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Homeworkma.docxRunning head: 1 COMPREHENSIVE SOAP NOTE 1
COMPREHENSIVE SOAP NOTE
Comprehensive Soap Note
Helen Sulonteh- Walden University
Pediatrics &Adult Medicine
Nurs-6531
Comprehensive Soap Note
Patient Initials: J.S. Age: 61 Gender: F
SUBJECTIVE DATA:
3 Chief Complaint (CC): “I’m here for my Annual physical and medication review.” History of Present Illness (HPI): J.S. is a 61-year-old African American female who comes into the hospital for his yearly physical and to follow up on medical review. She reports that she continues feeling the pain in her right hip and bilateral knees. She reports that her pain is intermittent, and she take Tramadol. She reports that she needs a referral for a Gynecologist due to the calcification of her Ovary. She also wants to get back on the Niacin protocol to help lower her cholesterol. She also needs a prescription to refill her Tramadol. She also wants to see if she can get back on Felodipine 5 mg.
Medications: 3 Felodipine 5mg PO daily, and Tramadol 10mg PO daily.
Allergies: 4 NKDA or food allergies
Uveitis
Blind in Right Eye
Osteoporosis
Anxiety
Visually impaired
CAD
4 Past Surgical History (PSH):
Lumpectomy of Left Breast - 03/2012
C-section – UNKNOWN
4 Personal/Social History: Pass Smoker. 3 The patient works full-time in a stressful and demanding environment. She is married with three grown children. Denies any illicit drug use. She performs his ADL’s and IADL’s independently. Snacks in between her 3 meals of the day. 3 She is not physically active because her job is so demanding and exhausting. 5 In a monogamous relationship and sexually active.
Immunization History: 3 up to date Significant Family History:
· Mother: 3 Stroke, anxiety, HTN, hyperlipidemia · Father: HTN, aneurysm · Grandparents: unknown · Siblings (2): 4 Brother- HTN, Sister- unknown, no contact
General: 7 Refutes no mass gain/loss recently, tiredness, fever, or chills.
HEENT: 3 Refutes sore throat, dizziness, lightheadedness, nasal congestion, double vision, tinnitus, vision changes, hearing loss, or drainage. Confirms she is visually impaired and has occasional headaches. Wears glasses.
Neck: 3 Denies neck pain, recent injury, tenderness, swollen nodules, or stiffness.
Breasts: Normal Respiratory: 3 Refutes cough, breathing difficulty, hemoptysis, or SOB.
Cardiovascular/Peripheral Vascular: 8 RRR, No M, R, G. 9 S1, S2 present. 3 No clubbing, or cyanosis. Refutes discomfort, heart palpitations, or edema.
Gastrointestinal: 10 No rebound, guarding. 11 Abdomen non-distended soft, non-tender.
Genitourinary: 3 No incontinence or dysuria. Urinary pattern has not changed.
Musculoskeletal: 12 no deformity, no swelling, no tenderness, normal strength, Normal ROM. Psychiatric: 3 Denies anxiety or depression.
Neurological: 3 Denies dizziness, numbness, tingling, or loss of consciousness.
Hematologic: Refutes any excessive breeding issues. History shows she does not bruise easily.
Endocrine: 3 Refutes having excessive thirst, cold intolerance, or heat or tremors.
Allergic/Immunologic: 3 Refutes allergic or immunologic problems. No recurring diseases. 3 History show no atopy or asthma.
OBJECTIVE DATA:
Vital signs: TEMP- 98.4, HEART RATE-72, BP- 124/80, RR- 18, OXYGEN- 98%, WEIGHT 283 LBS, HEIGHT- 64.5, BMI 47.84
General: 13 She is a 61-year-old African American female well-groomed and presentable.
Neck: No tracheal deviation noted or any recent injury and neck pain.
Chest/Lungs: 3 No SOB noted.
Heart/Peripheral Vascular: Pedal and radial pulses 2+ bilaterally.
Abdomen: soft, nontender. 3 Abd is flat. No organomegaly, all 4 quads produce positive abdomen sound.
Genital/Rectal: 3 No irritation, rashes or lesions detected. Genital/Rectal skin intact.
Musculoskeletal: 12 no deformity, no swelling, no tenderness, normal strength, Normal ROM.
Neurological: 3 DTRs 2+ bilaterally also symmetrical. Appropriate mood.
Skin: No jaundice, pallor, or cyanosis, good turgor, no lashes noted, skin dry and intact.
Labs:
BMI - BMI of 47 indicate that the patient is hypertensive. According to Mayo Clinic (2018), a BMI over 30 indicates obesity.
X-ray – done to help reveal whether the knee has fractures or other joint degenerative illnesses.
MRI scan - to detect whether soft tissues of the client’s right knee like cartilage, muscles, tendons, or ligaments are injured.
ASSESSMENT:
1. Hypertension
According to Mayo Clinic (2018), blood pressure is the high force that blood pushes against the walls of the blood vessels. An important thing to note about hypertension condition is about its signs and symptoms. Not all patients with HTN experiences signs and symptoms like nosebleeds, shortness of breath, and headaches. In this case, my client didn’t show these symptoms though the primary diagnosis was hypertension. There exist two types of HTN, one is primary, and the second is secondary hypertension. 3 The former develops over a long time, and its cause is not known, while the latter, according to (Mayo Clinic, 2018) is caused by an underlying condition like congenital vessel defects, illegal drugs, drug abuse, goiter, adrenal gland and tumors, kidney failure, as well as obstructive sleep apnea (Mayo Clinic, 2018). Examples of risk factors of HBP, are heritage, age, inactive lifestyle, obesity, race, too much alcohol consumption, low intake of potassium and vitamin D, as well as taking too much sodium (Mayo Clinic, 2018).
Differential diagnosis
1. Right knee pain ICD M25.561
Considering a knee is a major joint of the body that bears heavy pressures, it is susceptible to developing pain and get damage. The soft tissue that surrounds the knee is the source of discomfort when it gets worn. Other risk conditions leading to knee pain are athletic movement, acute injury, or trauma (Garcia, 2017).
Plan
Treatment Plan:
Continue Simvastatin 10 mg 1 tablet daily in the evening for Hyperlipidemia Tramadol for Arthritis, Isosorbide mononitrate. Give 30mg 1 tablet daily Cellcept 500 mg 2 tablets two times daily, and Lasix 20 mg 1 tablet daily Felodipine 5 mg 1 tablet daily. 3 I ordered the lab work of UA, lipid, panel, CMP, and CBC to monitor HTN (Buttaro et., 2012). Discussed referral to a cardiologist if blood pressure continued to stay high and referral to a dietician for cardiac diet, both were deferred at this time. The patient is to monitor his blood pressure twice a day for a month and record it. The patient will follow up in one month.
Quadriceps muscles are imperative to maintaining the strength and stability of the knee joint. Hence, to strengthen her muscles, I recommend, my patient, to begin with, a home exercise program and include exercises that specifically reinforce these muscles. If necessary, I may need her to undergo a dedicated strengthening program with physical therapy for a couple of weeks. On her get-healthy plan, my client shedding pounds will be a crucial component in her reducing the right knee pain. I will give simple eating regimen modifications and suggestions and assesses whether she is adhering to it every time she comes for a referral. Her referral will just require a progressively tailored approach to deal with weight reduction, and I will do by referring her to a nutritionist.
15 References Buttaro, T. M., Polgar-Bailey, P., Sandberg-Cook, J., & Trybulski, J. (2012). Primary Care-E-Book: 6 A Collaborative Practice. 16 Elsevier Health Sciences.
Garcia, M. G. (2017). Exploration of Right Knee Pain. Journal of Pediatric Surgical Nursing, 6(3), 56-57.
Mayo Clinic. (2018). 3 High blood pressure (hypertension). Retrieved from: 17 https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/symptoms-causes/syc-20373410
