- QUESTION
Title: soap note one
Paper Details
C.C is a healthy 41y old G2P2 Hispanic African American female who presents for a well woman examination. At present she has no active medical complaints. she is concerned, regarding her risk status for breast cancer. Both her mother (age 63) and her maternal first cousin (age44) have recently been diagnosed with breast CA (NOS).
The patient herself had a reportedly normal baseline mammogram at 40y. GYN review indicates menarch age 10.5y, first pregnancy age 33, and that she breast fed each of her infants x 4 months. There is no other family history of malignancies. Ms Cross physical exam is significant for the following. mildly overweight (BMI 27.5), bilateral fibrocystic breast changes, without dominant suspicious lumps, cervical eversion without friability, and small firm slightly irregular uterus. screening test identified that pt is a prediabetic.
Diagnosis
Diabetes Melitus type 2
Hyperlipidemia
Differential Diagnosis
Cervical neoplasm
breast cancer
Please follow this soap note format
Name: J.J. Date: 09/20/17 Time: 1145am Age: 75y Sex: female SUBJECTIVE CC: Pt. states “I came for my monthly checkup, I also noticed my right ankle is more
swollen compared to last month”
HPI:
Patient is a 75 years old AA female with chronic bilateral knee pain, 5/10 on pain scale today. Patient has had arthritis for about 10 years, undecided about having a knee replacement because she does not like surgeries,
but she is now in the process of considering surgery because it's getting progressively worse.
Medications:
Amlodipine 10mg daily for HTN
Lipitor 10mg HSfor hyperlipidemia
cetirizine for seasonal allergies
clonodine for HTN
Doxazosin 2mg urinary incontinence
glyburide 5mg for DM
Insulin glargine (lantus) 100u/ml SQ solution.
levothyroxine sodium 150mcg for hypothyroidismlisinopril & hctz 10-12.5mg for HTN
metoprolol 50mg for HTN
Tramadol 50mg Prn for bilateral knee pain
PMH
Edem, HTN, arthritis, urinary incontinence, DM without complication, Insomnia, hypothyroidism.
Allergies:
NKDA
Chronic Illnesses/Major traumas
HTN, hyperlipidemia, Dm type 2, urinary incontinence, hypothyroidism.
Hospitalizations/Surgeries
C/Section x 2
Family History
Mother - HTN deceased 10 years ago.
Father- Prostate cancer deceased 4 years ago.
Social History
Patient has a high school diploma, and worked as an administrative assistant with the city of Houton, retired at 68 years old.
Former smoker, Has three children, and drinks occasionally. Her husband of 40 years passed away 5 years ago. She
maintains a healthy life style, and is just concerned about the right leg swelling and aches and pain she has sometimes.
ROS General
Gained five pounds over the last month, said she went to jamaica on vacation with her friends.
Cardiovascular
Pt denies Chest pain, palpitations, PND, orthopnea, has right leg edema that has increased to +2 pitting, compared to last month as per patient.
Skin
Intact
Respiratory
Pt denies Cough, wheezing, hemoptysis, dyspnea, pneumonia
Denies history of TB
Eyes
Pt wears prescription glasses, no redness noted
Gastrointestinal
Denies abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools
Ears
Ear pain, hearing loss, ringing in ears, discharge
Genitourinary/Gynecological
Pt has urinary incontinence, on doxazin.
Last pap smear in February 2017.
Pt had a mammogram in June, 2017
Nose/Mouth/Throat
Pt denies Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain
Musculoskeletal
Pt has bilateral knee arthritis, on tramadol for pain, and OTC ibuprofen 200mg Q6h PRN
Breast
Intact, pt states she just had a mammogram.
Neurological
Pt denies syncope, seizures, transient paralysis, weakness, paresthesias, black out spells
Heme/Lymph/Endo
Pt is HIV negative
Psychiatric
No psychiatric history
OBJECTIVE Weight 180 pounds
BMI 28
Temp 96.5 BP 132/55 Height 5'7 Pulse 68 Resp 22 General Appearance
Pt is alert and oriented X 4, denies acute distres or discomfort, appears healthy.
Skin
Skin is warm, clean, intact and dry, no lesions or rashes 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 grey with positive light reflex; landmarks easily visualized.
Nose: Nasal mucosa pink; normal 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 nonerythematous and without exudate.
Teeth are in good repair.
Cardiovascular
S1, S2 with a consistent rhythm and pulse rat. Absence of extra sounds, murmurs, rubs, clicks, or rubs. the capillary refill is <two seconds. Pulses intact. Edema noted to right lower leg +2 pitting.
Respiratory
The chest wall is symmetrical in shape, respirations regular. Lungs are clear bilaterally to auscultation.
Gastrointestinal
Abdomen is soft, non-tender; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly.
Breast
Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin.
Genitourinary
Bladder is non-distended; no CVA tenderness.
Musculoskeletal
Full ROM noted in upper extremities, observed with unsteady gait to bilateral lower extremities, secondary to bilateral lower
extremities arthritis.
Neurological
Clear speech, good tone, posture erect, unsteady gait, balance stable.
Psychiatric
Alert and oriented. Dressed in clean jeans and sweater. Maintains good eye contact. Speech is soft, answers questions appropriately.
Lab Tests
Urinalysis –
CBC,
electrolytes
creatinine
Albumin
Thyroid stimulating hormone
(These tests are to rule out systemic disease)
Special Tests
Doppler
Diagnosis Differential Diagnoses
1- CHF
2- Venous insufficiency
3- DVT
Diagnosis
Venous insufficiency
Plan/Therapeutics Plan:
EKG, echocardiogram
Medications- lasix 20mg
Teach pt to wear support panty hose, elevate legs.
Education- Teach patient to increase potassium intake, monitor weight, Heart healthy diet, eat less salt
Exercise
| Subject | Nursing | Pages | 9 | Style | APA |
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Answer
Soap Note for a Prediabetic Patient
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Name: Rose |
Date: 10/17/17 |
Time: 1145am |
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Age: 41y |
Sex: female |
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SUBJECTIVE |
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CC: Pt. states “I came for my routine well woman examination. However, I am concerned with regard to my risk status for breast cancer.” |
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HPI:
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Medications: Sulfonylureas: for stimulation of insulin secretion Meglitinides to be used are either; Repaglinide (Prandin NovoN) 0.5, 1, 2 mg Nateglinide (Starlix Novartis) 60, 120 mg |
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PMH At present she has no active medical complaints.
Allergies: NKDA
Chronic Illnesses/Major traumas No reported chronic illness
Hospitalizations/Surgeries No recorded surgeries or hospitalization.
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Family History Mother – 63years old, diagnose with breast cancer. Cousin- 44 years old, diagnosed with breast cancer.
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Social History
She tries to maintain a healthy life style, and currently she is just concerned about her risk status for breast cancer.
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ROS |
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General mildly overweight |
Cardiovascular She denies Chest pain, palpitations, |
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Skin Intact with no signs of melanomas, warm and dry. |
Respiratory She denies wheezing, hemoptysis, dyspnea, pneumonia Has no history of respiratory disorders |
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Ears Normal hearing, no pain or any complication. |
Genitourinary/Gynecological cervical eversion without friability, and small firm slightly irregular uterus |
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Nose/Mouth/Throat Normal |
Musculoskeletal Normal motion range and curvature of the spine. |
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Breast Reportedly had a normal baseline mammogram at 40y. |
Neurological Non-focal |
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Heme/Lymph/Endo She is HIV negative |
Psychiatric No psychiatric history |
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OBJECTIVE |
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Weight 180.88 pounds BMI 27.5 |
Temp 97.5 |
BP 130/55 |
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Height 5'8 |
Pulse 71 |
Respiration 18 |
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General Appearance Awake, alert, in no acute distress and appears healthy |
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Skin Skin is warm, clean, and intact and dry, no lesions or rashes noted. |
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Cardiovascular
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Respiratory Her lungs are clear bilaterally to auscultation and thus she presents no chest pains. |
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Gastrointestinal
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Breast
Bilateral fibrocystic breast changes, without dominant suspicious lumps |
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Musculoskeletal
Normal motion range and curvature of the spine. |
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Neurological The patient exhibited good tone while speaking, steady gait and balance stable. |
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Psychiatric The patient act normal evident from her speaking style, hygiene standards, openness and respect. |
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Lab Tests Urinalysis – CBC, electrolytes mammogram Hemoglobin A1C test Random blood sugar test |
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Diagnosis |
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Differential Diagnoses Cervical neoplasm breast cancer
Diagnosis Diabetes Mellitus type 2 Hyperlipidemia
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Treatment Plan |
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Plan: The treatment for prediabetes will focus on the client’s change of diet to healthy food, getting active and continuous loss of weight. Medication to reverse this condition would be meglitinides and its main effect is to stimulate secretion of insulin. According to Phillippe and Wargo (2013), examples of meglitinides to be used are either; Repaglinide (Prandin NovoN) 0.5, 1, 2 mg Nateglinide (Starlix Novartis) 60, 120 mg Short term goals for the patient would be to cut back on consumption of fast food products to only twice a week and switching to low fat milk products. The patient will be required to aim at least an hour of moderate physical exercises four days a week. |
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References
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American Diabetes Association. (2014). Standards of medical care in diabetes—2014. Diabetes care, 37(Supplement 1), S14-S80. American Diabetes Association. (2016). Standards of medical care in diabetes—2016 abridged for primary care providers. Clinical diabetes: a publication of the American Diabetes Association, 34(1), 3. Phillippe, H. M., & Wargo, K. A. (2013). Mitiglinide for type 2 diabetes treatment. Expert opinion on pharmacotherapy, 14(15), 2133-2144.
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