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NURS_6512_comprehensiveSOAPExemplar

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Comprehensive SOAP ExemplarPurpose: To demonstrate what each section of the SOAP Note should include. Remember that nurse practitioners treat patients in a holistic manner, and your SOAP Note should reflect that premise.Patient Initials: _______     Age: _______           Gender: _______SUBJECTIVE DATA: Chief Complaint (CC): Coughing up phlegm and feverHistory of Present Illness (HPI): Sara Jones is a 65-year-old Caucasian female who presents today with a productive cough x 3 weeks and fever for the last 3 days. She reported that the “cold feels like it is descending into her chest.” The cough is nagging and productive. She brought in a few paper towels with expectorated phlegm – yellow/brown in color. She has associated symptoms of dyspnea of exertion and fever. Her Tmax was reported to be 102.4 last night. She has been taking Ibuprofen 400mg about every 6 hours and the fever breaks, but it returns after the medication wears off. She rated the severity of her symptom discomfort at 4/10. Medications: 1.) Lisinopril 10mg daily2.) Combivent 2 puffs every 6 hours as needed3.) Serovent daily4.) Salmeterol daily 5.) Over-the-counter Ibuprofen 200mg -2 PO as needed6.) Over-the-counter Benefiber7.) Flonase 1 spray each night as needed for allergic rhinitis symptomsAllergies:Sulfa drugs – rash Past Medical History (PMH):1.) Emphysema with recent exacerbation 1 month ago – deferred admission – RX’d with outpatient antibiotics and hand held nebulizer treatments. 2.) Hypertension – well controlled3.) Gastroesophageal reflux (GERD) – quiet, on no medication4.) Osteopenia 5.) Allergic rhinitisPast Surgical History (PSH):1.) Cholecystectomy 19942.) Total abdominal hysterectomy (TAH) 1998 Sexual/Reproductive History:HeterosexualG1P1A0Non-menstruating – TAH 1998Personal/Social History:She has smoked 2 packs of cigarettes daily x 30 years; denied ETOH or illicit drug use.Immunization History:Her immunizations are up to date. She received the influenza vaccine last November and the Pneumococcal vaccine at the same time.  Significant Family History:Two brothers – one with diabetes, dx at age 65, and the other with prostate CA, dx at age 62. She has one daughter in her 30s, healthy, living in nearby neighborhood.Lifestyle: She is retired, has been widowed x 8 years, and lives in the city in a moderate crime area with good public transportation. She is a college graduate, owns her home, and receives a pension of $50,000 annually – financially stable. She has a primary care nurse practitioner provider and goes for annual and routine care twice annually and as needed for episodic care. She has medical insurance but often asks for drug samples for cost savings. She has a healthy diet and eating pattern. There are resources and community groups in her area at the senior center that she attends regularly. She enjoys bingo. She has a good support system composed of family and friends.Review of Systems: General: + fatigue since the illness started; + fever, no chills or night sweats; no recent weight gains of losses of significanceHEENT: No changes in vision or hearing; she does wear glasses, and her last eye exam was 1 ½ years ago. She reported no history of glaucoma, diplopia, floaters, excessive tearing, or photophobia. She does have bilateral small cataracts that are being followed by her ophthalmologist. She has had no recent ear infections, tinnitus, or discharge from the ears. She reported her sense of smell is intact. She has not had any episodes of epistaxis. She does not have a history of nasal polyps or recent sinus infection. She has a history of allergic rhinitis that is seasonal. Her last dental exam was 3/2014. She denied ulceration, lesions, gingivitis, gum bleeding, and has no dental appliances. She has had no difficulty chewing or swallowing.Neck: No pain, injury, or history of disc disease or compression. Her last Bone Mineral density (BMD) test was 2013 and showed mild osteopenia, she said. Breasts: No reports of breast changes. No history of lesions, masses, or rashes. No history of abnormal mammograms.Respiratory: + cough and sputum production (see HPI); denied hemoptysis, no difficulty breathing at rest; + dyspnea on exertion; she has history of COPD and community acquired pneumonia 2012. Last PPD was 2013. Last CXR – 1 month ago.CV: No chest discomfort, palpitations, history of murmur; no history of arrhythmias, orthopnea, paroxysmal nocturnal dyspnea, edema, or claudication. Date of last ECG/cardiac work up is unknown by patient.GI: No nausea or vomiting, reflux controlled. No abd pain, no changes in bowel/bladder pattern. She uses fiber as a daily laxative to prevent constipation.GU: No change in her urinary pattern, dysuria, or incontinence. She is heterosexual. She has had a total abd hysterectomy. No history of STDs or HPV. She has not been sexually active since the death of her husband.MS: She has no arthralgia/myalgia, no arthritis, gout or limitation in her range of motion by report. No history of trauma or fractures.  Psych: No history of anxiety or depression. No sleep disturbance, delusions, or mental health history. She denied suicidal/homicidal history. Neuro: No syncopal episodes or dizziness, no paresthesia, headaches. No change in memory or thinking patterns; no twitches or abnormal movements; no history of gait disturbance or problems with coordination. No falls or seizure history.Integument/Heme/Lymph: No rashes, itching, or bruising. She uses lotion to prevent dry skin. She has no history of skin cancer or lesion removal. She has no bleeding disorders, clotting difficulties, or history of transfusions. Endocrine: No endocrine symptoms or hormone therapies.Allergic/Immunologic: Has hx of allergic rhinitis, but no known immune deficiencies. Her last HIV test was 10 years ago. OBJECTIVE DATAPhysical Exam:Vital signs: B/P 110/72, left arm, sitting, regular cuff; P 70 and regular; T 98.3 orally; RR 16; non-labored; Wt: 115 lbs; Ht: 5’2; BMI 21General: A&O x3, NAD, appears mildly uncomfortableHEENT: PERRLA, EOMI, oronasopharynx is clearNeck: Carotids no bruit, jvd or tmegallyChest/Lungs: CTA AP&LHeart/Peripheral Vascular: RRR without murmur, rub, or gallop; pulses+2 bilat pedal and +2 radial ABD: benign, nabs x 4, no organomegaly; mild suprapubic tenderness – diffuse – no rebound Genital/Rectal: external genitalia intact, no cervical motion tenderness, no adnexal masses.Musculoskeletal: symmetric muscle development – some age-related atrophy; muscle strengths 5/5 all groupsNeuro: CN II – XII grossly intact, DTR’s intact Skin/Lymph Nodes: No edema, clubbing, or cyanosis; no palpable nodesASSESSMENT: Lab Tests and Results: CBC – WBC 15,000 with + left shiftSAO2 – 98%Diagnostics:Lab:Radiology:CXR – cardiomegaly with air trapping and increased AP diameterECGNormal sinus rhythmDifferential Diagnosis (DDx):1.) Acute Bronchitis2.) Pulmonary Embolis3.) Lung CancerDiagnoses/Client Problems: 1.) COPD2.) HTN, controlled3.) Tobacco abuse – 40-pack-a-year history4.) Allergy to sulfa drugs – rash5.) GERD – quiet, on no current medicationPLAN: [This section is not required for the assignments in this course but will be required for future courses.]