Soap Note 2 Chronic Conditions

   Soap Voice 2 Chronic Conditions Soap Voice  Chronic Conditions (15 Points) Pick any Chronic Malady from Weeks 6-10 Soap voices obtain be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)  Follow the MRU Soap Voice Rubric as a guide Turn it in Score must be short than 50% or obtain not be veritable for security, must be your own result and in your own suffrage. You can resubmit, Final yielding obtain be veritable if short than 50%. Copy paste from websites or textbooks obtain not be veritable or tolerated. Please see College Handbook after a while regard to Academic Misconduct Statement   Please use one of the templates supposing to format your soap voice. Protect these templates for forthcoming clinical rotations.                          SAMPLE Block format Soap Voice   Template.docx     Sample Soap Voice Template.docx PATIENT INFORMATION Name: Mr. W.S. Age: 65-year-old Sex: Male Source: Patient Allergies: None Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime PMH: Hypercholesterolemia Immunizations: Influenza ultimate 2018-year, tetanus, and hepatitis A and B 4 years ago. Surgical History: Appendectomy 47 years ago. Family History: Father- died 81 does not narration counsel Mother-alive, 88 years old, Diabetes Mellitus, HTN Daughter-alive, 34 years old, healthy Social Hx: No smoking fact or illicit refuse use, occasional alcoholic beverage lessening on gregarious celebrations. Retired, widow, he lives fantastical. SUBJECTIVE: Chief complain: “headaches” that inaugurated two weeks ago Symptom analysis/HPI: The enduring is 65 years old manful who dissatisfied of episodes of mindaches and on 3 opposed occasions pursuit urgency was measured, which was lofty (159/100, 158/98 and 160/100 respectively). Enduring noticed the tenor inaugurated two weeks ago and sometimes it is accompanied by dizziness. He states that he has been underneathneath importance in his resultsituate for the ultimate month. Patient denies chest suffering, palpitation, omission of exhalation, abomination or vomiting. ROS: CONSTITUTIONAL: Denies heat or chills. Denies inconclusiveness or impressiveness injury. NEUROLOGIC: Headache and dizzeness as illustreprimand balancehead. Denies alters in LOC. Denies fact of tremors or seizures.  HEENT: HEAD: Denies any mind waste, or alter in LOC. Eyes: Denies any alters in longing, diplopia or blurred longing. Ear: Denies suffering in the ears. Denies injury of hearing or drainage. Nose: Denies nasal drainage, accumulation. THROAT: Denies throat or neck suffering, hoarseness, awkwardness gluttony. Respiratory: Enduring denies omission of exhalation, cough or hemoptysis. Cardiovascular: No chest suffering, tachycardia. No orthopnea or paroxysmal nocturnal dyspnea. Gastrointestinal: Denies abdominal suffering or trouble. Denies flatulence, abomination, vomiting or diarrhea. Genitourinary: Denies hematuria, dysuria or alter in urinary abundance. Denies awkwardness starting/stopping flow of urine or incontinence. MUSCULOSKELETAL: Denies falls or suffering. Denies hearing a clicking or snapping investigate. Skin: No alter of coloration such as cyanosis or jaundice, no rashes or pruritus. Objective Data CONSTITUTIONAL: Vital signs: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on compass air, Ht- 6’4”, Wt 200 lb, BMI 25. Narration suffering 0/10. General appearance: The enduring is lively and oriented x 3. No intelligent diimportance voiced. NEUROLOGIC: Alert, CNII-XII grossly uncorrupted, oriented to special, situate, and season. Sensation uncorrupted to bilateral eminent and inferior extremities. Bilateral UE/LE ability 5/5. HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no benevolence. Eyes: No conjunctival introduction, no icterus, visual acuity and extraocular eye movements uncorrupted. No nystagmus voiced. Ears: Bilateral canals evident after a whileout erythema, edema, or exudate. Bilateral tympanic membranes uncorrupted, pearly frosty after a while severe cone of easy. Maxillary sinuses no benevolence. Nasal mucosa lively after a whileout bleeding. Oral mucosa lively after a whileout lesions,.Lids non-remarkable and misapply for pursuit. Neck: adulatory after a whileout cervical lymphadenopathy, no jugular disposition distention, no thyroid protuberance or concretiones. Cardiovascular: S1S2, formal reprimand and rhythm, no babble or gallop voiced. Capillary refill < 2 sec. Respiratory: No dyspnea or use of assistant muscles observed. No egophony, whispered pectoriloquy or substantial fremitus on palpation. Exhalation investigates confer-upons and free bilaterally on auscultation. Gastrointestinal: No concretion or hernia observed. Upon auscultation, bowel investigates confer-upon in all foul-mouthed quadrants, no bruits balance renal and aorta arteries. Abdomen luxurious non-tender, no enriching, no recoil no distention or organomegaly voiced on palpation Musculoskeletal: No suffering to palpation. Active and inert ROM after a whilein recognized limits, no slang. Integumentary: uncorrupted, no lesions or rashes, no cyanosis or jaundice. Assessment  Essential (Primary) Hypertension (ICD10 I10): Given the symptoms and lofty pursuit urgency (156/92 mmhg), classified as step 2. Once the radical suit of hypertension has been determined out, such as renal, adrenal or thyroid, this peculiarity is grown. Differential peculiarity: Ø Renal artery stenosis (ICD10 I70.1) Ø Chronic relationship malady (ICD10 I12.9) Ø Hyperthyroidism (ICD10 E05.90) Plan Diagnosis is inveterate on the clinical evaluation through fact, material test, and order laboratory tests to assess facilitate factors, discover identifiable suits and expose target-organ injury, including deposition of cardiovascular malady. These basic laboratory tests are: · CMP · Complete pursuit count · Lipid profile · Thyroid-stimulating hormone · Urinalysis · Electrocardiogram Ø Pharmacological treatment:  The treatment of dainty in this occurrence would be: Thiazide-like diuretic and/or a CCB · Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily.  Ø Non-Pharmacologic treatment:  · Impressiveness injury · Healthy food (DASH foodary mould): Food superb in income, vegetables, healthy grains, and low-fat dairy products after a while mean pleased of saturated and trans l fat · Mean intake of foodary sodium: <1,500 mg/d is optimal goal but at smallest 1,000 mg/d diminution in most adults · Enhanced intake of foodary potassium · Formal material intelligence (Aerobic): 90–150 min/wk · Tobacco cessation · Measures to loose importance and telling coping mechanisms. Education · Provide after a while nutrition/dietary counsel. · Daily pursuit urgency monitoring at home twice a day for 7 days, protect a archives, cause the archives on the proximate mark after a while her PCP · Instruction about medication intake consent.  · Education of likely complications such as pat, feeling aggression, and other tenors. · Enduring was educated on method of hypertension, as courteous as premonition signs and symptoms, which could show the demand to watch the E.R/U.C. Answered all pt. questions/concerns. Pt verbalizes underneathstanding to all Follow-ups/Referrals · Evaluation after a while PCP in 1 weeks for managing pursuit urgency and to evaluate running hypotensive therapy. Urgent Care mark prn. · No referrals demanded at this season. References Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Clinical Consult 2017 (25th ed.). Print (The 5-Minute Consult Series). Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.). ISBN 978-0-8261-3424-0