NSG6420 Week 2 Assignment SOAP NOTE latest

NSG6420 Week 2 Assignment SOAP NOTE latest

NSG6420 Week 2 Assignment SOAP NOTE latest

SOAP Note and CORE Entries

Each week, you are required to enter your patient encounters into eMedley. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. You will also need to include a minimum of one complete SOAP note using this template. The SOAP note should be related to the content covered in this week, and the completed note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE.

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Submission Details for NSG6420 Week 2 Assignment SOAP NOTE latest:

By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.

Name your SOAP note document SU_NSG6420_W2_A3_LastName_FirstInitial.doc.

Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date assigned.

Week 5 Solution Approach

Name:  A.P.	Pt. Encounter Number:
Date: 11/01/	Age: 47		Sex: Male
SUBJECTIVE
CC: “Here for a follow up; my insomnia is no better”
HPI:  Pleasant African American male presents to the office for routine follow up and with complaints of a insomnia not improving with prescription medication. He states he sleeps approximately 3-4 hours a night. He states he falls asleep 30 minutes after taking Ambien but wakes after 3 to 4 hours and cannot return to sleep. He states he is a veteran of the Iraq war and believes he is suffering from PTSD. He shares the traumatic events of which he was a part of and saw during his time as a Marine in Iraq.  He admits to irritability with sweating at inappropriate times. He denies depression, suicidal or homicidal ideations. He wishes to be referred to psychology for an evaluation.
Medications: Amlodipine 10mg by mouth every day for hypertension. Lisinopril 5mg by mouth every day for hypertension. Zolpidem 10 mg by mouth every night for insomnia. Sildenafil 100mg by mouth as needed 30 minutes prior to intercourse.
PMH Allergies: Denies Medication Intolerances: Denies Chronic Illnesses/Major traumas Essential Hypertension Insomnia Erectile Dysfunction Hospitalizations/Surgeries  Denies
Family History Mother deceased; unknown cause. Father living; congestive heart failure. Brother living; hypertension. Sister living; no known issues.
Social History Works as an electrician for power company; Iraq war veteran, Marine. Lives with wife; has no children. Denies illicit drug, tobacco, or alcohol use. Wears seatbelt.
ROS
General Positive for sleep disturbances. Negative for any weight change, fatigue, fever, chills, night sweats		Cardiovascular Negative for chest pain, palpitations, PND, orthopnea, and edema
Skin Negative for delayed healing, rashes, bruising, bleeding or skin discolorations, and any changes in lesions or moles. NSG6420 Week 2 Assignment SOAP NOTE latest		Respiratory Negative for cough, wheezing, hemoptysis, dyspnea
Eyes Negative for corrective lenses, blurring, and visual changes of any kind		Gastrointestinal Negative for abdominal pain, N/V/D, ingestion, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, and black, tarry stools
Ears Negative for ear pain, hearing loss, ringing in ears, and discharge		Genitourinary Negative for urgency, frequency, burning, or change in color of urine.
Nose/Mouth/Throat Negative for sore throat, sinus pressure, nasal congestion.		Musculoskeletal Negative for back pain, joint swelling, stiffness, or pain
Breast Negative for lumps, bumps, or changes		Neurological Negative for syncope, weakness, numbness, or tingling
Heme/Lymph/Endo Negative for night sweats, swollen glands, increased thirst, increased hunger, and cold or heat intolerance		Psychiatric Positive for irritability with sweating. Negative for depression or suicidal ideations
OBJECTIVE
Weight 173lbs  BMI 24.8	Temp 98.2		BP 130/84
Height 5’10”	Pulse 83		Resp 18
General Appearance Pleasant adult male in no acute distress. Alert and oriented; answers questions appropriately.
Skin Skin is appropriate for ethnicity, warm, dry, clean, and intact. No rashes or lesions noted.
HEENT Head is normocephalic, atraumatic, and without lesions; hair evenly distributed. Eyes:  PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly gray with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa red; swollen erythematous turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa, pink and moist. Pharynx is erythematous and without exudate. Teeth are in good repair.NSG6420 Week 2 Assignment SOAP NOTE latest
Cardiovascular S1, S2 with regular rate and rhythm. No clicks, rubs, or murmurs. Capillary refills two seconds. Pulses 3+ throughout. No edema.
Respiratory Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.
Gastrointestinal Abdomen soft nondistended, nontender; BS active in all the four quadrants. No hepatosplenomegaly.
Breast Deferred
Genitourinary Bladder is nondistended; no CVA tenderness.
Musculoskeletal Full ROM seen in all four extremities.
Neurological Speech clear. Good tone. Posture erect. Balance stable; gait normal.
Psychiatric Alert and oriented. Appropriate clothing for the season. Maintains eye contact. Speech is clear and of normal rate and cadence; answers questions appropriately. NSG6420 Week 2 Assignment SOAP NOTE latest
Lab Tests None
Special Tests PHQ-9 PTSD Checklist for DSM-5
Diagnosis
Depression Anxiety disorder Post-traumatic stress disorder   Post-traumatic stress disorder
PLAN including education
Plan: Referral to psychology for further work up and per patient’s request.

 

The final diagnosis of post-traumatic stress disorder (PTSD) was based on a thorough examination of the pertinent presenting symptoms and the positive and negative findings in the review of systems with this patient. The differential diagnosis chosen for this patient are depression, anxiety disorder, and PTSD. The patient’s full interview process, review of systems and physical assessment assisted in the diagnoses, but the final conclusive diagnosis was made through the history of presenting illness, review of symptoms and PHQ-9. The differential diagnoses depression and anxiety, were then ruled out.

Depression in the primary setting often presents with somatic complaints such as fatigue, headaches, abdominal distress, irritability, difficulty in concentrating, or changes in weight more so than a low mood or feeling of sadness (Halverson, 2017). The patient did report irritability, but denied any of the other common presentations of depression. The patient also denies depressive mood in the interview. Through the patient reporting only irritability at inappropriate times with sweating, denying depression, and a score of zero on the PHQ-9, the diagnosis of depression was eliminated.

Anxiety disorder is characterized by excessive anxiety and difficulty controlling worrying (Bhatt, 2017). Anxiety is consistent with restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance (Bhatt, 2017). Physical signs of anxiety may include sweaty palms, restlessness, and distractibility (Bhatt, 2017). This patient had positive findings related to anxiety such as irritability and sleep disturbance, but in order for anxiety to be diagnosed at least 3 of the six symptoms should be present (Bhatt, 2017). Anxiety disorder was ruled out based on the diagnostic criteria.

Post-traumatic stress disorder is the persistent reexperiencing of the event, disturbing thoughts related to the traumatic event, nightmares or distressing dreams, recurrent involuntary memories, dissociation (including flashbacks) and intense, negative emotional or physiological reaction on exposure to reminders (traumatic triggers) (Gore, 2017). Presentation of those with PTSD often display irritability, sleep disturbances, increased startle reaction, self-harming behaviors, and acts (Gore, 2017). This patient was open and honest about his experiences in Iraq as a Marine. He also reported sleep disturbances unrelieved by Ambien and irritability at inappropriate time with sweating. He did deny any suicidal or homicidal ideations. Through the interview of present illness, review of symptoms, and a score of 45 on the PTSD checklist for DSM-5, it was concluded the patient suffers from PTSD.

The treatment recommended for PTSD is still an ongoing process. This patient was referred to psychology for further evaluation and treatment. While many medications have been tried and tested in those with PTSD, few have been shown to have any efficacy (Gore, 2017).  The SSRIs and SNRIs are generally the first-line medications for adults (Gore, 2017).  Sertraline and paroxetine are the only ones carrying the FDA approval, but they also have a black box warning for suicidal ideation and monitoring of the patient should be close (Gore, 2017).  Agitation and irritability is best treated with Clonidine and Guanfacine (Gore, 2017). This patient refused to take any prescription medication other than the already prescribed medications until psychology evaluated him. Insomnia is a common problem for patients with PTSD and may be treated though reinforcing sleep hygiene and with medications such as Clonidine and Prazocin (Gore, 2017). Prazosin decreases trauma-related nightmares (Gore, 2017). Again, this patient did not wish to change his Ambien at this point until further evaluation. NSG6420 Week 2 Assignment SOAP NOTE latest

 

References

Bhatt, N. (2017). Anxiety disorder. Retrieved from https://emedicine.medscape.com/article/286227-overview

Gore, A. (2017). Posttraumatic stress disorder. Retrieved from https://emedicine.medscape.com/article/288154-treatment

Halverson, J. (2017). Depression. Retrieved from  https://emedicine.medscape.com/article/286759-overview. NSG6420 Week 2 Assignment SOAP NOTE latest