ASSIGNMENT 1 COMPREHENSIVE SOAP NOTE Soap Note

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ASSIGNMENT1: COMPREHENSIVE SOAP NOTE

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Client Information

Day#__

Day#

The plan Care supporting theory

The Roy Adaptation Model posits that the physiologic adaptations have basic needs of electrolyte and fluid, and acid-base balance (Buttaro, Trybulski, Polgar &amp Sandberg-Cook, 2013).

Subjective data:

1. Biographical Data

a. C.J

b. Age: 28 years

c. Phone number xx xxx xx

d. Primary language- English

e. Authorized representative- xx xxx xx

f. Age and Date of Birth- xx xxx xx

g. Place of Birth- xx xxx xx

h. Gender- Female

i. Race- White

j. Marital Status- Single

k. Ethnic/Cultural Origin- German ancestry

l. Education (highest level completed) – Bachelor’s Degree

m. Occupation/Professional- Administrative Assistant

n. Health Insurance- Yes

2. Chief Complaint: Influenza

C.J is a 28-year-old female. She complains of a runny nose, a sore throat and a persistent headache that has lasted for four days. She presents a situation of pain and outlines that she has taken “Tylenol” (six tablets daily) over the past two days. Nevertheless, she continues to suffer from the stated symptoms

3. History of Present Illness:

Provocative (P)- C.J reports that the onset of the irritation was six days ago when she had a sudden and unusual urge to sneeze. Five days ago, she noticed that she had started to develop a runny nose after being exposed to dust and coldness.

Quality or Quantity (Q)- She experiences a mild headache. Three days ago, she suffered mild coughs before developing a fever. Currently, she looks chilly and disorientated. Speech is sluggish.

Region/ Radiation (R)- She has pains on the sides of her head and behind the eyes making her cheekbones reddish. Nose is still runny, and she has a moderate cough.

Severity (S)- 7 on a scale of 0-10

Understand (U)- C.J believes she suffers from a serious health problem, possibly implying that she is in a lot of pain and discomfort.

4. Past Medical History: C.J has previously used hypothyroidism

C.J was administered Tylenol for purposes of reducing pain for the previous two days, but she believes that the drugs are doing little to help her. She says that the pain exists the whole day and it is worse during the night. For this reason, C.J took another dose of ibuprofen, a painkiller yesterday night and today morning. Still, she is experiencing a purulent drainage from the nose accompanied by all of the other above stated symptoms.

a. Medical Hx (major illnesses): None, C.J denies having any significant injury or hospitalization in the past.

b. Childhood Illnesses: there are reports of strep throat and chicken pox, but she denies having measles, mumps, rubella, rheumatic fever and pertussis.

c. Surgical Hx: C.J reports having Catheter ablation in 2014

d. Obstetric HX: None

e. Immunizations: Received all required Childhood Immunizations, TDaP in 5/2014

f. Psychiatric Hx: None

g. Allergies: C.J has medical reports of Allergic rhinitis causing more urination, headache, runny nose, itchiness, and diarrhea. She has a food allergy for fish, which causes rashes on the skin, cramps, diarrhea and vomiting. No allergies are reported that associate with acute sinusitis.

h. Current Medications: C.J reports being administered with Excedrin (1 gram) and pseudoephedrine nasal decongestant for oral intake for one day now the over the counter medication was prescribed by a pharmacist. A total of six tablets of pseudoephedrine nasal decongestant has so far been taken. The patient has the labels for the medications outlined above well noted. Further, she denies any complementary or alternative treatment aside from the described medications.

i. Last Examination C.J reports to have had a full body medical examination six months ago, 5 May 2016. The exam involved Physical, eye exam, foot exam, dental exam, hearing screen, EKG, chest X-Ray, Pap test, mammogram, serum cholesterol, stool occult blood, prostate, PSA, UA, and TB skin test

5. Family History: It emerges that C.J’s father was diagnosed with a stent at age 35, while the mother was diagnosed with HTN at age 32. (list FHx and design a genogram (computer)-include a key with the genogram). The Genogram must include three generations. The patient has a brother who was treated for hypothyroidism. The family has a history of nasal allergies but none of the sinusitis. The family history of nasal allergies is, therefore, useful for the matter of Chief Complaint (CC).

II. Lifestyle patterns

a. Immigrant status: C.J is an American by birth and so immigrant status is non-applicable.

b. Spiritual resources/religion: C.J indicated that she had a firm belief in God and that she was of the Christian faith.

c. Health perception: The patient states that she was very much concerned when it comes to matters of health and she would not hesitate to visit a medical center as soon as she noticed some symptoms on herself. She also believes that the healthcare system of the country offers professional and reliable services to people.

d. Nutritional patterns: the patient maintains that she has an average appetite for food and that her current illness has had major negative impacts on her appetite. Still, she is satisfied with her average weight of 128lbs.

e. Elimination patterns: both the patient`s bowel and bladder elimination patterns are normal

f. Living environment: C.J lives and works in the city, a place where exposure to toxins in the environment is common

g. Occupational health: C.J works in a building office environment where there are little concerns for occupational health hazards that can associate with her illness

h. Functional assessment: the patient’s activities of daily living (ADL’s) and or instrumental activities of daily living (IADL’s) are those of everyday American citizens living in a city environment.

i. Role and family relationships: C.J lives alone and only interacts with members of her immediate family once in a while. She is very responsible for her wellbeing.

j. Cognitive function: the patient’s functions of thought, memory, speech, judgment and other senses are perfectly normal.

k. Rest/sleep patterns: the patient reports of a healthy sleeping routine of eight hours every night. She, however, indicates that her current condition has significantly disrupted this routine. So far, she has not made use of any aids for sleep.

l. Exercise patterns: C.J reports going for a morning run thrice in a week

m. Hobbies/Recreation: for leisure, C.J loves to watch movies or read novels

n. Social habits: the patient indicates that she likes to hang out with her girlfriends whenever she has the time

o. Intimate partner violence: C.J notes that she is currently single with little interest of getting into a relationship

p. Coping/Stress management: the patient reports no major issue that has happened in her life in the past two years that has caused her to be stressful

q. Sexual patterns: C.J is straight but is currently not sexually active

II. Review of Symptoms

General: Headache, running nose, weakness

Skin: No symptoms

Head: A headache

Eyes: Redness, blurred vision

Ears: No symptoms

Nose: Nasal discharge, obstruction

Neck: No Symptoms

Breasts: No symptoms

Pulmonary: Mild a cough, Pleurisy

Cardiac: No symptoms

G/I: No symptoms

GU: No symptoms

Peripheral Vascular: No symptoms

Musculoskeletal: No symptoms

Neuro: No symptoms

Heme: No symptoms

Endo: No symptoms

Psych: No symptoms

Objective data:

Physical Examination: The patient seems to be in pain.

Blood pressure is 118/75, the weight of 128lbs, and pulse rate of 81.

HEENT: Head is symmetrical, face features are symmetrical, no eye examination owing to no complaints, clear tymphanic membrane, and no pineal pain. No rhinne or Weber test owing to no complaints. No nasal swelling and no polyps. The sense of smell test shows a little discrepancy. Oropharynx has exudates. Detention has a gingival swelling. As the patient says ‘aah,` a small rise is observed on the soft palate. Examination of taste shows problems.

Lymphatic: no lymphadenopathy

Chest/Lungs/Respiration: problematic breathing is observed. Heart: rate higher than normal

Abdomen: flat, no palsations, or hepatomegaly.

Neurological: No assessment

Musculoskeletal: spine is normal, no curving, no pain, and appears symmetrical.

Diagnostic Test: the electrocardiogram indicates the sinus rate is high with 85 beats per minute.

Neck &amp Regional Lymph Nodes: Normal

Breasts: Normal

Lungs &amp Thorax: presence of rales,&nbsprhonchi, and there is reduced breath sounds. Implying accumulation of fluid in lungs and little air exchange

Gastrointestinal: Normal

Genitourinary: Normal

Extremities: Normal

Musculoskeletal: Normal

Neurological: Normal

Assessments

Differential Diagnoses:

  1. Acute Respiratory Distress Syndrome – (ARDS)

  2. Adenoviruses

  3. Cytomegalovirus (CMV)

ARDS was a primary diagnosis because of the possibility of respiratory failure only after a few days of infection (Harman, 2013). Adenoviruses as also a diagnosis owing to it being a common cause of asymptomatic respiratory tract infection (Gomph, 2012). CMV is believed to be the cause of fever in the patient that is of unknown origin and the visual impairment reported by the patient (Akhter, &amp Wills)

Nursing Diagnosis:

  1. Ineffective Breathing Pattern

Medical Diagnosis:

  1. Acute respiratory infection (ARI)

Plan of Care

Nursing Theory

Referral and Treatment Plan

  1. Continue with the current Excedrin (1 gram) and pseudoephedrine nasal decongestant

  2. If condition continues to worsen, start medical management involving oseltamivir (Tamiflu®)

Goal Attainment Theory: the patient needs to develop a goal of aiding herself and her environment, well during the healing period

Preventative Care

Developmental stage

Cultural characteristics

Control exposure to dust and coldness

Early stages of the infection since symptoms relate with influenza A

C.J is a typical White person. She has high regards for the healthcare sector and profession. She values respect and honesty and should be treated with the same

Evaluation of care

Refer to a more in-depth ENT assessment

Assess patient to find out if there are signs of asthma

References

Akhter, K., &amp Wills, T. S. eMedicine Specialties&gt Infectious Diseases&gt Viral Infections.

Buttaro, T., Trybulski, J., Polgar, B., &amp Sandberg-Cook, J. (2013). Primary care: The collaborative practice (4th ed., pp. 487-611). St. Louis, Mo.: Elsevier/Mosby.

Gompf, S. G. (2012). FIDSA Chief Editor: Burke A Cunha. MD. Adenoviruses. WebMD LLC. Retrieved 15 October 2016, from http://emedicine.medscape.com/article/211738-overview

Harman, E. M., &amp Pinsky, M. R. (2013). Acute respiratory distress syndrome. Medicine. Retrieved 15 October 2016, from http://emedicine.medscape.com/article/165139-overview

Preceptor’s Signature

ASSIGNMENT 1 COMPREHENSIVE SOAP NOTE Soap Note

  • Uncategorized

ASSIGNMENT1: COMPREHENSIVE SOAP NOTE

SoapNote

Client Information

Day#__

Day#

The plan Care supporting theory

The Roy Adaptation Model posits that the physiologic adaptations have basic needs of electrolyte and fluid, and acid-base balance (Buttaro, Trybulski, Polgar &amp Sandberg-Cook, 2013).

Subjective data:

1. Biographical Data

a. C.J

b. Age: 28 years

c. Phone number xx xxx xx

d. Primary language- English

e. Authorized representative- xx xxx xx

f. Age and Date of Birth- xx xxx xx

g. Place of Birth- xx xxx xx

h. Gender- Female

i. Race- White

j. Marital Status- Single

k. Ethnic/Cultural Origin- German ancestry

l. Education (highest level completed) – Bachelor’s Degree

m. Occupation/Professional- Administrative Assistant

n. Health Insurance- Yes

2. Chief Complaint: Influenza

C.J is a 28-year-old female. She complains of a runny nose, a sore throat and a persistent headache that has lasted for four days. She presents a situation of pain and outlines that she has taken “Tylenol” (six tablets daily) over the past two days. Nevertheless, she continues to suffer from the stated symptoms

3. History of Present Illness:

Provocative (P)- C.J reports that the onset of the irritation was six days ago when she had a sudden and unusual urge to sneeze. Five days ago, she noticed that she had started to develop a runny nose after being exposed to dust and coldness.

Quality or Quantity (Q)- She experiences a mild headache. Three days ago, she suffered mild coughs before developing a fever. Currently, she looks chilly and disorientated. Speech is sluggish.

Region/ Radiation (R)- She has pains on the sides of her head and behind the eyes making her cheekbones reddish. Nose is still runny, and she has a moderate cough.

Severity (S)- 7 on a scale of 0-10

Understand (U)- C.J believes she suffers from a serious health problem, possibly implying that she is in a lot of pain and discomfort.

4. Past Medical History: C.J has previously used hypothyroidism

C.J was administered Tylenol for purposes of reducing pain for the previous two days, but she believes that the drugs are doing little to help her. She says that the pain exists the whole day and it is worse during the night. For this reason, C.J took another dose of ibuprofen, a painkiller yesterday night and today morning. Still, she is experiencing a purulent drainage from the nose accompanied by all of the other above stated symptoms.

a. Medical Hx (major illnesses): None, C.J denies having any significant injury or hospitalization in the past.

b. Childhood Illnesses: there are reports of strep throat and chicken pox, but she denies having measles, mumps, rubella, rheumatic fever and pertussis.

c. Surgical Hx: C.J reports having Catheter ablation in 2014

d. Obstetric HX: None

e. Immunizations: Received all required Childhood Immunizations, TDaP in 5/2014

f. Psychiatric Hx: None

g. Allergies: C.J has medical reports of Allergic rhinitis causing more urination, headache, runny nose, itchiness, and diarrhea. She has a food allergy for fish, which causes rashes on the skin, cramps, diarrhea and vomiting. No allergies are reported that associate with acute sinusitis.

h. Current Medications: C.J reports being administered with Excedrin (1 gram) and pseudoephedrine nasal decongestant for oral intake for one day now the over the counter medication was prescribed by a pharmacist. A total of six tablets of pseudoephedrine nasal decongestant has so far been taken. The patient has the labels for the medications outlined above well noted. Further, she denies any complementary or alternative treatment aside from the described medications.

i. Last Examination C.J reports to have had a full body medical examination six months ago, 5 May 2016. The exam involved Physical, eye exam, foot exam, dental exam, hearing screen, EKG, chest X-Ray, Pap test, mammogram, serum cholesterol, stool occult blood, prostate, PSA, UA, and TB skin test

5. Family History: It emerges that C.J’s father was diagnosed with a stent at age 35, while the mother was diagnosed with HTN at age 32. (list FHx and design a genogram (computer)-include a key with the genogram). The Genogram must include three generations. The patient has a brother who was treated for hypothyroidism. The family has a history of nasal allergies but none of the sinusitis. The family history of nasal allergies is, therefore, useful for the matter of Chief Complaint (CC).

II. Lifestyle patterns

a. Immigrant status: C.J is an American by birth and so immigrant status is non-applicable.

b. Spiritual resources/religion: C.J indicated that she had a firm belief in God and that she was of the Christian faith.

c. Health perception: The patient states that she was very much concerned when it comes to matters of health and she would not hesitate to visit a medical center as soon as she noticed some symptoms on herself. She also believes that the healthcare system of the country offers professional and reliable services to people.

d. Nutritional patterns: the patient maintains that she has an average appetite for food and that her current illness has had major negative impacts on her appetite. Still, she is satisfied with her average weight of 128lbs.

e. Elimination patterns: both the patient`s bowel and bladder elimination patterns are normal

f. Living environment: C.J lives and works in the city, a place where exposure to toxins in the environment is common

g. Occupational health: C.J works in a building office environment where there are little concerns for occupational health hazards that can associate with her illness

h. Functional assessment: the patient’s activities of daily living (ADL’s) and or instrumental activities of daily living (IADL’s) are those of everyday American citizens living in a city environment.

i. Role and family relationships: C.J lives alone and only interacts with members of her immediate family once in a while. She is very responsible for her wellbeing.

j. Cognitive function: the patient’s functions of thought, memory, speech, judgment and other senses are perfectly normal.

k. Rest/sleep patterns: the patient reports of a healthy sleeping routine of eight hours every night. She, however, indicates that her current condition has significantly disrupted this routine. So far, she has not made use of any aids for sleep.

l. Exercise patterns: C.J reports going for a morning run thrice in a week

m. Hobbies/Recreation: for leisure, C.J loves to watch movies or read novels

n. Social habits: the patient indicates that she likes to hang out with her girlfriends whenever she has the time

o. Intimate partner violence: C.J notes that she is currently single with little interest of getting into a relationship

p. Coping/Stress management: the patient reports no major issue that has happened in her life in the past two years that has caused her to be stressful

q. Sexual patterns: C.J is straight but is currently not sexually active

II. Review of Symptoms

General: Headache, running nose, weakness

Skin: No symptoms

Head: A headache

Eyes: Redness, blurred vision

Ears: No symptoms

Nose: Nasal discharge, obstruction

Neck: No Symptoms

Breasts: No symptoms

Pulmonary: Mild a cough, Pleurisy

Cardiac: No symptoms

G/I: No symptoms

GU: No symptoms

Peripheral Vascular: No symptoms

Musculoskeletal: No symptoms

Neuro: No symptoms

Heme: No symptoms

Endo: No symptoms

Psych: No symptoms

Objective data:

Physical Examination: The patient seems to be in pain.

Blood pressure is 118/75, the weight of 128lbs, and pulse rate of 81.

HEENT: Head is symmetrical, face features are symmetrical, no eye examination owing to no complaints, clear tymphanic membrane, and no pineal pain. No rhinne or Weber test owing to no complaints. No nasal swelling and no polyps. The sense of smell test shows a little discrepancy. Oropharynx has exudates. Detention has a gingival swelling. As the patient says ‘aah,` a small rise is observed on the soft palate. Examination of taste shows problems.

Lymphatic: no lymphadenopathy

Chest/Lungs/Respiration: problematic breathing is observed. Heart: rate higher than normal

Abdomen: flat, no palsations, or hepatomegaly.

Neurological: No assessment

Musculoskeletal: spine is normal, no curving, no pain, and appears symmetrical.

Diagnostic Test: the electrocardiogram indicates the sinus rate is high with 85 beats per minute.

Neck &amp Regional Lymph Nodes: Normal

Breasts: Normal

Lungs &amp Thorax: presence of rales,&nbsprhonchi, and there is reduced breath sounds. Implying accumulation of fluid in lungs and little air exchange

Gastrointestinal: Normal

Genitourinary: Normal

Extremities: Normal

Musculoskeletal: Normal

Neurological: Normal

Assessments

Differential Diagnoses:

  1. Acute Respiratory Distress Syndrome – (ARDS)

  2. Adenoviruses

  3. Cytomegalovirus (CMV)

ARDS was a primary diagnosis because of the possibility of respiratory failure only after a few days of infection (Harman, 2013). Adenoviruses as also a diagnosis owing to it being a common cause of asymptomatic respiratory tract infection (Gomph, 2012). CMV is believed to be the cause of fever in the patient that is of unknown origin and the visual impairment reported by the patient (Akhter, &amp Wills)

Nursing Diagnosis:

  1. Ineffective Breathing Pattern

Medical Diagnosis:

  1. Acute respiratory infection (ARI)

Plan of Care

Nursing Theory

Referral and Treatment Plan

  1. Continue with the current Excedrin (1 gram) and pseudoephedrine nasal decongestant

  2. If condition continues to worsen, start medical management involving oseltamivir (Tamiflu®)

Goal Attainment Theory: the patient needs to develop a goal of aiding herself and her environment, well during the healing period

Preventative Care

Developmental stage

Cultural characteristics

Control exposure to dust and coldness

Early stages of the infection since symptoms relate with influenza A

C.J is a typical White person. She has high regards for the healthcare sector and profession. She values respect and honesty and should be treated with the same

Evaluation of care

Refer to a more in-depth ENT assessment

Assess patient to find out if there are signs of asthma

References

Akhter, K., &amp Wills, T. S. eMedicine Specialties&gt Infectious Diseases&gt Viral Infections.

Buttaro, T., Trybulski, J., Polgar, B., &amp Sandberg-Cook, J. (2013). Primary care: The collaborative practice (4th ed., pp. 487-611). St. Louis, Mo.: Elsevier/Mosby.

Gompf, S. G. (2012). FIDSA Chief Editor: Burke A Cunha. MD. Adenoviruses. WebMD LLC. Retrieved 15 October 2016, from http://emedicine.medscape.com/article/211738-overview

Harman, E. M., &amp Pinsky, M. R. (2013). Acute respiratory distress syndrome. Medicine. Retrieved 15 October 2016, from http://emedicine.medscape.com/article/165139-overview

Preceptor’s Signature

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