NSG 6020 SOAP1 – Millennium Urgent Care: Hyperlipidemia

NSG 6020 SOAP1 – Millennium Urgent Care: Hyperlipidemia

NSG 6020 SOAP1 – Millennium Urgent Care: Hyperlipidemia

HPI:
Mr. Daniel Spreng is a 72-year-old male with past medical history that includes hyperlipidemia, gout, benign prostate hyperplasia, hypertensive renal disease, deep venous thrombosis, acute sinusitis, chronic kidney disease stage 3, sleep apena, hyperglycemia, colon polyps, aortic valve replacement, and heart transplant as of 2014. Today, Mr. Spreng presents to the clinic with bloody drainage from his right ear overnight. Mr. Spreng is currently anticoagulated on Xarelto due to cardiac history and recent onset of DVT. Mr. Spreng is concerned that there is something wrong with his ear, due to the bleeding. He denies head trauma but admits to utilizing Q-tips every morning. He attempted to stop the bleeding at home by utilizing styptic powder. NSG 6020 SOAP1 – Millennium Urgent Care: Hyperlipidemia

PMH:
As noted above.
Medications:
– Align 4mg capsules daily P.O.
– Aspirin 81mg delayed release daily P.O.
– Atorvastatin 10mg tablet daily P.O.

…

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NSG 6020 SOAP1 – Millennium Urgent Care: Hyperlipidemia

Rights of Medication Administration

Right dose

• Check the order.
• Confirm appropriateness of the dose using a current drug reference.
• If necessary, calculate the dose and have another nurse calculate the dose as well. NSG 6020 SOAP1 – Millennium Urgent Care: Hyperlipidemia.

4. Right route

• Again, check the order and appropriateness of the route ordered.
• Confirm that the patient can take or receive the medication by the ordered route.

5. Right time

• Check the frequency of the ordered medication.
• Double-check that you are giving the ordered dose at the correct time.
• Confirm when the last dose was given.

6. Right documentation

• Document administration AFTER giving the ordered medication.
• Chart the time, route, and any other specific information as necessary. For example, the site of an injection or any laboratory value or vital sign that needed to be checked before giving the drug. NSG 6020 SOAP1 – Millennium Urgent Care: Hyperlipidemia.

7. Right reason

• Confirm the rationale for the ordered medication.  What is the patient’s history?

NSG 6020 SOAP1 – Millennium Urgent Care: Hyperlipidemia

NSG 6020 Week 9 Soap Note – Lumbar Herniated Disk

Name: Mr. D	Date: May 25,	Time: 1300
	Age: 52 years old	Sex: Male
SUBJECTIVE
CC: “I experience back pains that I have never felt before”.
HPI: Seen and examined Mr. D., a 52-year old Italian male, presented in the clinic with complain of experiencing unusual back pains. (5/10) Reports to have started one week ago, isolated on lower back, usually worsens when lifting and prolonged walking, usually relieves by rest and by lying down. He denies taking any pharmacological treatments. Had history of cholecystectomy 4 years ago, has chronic diagnosis of HTN, and recently diagnosed with Type II DM (non-insulin).
Medications: NSG 6020 Wk9 Soap Note – Lumbar Herniated Disk
PMH Allergies: Penicillin Medication Intolerances: None Chronic Illnesses/Major traumas: Hypertension >10 years – controlled with medications Type II DM – 2 years ago. Hospitalizations/Surgeries Cholecystectomy – 4 years ago
Family History Mother – Hypertension & Breast CA Father – Hypertension, Type II DM Patient has a 2 daughter and 1 son Patient has a sister who also has HTN Indicates Patient   Living Male              Living Female     NSG 6020 Wk9 Soap Note – Lumbar Herniated Disk
Social History   Patient is a truck driver, who used to spend long hours in driving but now he only drives locally but still 100 miles minimum per day. He is divorced, lives in a ranch type house with son who is overall in healthy condition. 2 daughters has their own family and reports to have 2 grandchildren. He reports history of smoking about a pack a day but stopped 2 years ago when diagnosed with type II diabetes but still currently intakes alcohol about 3-5 bottles of beer every weekend. Denies being intoxicated, denies any use of illicit drugs.

NSG 6020 SOAP1 – Millennium Urgent Care: Hyperlipidemia

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ROS
General   52 years old, Italian male, alert and oriented x 3, able to make needs known and alert during interview	Cardiovascular   Denies experiencing chest pains, palpitations and lightheadedness.
Skin   Denies delayed healing or bruising. Skin color is appropriate for ethnicity. Denies any changes in moles.	Respiratory   Denies wheezing, shortness of breath or history of TB.
Eyes     Denies wearing any corrective lense glasses. Denies having exudates and discharges from eyes	Gastrointestinal   Denies abdominal pain, nausea and vomiting, ulcers, black tarry stools. Reports no problems moving bowels.
Ears   Denies Ear pain, hearing loss, ringing in ears, and any discharges.	Genitourinary/Gynecological   Denies urgency, frequency burning, change in color of urine.   Denies hx of STI’s.
Nose/Mouth/Throat   Denies having any lesions, masses and tenderness. Also denies difficulty of hearing, vertigo and throat pain.	Musculoskeletal   Complains isolated aching low back pain (5/10)
Breast   Denies rashes, bruising, sores, lumps, dryness and color changes.	Neurological   Denies numbness and tingling, tremors.
Heme/Lymph/Endo   Denies easy bruising and bleeding, Denies heat or cold intolerance, and denies having swollen lymph nodes.	Psychiatric   Denies anxiety, depression, difficulty sleeping and suicidal ideation.
OBJECTIVE

NSG 6020 Wk9 Soap Note – Lumbar Herniated Disk

Weight 185 lbs BMI 28.13	Temp 98.1	BP 132/72
Height 5’8”	Pulse 52 years old	Resp 16
General Appearance   Seen and examined Mr. D. 52-year old Italian male. Appears to be pleasant, mobile, and active. Works as a truck driver for 15 years. Alert and oriented x 3, answers all questions appropriately and very cooperative.
Skin   Intact, warm to touch and dry with no bruising, lesions, rashes or discoloration noted. No cyanosis or clubbing noted. No visible scars observed.
HEENT   ·        Normocephalic ·        Conjunctiva pink,  sclerae white, no jaundice, free from drainage, PERRLA. ·        Ears non-tender, no swelling and free from drainage ·        Nose: nasal mucosa moist without drainage, septum midline, free from swelling and lesions ·        Throat: free from lesions and not enlarged ·        Neck: Trachea is midline, non-palpable thyroid and lymph nodes, neck supple with no masses or tenderness.
Cardiovascular   S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. Localized edema on B/L LE
Respiratory   Symmetrical chest expansion. Respirations even and unlabored, breath sounds clear upon auscultation bilaterally. No wheezing, rhonchi, or stridor noted. No increased tactile fremitus.
Gastrointestinal   Abdomen flat, soft, non-distended, Bowel sounds present on all quadrants. Abdomen tympanic with percussion, Non-tender when palpated and no hepatosplenomegaly.
Breast   -Normal, symmetrical – No visible or nipple abnormalities -No spontaneous or expressed nipple discharge or blood NSG 6020 Wk9 Soap Note – Lumbar Herniated Disk
Genitourinary    -Normal external genitalia
Musculoskeletal   Complains isolated aching low back pain (5/10)
Neurological   CNII-XII intact,. Good coordination and body posture observed. Romberg and heel to toe were deferred at this time.
Psychiatric   AAO x 3. Apporpriate affect. Mr. D. is neatly dressed, maintains eye contact and answers all questions accordingly and appropriately.

NSG 6020 Wk9 Soap Note – Lumbar Herniated Disk

Lab Tests   CBC, CMP – pending  Lumbosacral Xray

Special Tests   None

Diagnosis

Differential Diagnoses. NSG 6020 Wk9 Soap Note – Lumbar Herniated Disk

Plan/Therapeutics

o    Plan:

Evaluation of patient encounter

M

 

References:

Mayo Clinic (2018) Herniated Disk retrieved from https://www.mayoclinic.org/diseases-conditions/herniated-disk/diagnosis-treatment/drc-20354101

Mayo Clinic (2018) High Blood Pressure retrieved from https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/diagnosis-treatment/drc-20373417

NSG 6020 SOAP1 – Millennium Urgent Care: Hyperlipidemia

NSG 6020 Week 8 SOAP Note – MS Patient Allergic to Sulfonamides

MS Patient Allergic to Sulfonamides

Allergies: sulfanomides caused extreme rash and hives Temp: 97.8
BP: deferred as patient was allowing more than she was comfortable with by seeing us both.
CC: none today other than “my catheter is having issues”
HPI: simple well check, however had occasion to check the catheter placement as they feel that it’s leaking. NSG 6020 Wk8 SOAP Note – MS Patient Allergic to Sulfonamides.

Subjective: 61 year old female with MS that is progressing. She has an appointment with urology on 10/01/2018 (first available) about the leaking catheter. Patient denies any unusual pain or discomfort, at the moment. Patient has a long and significant history if UTI’s so we will need to be cautious and observant.

Head: denies issues with headache or otherwise; with exception of the dry skin throughout scalp due to seborrhea. Eyes: clear, follows gaze text (CM) uses corrective lenses Ears: denies pain and or hearing loss; Nose: pink mucosa, clear and dry; Throat/Mouth: Pink oral mucosa, teeth are in adequate repair, swallows well, soft spoken; Neck: Denies complaints; Heart: denies Respiratory: denies GI: denies GU: suprapubic catheter was recently placed, but leakage is noted; Hematology: none; MSK: denies any trouble beyond normative paralysis; Neuro: no sensitivity in hands and, for the most part, feet. Denies seizures or headache.

NSG 6020 Wk8 SOAP Note – MS Patient Allergic to Sulfonamides

Current Medications:

PMHx:
Allergies: NKA/NKDA
Chronic or major illnesses:
Hospitalizations/Surgeries:
Family Hx:
Social Hx:
ROS:
General:
Skin:
Eyes:
Ears:
Nose/Throat/Mouth:
Breast:
Heme/Lymph/Endocrine:
Cardiovascular:
Respiratory:
GI
GU
MSK
Psychiatric:

OBJECTIVE DATA:
Wgt. BMI BP P RR Gen Appear:
Orientation:
HHEENT:
Cardiovascular:
Respiratory:
GI:
Breast:
GU
MSK
NEURO
PSYCH
Labs;

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Rights of Medication Administration

1. Right patient

• Check the name on the order and the patient.
• Use 2 identifiers.
• Ask patient to identify himself/herself.
• When available, use technology (for example, bar-code system).

2. Right medication

• Check the medication label.
• Check the order.

3. Right dose

• Check the order. NSG 6020 Wk8 SOAP Note – MS Patient Allergic to Sulfonamides.
• Confirm appropriateness of the dose using a current drug reference.
• If necessary, calculate the dose and have another nurse calculate the dose as well.

NSG 6020 Wk8 Soap Note – Chronic HTN and HLD

Name: Mr. G
Date: 05/22/2018
Time: 10:30 AM
Age: 56 years old
Sex: Male

SUBJECTIVE
CC:
“ I have urgency and frequency problem when urinating. Also, at night I have observed that I need to wake up couple of times to urinate. Normally, I would wake up once through the night but now I have to wake up 2-3 times and sometimes more.”

HPI:
Seen Mr. F, 56 years old Caucasian male with past medical history of Chronic HTN and HLD presented to the clinic complaining of urinary frequency, urgency and nocturia, had a history of appendicitis and
appendectomy 5 years ago. Denies pain or any discomfort at this time or when urinating.

Medications:
Lisinopril 20mg once daily for Hypertension
Atorvastatin 10mg once daily at bedtime for Hyperlipidemia
Vitamin D3 1000units as supplement
Vitamin C 500mg daily as supplement

NSG 6020 Wk8 Soap Note – Chronic HTN and HLD

PMH
Allergies:
No known Drug or Food allergies

Medication Intolerances:
No known Medication intolerance
Chronic Illnesses/Major traumas
Hypertension (I10) – 20 years ago
Hyperlipidemia (E78.5) – 10 years ago
Hospitalizations/Surgeries
Appendectomy – 5 years ago

Family History
Mother – Hypertension, Type II DM
Father – Hypertension, HLD
Sibling – 1 elder sister who has Hypertension
Indicates Patient
Living Male
Living Female
PP

HEENT ·        Normocephalic ·        Conjunctiva normal in color, free from drainage, PERRLA, (-) ·        Ears non-tender, no swelling and free from drainage ·        Nose: free from swelling, lesions and discharges ·        Throat: free from lesions and not enlarged ·        Neck: Trachea is midline, non-palpable thyroid and lymph nodes, neck supple with no masses or tenderness. NSG 6020 Wk8 Soap Note – Chronic HTN and HLD

Cardiovascular S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.

Respiratory Symmetrical chest expansion. Respirations even and unlabored, breath sounds clear upon auscultation bilaterally. No wheezing, rhonchi, or stridor noted. No increased tactile fremitus.

Gastrointestinal Abdomen flat, soft, non-distended, Bowel sounds present on all quadrants. Abdomen tympanic with percussion, Non-tender when palpated and no hepatosplenomegaly. NSG 6020 Wk8 Soap Note – Chronic HTN and HLD.

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NSG 6020 Soap Note – Hypothyroidism and Hyperglycemia

SOAP NOTE
Name:
J K
7/15/2016
Time: 9:00 am
Age: 43
Sex: Female

SUBJECTIVE
CC:
“I’m here to follow up after having an ear infection and to talk about my lab results and why I’m so tired
all the time”.

HPI:
Mrs. Keenan is 23 year old female patient presenting to the office today for a follow up after being treated with for an ear infection and complaints of constant fatigue. Her last visit consisted of an evaluation and lab work to determine the cause of fatigue. She denies any fever, shortness of breath or pain.

Medications:
Ciprodex 0.3-0.1% suspension. 4 gtts twice daily
Levothyroxine Sodium-250 mcg daily (ran out of medications 3 weeks ago)
Lasix-40 mg 1 tab daily
PMH

Allergies: NKA

Medication Intolerances: None listed

Chronic Illnesses/Major traumas

-Iron Deficiency Anemia (IDA)
-Hypothyroidism
-Hyperglycemia
-Vitamin D deficiency

Chronic Health Problems:
1. Iron Deficiency Anemia (IDA) (D50.9)
2. Hypothyroidism (E03.9)
3. Vitamin D Deficiency (E55.9)
4. Hyperglycemia (R73.9)

Hospitalizations/Surgeries
-Gallbladder surgery in 2003
-Breast biopsy in 2003

Other:
Immunizations:
Received flu vaccine in November 2015 and plans to receive it again when its time.
Environmental hazards:
Denies any environmental hazards. Lives at home with husband in a clean home.
Able to perform ADLs without difficulty.
Safety measures:
Stated “I always put my seatbelt on”.

NSG 6020 Soap Note – Hypothyroidism and Hyperglycemia

…

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Rights of Medication Administration

Right time

• Check the frequency of the ordered medication.
• Double-check that you are giving the ordered dose at the correct time.
• Confirm when the last dose was given.

Right documentation

• Document administration AFTER giving the ordered medication.
• Chart the time, route, and any other specific information as necessary. For example, the site of an injection or any laboratory value or vital sign that needed to be checked before giving the drug.

Right reason

• Confirm the rationale for the ordered medication.  What is the patient’s history?

NSG 6020 SOAP1 – Millennium Urgent Care: Hyperlipidemia

NSG 6020 SOAP Note Assignments 

Week 5 SOAP Note Assignment

SOAP Note

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry. NSG 6020 Discussion Assignment Essay Papers

Submission Details:

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_NSG 6020_W5_A2_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 6 SOAP Note Assignment

SOAP Note

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submission Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.

Submission Details:

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_NSG 6020_W6_A4_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 6 Physical Exam Video and Write Up Assignment

Complete Health History and Physical Assessment Write-Up Presentation

This assignment consists of complete head to toe physical while being videoed. You will also need to complete a written assignment of your findings. Review the Expanded rubric to note how you will be graded on this assignment. NSG 6020 SOAP1 – Millennium Urgent Care: Hyperlipidemia.

Week 7 SOAP Note Assignment

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.

Submission Details:

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_NSG 6020_W7_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 8 SOAP Note Assignment

SOAP Note

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry. NSG 6020 SOAP1 – Millennium Urgent Care: Hyperlipidemia.

Submission Details:

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_NSG 6020_W8_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 9 SOAP Note Assignment

SOAP NOTE

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.

Submission Details:

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_NSG 6020_W9_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.