Diagnostic Tests: Not warranted Therapeutic • Continue current medications as prescribed (See medication history) • Keep food intake diary and bring it to next visit • Consider dietician referral next visit • Weight reduction o Increase physical activity 30 to 50 minutes per day, three to five days per week o 1000 kcal per day, low-fat diet • Pharmacological Therapy: Not warranted Education • Reduce your weight at a rate of 1 to 2 lbs. per week for eight weeks Eat a healthy diet rich in fruits and vegetables whole grains and low-calorie. Avoid highfat foods. • Avoid junk foods such as sweets, potato chips, French fries, ice cream etc. • Avoid between meal snacking, remember, everything you put in your mouth may increase your weigh. • Reduce portion size, and do not go back for seconds. It is better to eat 2-3 small meals a day than one large meal. • Avoid sugared drinks, water or diet drinks are the only options • Exercise is an important part of losing weight and keeping it off. Increase your physical activity 30 to 40 minutes per day three to five times per week. • No smoking • Get regular health screenings to include BP, Cholesterol checks, DM, CA, colonoscopy, dental, eye Follow-up: Return to clinic in 4 weeks Referrals: Not warranted. Joseph, M. (2020) Older Adult SOAP Note Sample © 7 Health Maintenance/Anticipatory Guidance: • PSA screening more frequently Q 3-6 months • Yearly physical exam with PCP • Encouraged yearly immunizations (Influenza, Zoster), pneumococcal and Tdap every 10 years; Schedule Influenza vaccine August 2020; Schedule pneumococcal vaccine August 2029. • Educated on the importance of maintaining a healthy lifestyle, no smoking, exercise daily, and eat a healthy diet. • Schedule GI referral for colonoscopy next visit after the infection is treated • Yearly FOBT – schedule for next visit • Awaiting Pap smear result done today. Schedule Pap smear next year. • Provide three stool guaiac cards; next screening colonoscopy in 2028. • Advised the patient to move medications, caustic cleaning agents, gun and ammunition to locked cabinet, if possible, above shoulder height. • Encouraged to continue having yearly eye screenings, eye and dental exams Signature (with appropriate credentials): Magdaleina V. Joseph, MSN, FNP Student Joseph, M. (2020) Older Adult SOAP Note Sample © 8 STU Clinic 16401 NW 37th Avenue Miami Gardens, FL 33054 Phone (305) 555-1234; FAX: (305) 555-12222 Name: (Initials): MJ____________________ Age: 71__ Date: 10/20/2020 RX: Cipro 500 mg orally every 12 hours for 14 days SIG: Take 1 tablet by mouth every 12 hours, 1 in the morning after breakfast, 1 after dinner Dispense: 28 tablets Refills: None X No Substitution X X x Signature: Magdaleina V. Joseph, MSN, FNP Student DEA#: 101010101; NPI# 10000000 Joseph, M. (2020) Older Adult SOAP Note Sample © 9 References Joseph, M. (2020) Older Adult SOAP Note Sample © 10 Distinguised Excellent Fair Poor Includes a direct quote from patient about presenting problem Includes a direct quote from patient and other unrelated information Includes information but information is NOT a direct quote Information is completely missing 4 Points Begins with patient initials, age, race, ethnicity and gender (5 demographics) 3 Points Begins with 4 of the 5 patient demographics (patient initials, age, race, ethnicity and gender) 2 Points Begins with 3 or less patient demographics (patient initials, age, race, ethnicity and gender) Information is completely missing 2 Points 1.5 Points 1 Points 0 Points Includes the presenting problem and the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity) Includes the presenting problem and 7 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity) Includes the presenting problem and 6 of the 8 dimensions of the problem (OLD CARTS – Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity) Information is completely missing 5 Points 3 Points 2 Points 0 Points If allergies are present, students lists only the type of allergy name Information is completely missing 1 Points 0 Points Subjective Chief Complaint (Reason for seeking health care) Demographics History of the Present Illness (HPI) Allergies Includes NKA (including = Drug, If allergies are present, students lists type Drug, Environemental, Food, Herbal, and/or Latex environemtal factor, herbal, food, latex name and or if allergies are present (reports for each includes severity of allergy OR description of severity of allergy AND description of allergy allergy) 2 Points Review of Systems (ROS) 1.5 Points Includes 3 or fewer assessments for each body Includes 3 or fewer assessments for each body Includes a minimum of 3 assessments for each body system and assesses at least 9 system and assesses 5-8 body systems directed to system and assesses less than 5 body systems chief complaint AND uses the words “admits” directed to chief complaint OR student does not body systems directed to chief complaint use the words “admits” and “denies” and “denies” AND uses the words “admits” and “denies” 12 Points 6 Points 3 Points 0 Points Information is completely missing 0 Points Objective Vital Signs Includes all 8 vital signs, (BP (with patient Includes 7 vital signs, (BP (with patient position), Includes 6 or less vital signs, (BP (with patient position), HR, RR, temperature (with HR, RR, temperature (with Fahrenheit or Celsius position), HR, RR, temperature (with Fahrenheit Fahrenheit or Celsius and route of and route of temperature collection), weight, or Celsius and route of temperature collection), Information is completely missing temperature collection), weight, height, BMI height, BMI (or percentiles for pediatric weight, height, BMI (or percentiles for pediatric (or percentiles for pediatric population) and population) and pain.) population) and pain.) pain.) 2 Points Labs Medications Includes a list of the labs reviewed at the visit, values of lab results and highlights abnormal values OR acknowledges no labs/diagnostic tests were reviewed. 3 Points Includes a list of all of the patient reported medications and the medical diagnosis for the medication (including name, dose, route, frequency) 1.5 Points Includes a list of the labs reviewed at the visit, values of lab results but does not highlight abnormal va ...
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