NSG 6020 Wk8 SOAP Note – MS Patient Allergic to Sulfonamides

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

NSG 6020 Wk8 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 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.

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 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_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.