Posted: May 1st, 2022

case discussion(SOAP NOTE)

TITLE: NASAL FRACTURE

EXAMPLE: SOAP NOTE
  
Cleansing cleaning soap Bear in mind # Important Prognosis ( Exp: H&P Bear in mind #three DX: Hypertension)
Pupil Determine
Miami Regional Faculty
Date of Encounter:
Preceptor/Medical Website online:
Medical Trainer: Dr. Rafael Camejo
  
Cleansing cleaning soap Bear in mind # Important Prognosis ( Exp: Cleansing cleaning soap Bear in mind #three DX: Hypertension)
PATIENT INFORMATION
Determine: Mr. DT
Age: 68-year-old
Gender at Starting: Male
Gender Id: Male
Provide: Affected particular person
Allergic reactions: PCN, Iodine
Current Medicine: 
· Atorvastatin tab 20 mg, 1-tab PO at bedtime
· ASA 81mg po daily
· Multi-Vitamin Centrum Silver
PMH: Hypercholesterolemia
Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years prior to now.
Preventive Care: Coloscopy 5 years prior to now (Detrimental) 
Surgical Historic previous: Appendectomy 47 years prior to now.
Family Historic previous: Father- died 81 does not report information
 Mother-alive, 88 years outdated, Diabetes Mellitus, HTN
Daughter-alive, 34 years outdated, healthful
Social Historic previous: No smoking historic previous or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
Sexual Orientation: Straight
Food plan Historic previous: Diets on and off, Does not each seafood 
Subjective Data:
Chief Grievance: “problems” that started two weeks prior to now
Symptom analysis/HPI:
The affected particular person is 65 years outdated male who complaining of episodes of problems and on three completely totally different occasions blood stress was measured, which was extreme (159/100, 158/98 and 160/100 respectively). Affected particular person noticed the difficulty started two weeks prior to now and usually it is accompanied by dizziness. He states that he has been beneath stress in his workplace for the ultimate month. Affected particular person denies chest ache, palpitation, shortness of breath, nausea or vomiting.
Assessment of Applications (ROS)
CONSTITUTIONAL: Denies fever or chills. Denies weak level or weight discount. NEUROLOGIC: Headache and dizziness as describe above. Denies changes in LOC. Denies historic previous of tremors or seizures. 
HEENT: HEAD: Denies any head harm, or change in LOC. Eyes: Denies any changes in imaginative and prescient, diplopia or blurred imaginative and prescient. Ear: Denies ache inside the ears. Denies lack of listening to or drainage. Nostril: Denies nasal drainage, congestion. THROAT: Denies throat or neck ache, hoarseness, drawback swallowing.
RESPIRATORY: Affected particular person denies shortness of breath, cough or hemoptysis.
CARDIOVASCULAR: No chest ache, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
GASTROINTESTINAL: Denies stomach ache or discomfort. Denies flatulence, nausea, vomiting or
diarrhea.
GENITOURINARY: Denies hematuria, dysuria or change in urinary frequency. Denies drawback starting/stopping stream of urine or incontinence.
MUSCULOSKELETAL: Denies falls or ache. Denies listening to a clicking or snapping sound.
SKIN: No change of coloration akin to cyanosis or jaundice, no rashes or pruritus.
Objective Data:
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 ache 2/10.
GENERAL APPREARANCE: The affected particular person is alert and oriented x three. No acute distress well-known. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to particular person, place, and time. Sensation intact to bilateral increased and reduce extremities. Bilateral UE/LE energy 5/5.
HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, seen acuity and extraocular eye actions intact. No nystagmus well-known. Ears: Bilateral canals patent with out erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of sunshine. Maxillary sinuses no tenderness. Nasal mucosa moist with out bleeding. Oral mucosa moist with out lesions,. Lids non-remarkable and acceptable for race.
Neck: supple with out cervical lymphadenopathy, no jugular vein distention, no thyroid swelling or lots.
CARDIOVASCULAR: S1S2, widespread price and rhythm, no murmur or gallop well-known. Capillary refill < 2 sec.
RESPIRATORY: No dyspnea or use of accent muscle teams seen. No egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on auscultation.
GASTROINTESTINAL: No mass or hernia seen. Upon auscultation, bowel sounds present in all four quadrants, no bruits over renal and aorta arteries. Abdomen tender non-tender, no guarding, no rebound no distention or organomegaly well-known on palpation
MUSKULOSKELETAL: No ache to palpation. Energetic and passive ROM inside common limits, no stiffness.
INTEGUMENTARY: intact, no lesions or rashes, no cyanosis or jaundice.
ASSESSMENT:
Important Prognosis
Essential (Primary) Hypertension (ICD10 I10): Given the indicators and hypertension (156/92 mmhg), labeled as stage 2. As quickly because the pure purpose for hypertension has been dominated out, akin to renal, adrenal or thyroid, this prognosis is confirmed (Codina Leik, 2015). Prognosis depends on the medical Assessment by the use of historic previous, bodily examination, and routine laboratory assessments to guage hazard components, reveal identifiable causes and detect target-organ harm, along with proof of coronary heart issues (Domino et al,. 2017).
Differential prognosis:
Ø Renal artery stenosis (ICD10 I70.1)
Ø Energy kidney sickness (ICD10 I12.9)
Ø Hyperthyroidism (ICD10 E05.90)
PLAN:
Labs and Diagnostic Check out to be ordered:
· CMP
· Full blood rely (CBC)
· Lipid profile
· Thyroid-stimulating hormone (TSH)
· Urinalysis with Micro
· Electrocardiogram (EKG 12 lead)
Pharmacological remedy: 
· Hydrochlorothiazide tab 25 mg, Preliminary dose: 25 mg orally as quickly as daily. 
· Lisinopril 10mg PO Every day
Non-Pharmacologic remedy: 
· Weight discount
· Nutritious food plan (DASH dietary pattern): Weight-reduction plan rich in fruits, greens, total grains, and low-fat dairy merchandise with diminished content material materials of saturated and trans l fat
· Decreased consumption of dietary sodium: <1,500 mg/d is ideal intention nonetheless on the very least 1,000 mg/d low cost in most adults
· Enhanced consumption of dietary potassium
· Widespread bodily train (Cardio): 90–150 min/wk
· Tobacco cessation
· Measures to launch stress and environment friendly coping mechanisms.
Coaching
· Current with vitamin/dietary information.
· Every day blood stress monitoring log at dwelling twice a day for 7 days, maintain a doc, carry the doc on the next go to collectively together with her PCP
· Instruction about drugs consumption compliance. 
· Coaching of doable issues akin to stroke, coronary coronary heart assault, and totally different points.
· Affected particular person was educated heading in the right direction of hypertension, along with warning indicators and indicators, which could level out the need to attend the E.R/U.C. Answered all pt. questions/points. Pt verbalizes understanding to all
Adjust to-ups/Referrals
· Adjust to up appointment 1 weeks for managing blood stress and to guage current hypotensive treatment.
· No referrals needed in the meanwhile.
References
Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Medical Search the recommendation of 2017
(25th ed.). Print (The 5-Minute Search the recommendation of Sequence).
Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Assessment (2nd ed.). 
ISBN 978-Zero-8261-3424-Zero

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