Posted: May 1st, 2022

case discussion(SOAP NOTE)

TITLE: NASAL FRACTURE

EXAMPLE: SOAP NOTE
  
Cleaning soap Be aware # Essential Prognosis ( Exp: H&P Be aware #three DX: Hypertension)
Pupil Identify
Miami Regional College
Date of Encounter:
Preceptor/Medical Web site:
Medical Teacher: Dr. Rafael Camejo
  
Cleaning soap Be aware # Essential Prognosis ( Exp: Cleaning soap Be aware #three DX: Hypertension)
PATIENT INFORMATION
Identify: Mr. DT
Age: 68-year-old
Gender at Beginning: Male
Gender Id: Male
Supply: Affected person
Allergic reactions: PCN, Iodine
Present Drugs: 
· Atorvastatin tab 20 mg, 1-tab PO at bedtime
· ASA 81mg po day by day
· Multi-Vitamin Centrum Silver
PMH: Hypercholesterolemia
Immunizations: Influenza final 2018: 2024 – Write My Essay For Me | Essay Writing Service For Your Papers Online-year, tetanus, and hepatitis A and B four years in the past.
Preventive Care: Coloscopy 5 years in the past (Detrimental) 
Surgical Historical past: Appendectomy 47 years in the past.
Household Historical past: Father- died 81 doesn’t report info
 Mom-alive, 88 years outdated, Diabetes Mellitus, HTN
Daughter-alive, 34 years outdated, wholesome
Social Historical past: No smoking historical past or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
Sexual Orientation: Straight
Diet Historical past: Diets on and off, Doesn’t every seafood 
Subjective Knowledge:
Chief Grievance: “complications” that began two weeks in the past
Symptom evaluation/HPI:
The affected person is 65 years outdated male who complaining of episodes of complications and on three totally different events blood stress was measured, which was excessive (159/100, 158/98 and 160/100 respectively). Affected person observed the issue began two weeks in the past and generally it’s accompanied by dizziness. He states that he has been beneath stress in his office for the final month. Affected person denies chest ache, palpitation, shortness of breath, nausea or vomiting.
Assessment of Programs (ROS)
CONSTITUTIONAL: Denies fever or chills. Denies weak point or weight reduction. NEUROLOGIC: Headache and dizziness as describe above. Denies adjustments in LOC. Denies historical past of tremors or seizures. 
HEENT: HEAD: Denies any head damage, or change in LOC. Eyes: Denies any adjustments in imaginative and prescient, diplopia or blurred imaginative and prescient. Ear: Denies ache within the ears. Denies lack of listening to or drainage. Nostril: Denies nasal drainage, congestion. THROAT: Denies throat or neck ache, hoarseness, problem swallowing.
RESPIRATORY: Affected person denies shortness of breath, cough or hemoptysis.
CARDIOVASCULAR: No chest ache, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
GASTROINTESTINAL: Denies belly ache or discomfort. Denies flatulence, nausea, vomiting or
diarrhea.
GENITOURINARY: Denies hematuria, dysuria or change in urinary frequency. Denies problem beginning/stopping stream of urine or incontinence.
MUSCULOSKELETAL: Denies falls or ache. Denies listening to a clicking or snapping sound.
SKIN: No change of coloration comparable to cyanosis or jaundice, no rashes or pruritus.
Goal Knowledge:
VITAL SIGNS: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’four”, Wt 200 lb, BMI 25. Report ache 2/10.
GENERAL APPREARANCE: The affected person is alert and oriented x three. No acute misery famous. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to individual, place, and time. Sensation intact to bilateral higher and decrease extremities. Bilateral UE/LE power 5/5.
HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visible acuity and extraocular eye actions intact. No nystagmus famous. Ears: Bilateral canals patent with out erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly grey 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 plenty.
CARDIOVASCULAR: S1S2, common fee and rhythm, no murmur or gallop famous. Capillary refill < 2 sec.
RESPIRATORY: No dyspnea or use of accent muscle groups noticed. No egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on auscultation.
GASTROINTESTINAL: No mass or hernia noticed. Upon auscultation, bowel sounds current in all 4 quadrants, no bruits over renal and aorta arteries. Stomach tender non-tender, no guarding, no rebound no distention or organomegaly famous on palpation
MUSKULOSKELETAL: No ache to palpation. Energetic and passive ROM inside regular limits, no stiffness.
INTEGUMENTARY: intact, no lesions or rashes, no cyanosis or jaundice.
ASSESSMENT:
Essential Prognosis
Important (Main) Hypertension (ICD10 I10): Given the signs and hypertension (156/92 mmhg), labeled as stage 2. As soon as the natural reason for hypertension has been dominated out, comparable to renal, adrenal or thyroid, this prognosis is confirmed (Codina Leik, 2015 – Research Paper Writing Help Service). Prognosis relies on the medical analysis by means of historical past, bodily examination, and routine laboratory assessments to evaluate danger elements, reveal identifiable causes and detect target-organ injury, together with proof of heart problems (Domino et al,. 2017).
Differential prognosis:
Ø Renal artery stenosis (ICD10 I70.1)
Ø Power kidney illness (ICD10 I12.9)
Ø Hyperthyroidism (ICD10 E05.90)
PLAN:
Labs and Diagnostic Take a look at to be ordered:
· CMP
· Full blood rely (CBC)
· Lipid profile
· Thyroid-stimulating hormone (TSH)
· Urinalysis with Micro
· Electrocardiogram (EKG 12 lead)
Pharmacological therapy: 
· Hydrochlorothiazide tab 25 mg, Preliminary dose: 25 mg orally as soon as day by day. 
· Lisinopril 10mg PO Each day
Non-Pharmacologic therapy: 
· Weight reduction
· Nutritious diet (DASH dietary sample): Weight-reduction plan wealthy in fruits, greens, entire grains, and low-fat dairy merchandise with diminished content material of saturated and trans l fats
· Decreased consumption of dietary sodium: <1,500 mg/d is perfect aim however at the very least 1,000 mg/d discount in most adults
· Enhanced consumption of dietary potassium
· Common bodily exercise (Cardio): 90–150 min/wk
· Tobacco cessation
· Measures to launch stress and efficient coping mechanisms.
Training
· Present with vitamin/dietary info.
· Each day blood stress monitoring log at dwelling twice a day for 7 days, hold a document, carry the document on the following go to together with her PCP
· Instruction about medicine consumption compliance. 
· Training of doable problems comparable to stroke, coronary heart assault, and different issues.
· Affected person was educated on the right track of hypertension, in addition to warning indicators and signs, which might point out the necessity to attend the E.R/U.C. Answered all pt. questions/issues. Pt verbalizes understanding to all
Comply with-ups/Referrals
· Comply with up appointment 1 weeks for managing blood stress and to guage present hypotensive remedy.
· No referrals wanted at the moment.
References
Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Medical Seek the advice of 2017
(25th ed.). Print (The 5-Minute Seek the advice of Sequence).
Codina Leik, M. T. (2014: 2024 – Essay Writing Service | Write My Essay For Me Without Delay). Household Nurse Practitioner Certification Intensive Assessment (2nd ed.). 
ISBN 978-Zero-8261-3424-Zero

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