SU_NSG6420_W4_A5_Barrera_R.doc.
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South University, Savannah *
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Course
NSG6420
Subject
Medicine
Date
Apr 3, 2024
Type
docx
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4
Uploaded by flormachado
CONPH NSG6320/NSG6420 Subjective, Objective, Assessment, Plan (SOAP) Notes
Student Name: Course: NSG 6420
Patient Name: (Initials ONLY) JH Date:09/11/2023
Time: 10:00
Ethnicity: Hispanic
Age:
61 y/o
Sex:
Male
SUBJECTIVE (must complete this section)
CC: Chest pain
HPI: P
atient is a 61 yo male who presents to the office complaining of chest pain for 4 days ago states pain feel 7/10 of pain scale. Chest pain described as stabbing, burning, radiating to the left axillary region and back. He refers It does not relieve with the ingestion of analgesic medications acetaminophen 500 mg or with
rest. Denies it does not intensify with movements or changes in position. Denies trauma or fever. No nausea, vomiting or diarrhea or any other symptoms.
Medications: Lisinopril 10 mg 1 tablet daily for HTN
Previous Medical History: HTN for 11 years
Allergies: NKA
Medication Intolerances: None
Chronic Illnesses/Major traumas: none
Hospitalizations/Surgeries: none
FAMILY HISTORY (must complete this section)
M: Died at 63 y/o due to CHF
MGM:
MGF:
F: 90 y/o with HTN, DM type 2 and Dementia
PGM:
PGF:
Social History:
REVIEW OF SYSTEMS (must complete this section)
General:
There has been no change in weight, overall health, strength, or exercise tolerance.
Cardiovascular: Reports chest pain for 4 days described as stabbing, burning radiating to left axillary region and back . No palpitations, no syncope, no orthopnea.
Skin:
Denies rashes, jaundice or itching
.
Respiratory:
Denies Shortness Of Breath, cough, hemoptysis, wheezing.
Eyes:
No vision change, no diplopia, no tearing, no pain
Gastrointestinal: Denies experiencing nausea, vomiting,
diarrhea, melena, hematochezia, or constipation. BMs
on a regular basis. Denies having stomach discomfort.
Ears:
No change in hearing, no tinnitus, no bleeding, no vertigo
Genitourinary/Gynecological: Denies dysuria, hematuria or incontinence
Nose/Mouth/Throat: No epistaxis, coryza, obstruction, or discharge. There were no dental problems, gingival bleeding, denture use, or sore throat.
Musculoskeletal: Denies having any
joint or back pain or muscle problems.
Breast
: Denies having any breast lumps
Neurological: There have been no instances of syncope,
seizures, momentary paralysis, paresthesia, or blackouts. denies suffering memory loss, vertigo, headache, or trembling.
Heme/Lymph/Endo: N
o anemia denies having an excessive amount of hunger, thirst, or sweating. denies having changes in energy levels, a lowered body mass index, enlarged glands, or HIV positivity
Psychiatric: No mood swings, trouble sleeping, suicidal thoughts, or attempts.
OBJECTIVE (Document PERTINENT systems only. Minimum 3)
Weight: 192
Height: 64
BMI: 32.96
BP: 140/90
Temp
: 98 F
Pulse: 85
Resp: 20
General Appearance: Communicates without difficulty, well nourished, no acute distress.
Skin:
HEENT:
Cardiovascular: RR, no rubs, no gallops. Aortic focus murmur of medium intensity is auscultated.
Respiratory: Lungs clear, no rales, no rhonchi, no wheezes are heard Gastrointestinal:
Breast:
Genitourinary:
Musculoskeletal: No pain in muscles or joints, no limitation of range of motion, no paresthesias or numbness.
Neurological: No weakness, no tremor, no seizures, no changes in mentation, no ataxia.
Psychiatric:
Lab Tests: ECG Done in office
ST Segment depression
CBC: Done Pending for results.
Lipid Panel: Pending for results
Special Tests: None
DIAGNOSIS
Differential Diagnoses(At least three with rationales needed)
Stable Angina ICD 10 I20.9
Pain only happens in connection with physical activity or mental stress, does not become worse over
time, and is eased by nitrates or rest.
Congestive Heart Failure I50.22
The most common symptoms are often peripheral edema, orthopnea, tachycardia, and shortness of breath. If coronary perfusion is compromised, chest discomfort may develop (
Bozkurt B, Coats AJ, Tsutsui H, et al.2021).
Myocarditis ICD 10 I51.4
May affect persons of all ages, with a slightly greater frequency in men than in women and a similar incidence in blacks and whites. May manifest as acute, chronic, or fulminant miocarditis (
Law YM, Lal AK, Chen S, et al.2021).
Diagnosis: Include rationale for how you arrived at this.
1- Unstable Angina ICD 10 I20.0
Chest discomfort and/or dyspnea are the most usual signs of unstable angina, while other symptoms may also be present. ECG was positive with ST segment depression
Plan/Therapeutics
Nonpharmacological: Aspirin 81 mg 1 tablet daily
Pharmacological: Metoprolol 50 mg 1 tablet daily Continue with Lisinopril 10 mg 1 tablet daily
Education: Maintain the ADA diet. DASH diet Walk for 30 minutes on most days of the week.
Drink 8 glasses of water every day.
Continue taking drugs as directed.
Medication adherence was discussed with pt. The patient was educated on the significance of blood pressure regulation. Information on blood pressure measurement techniques was discussed. Discuss facts on the advantages of regular exercise. Hypertension complications such as CAD, stroke, renal failure, and imminent mortality were thoroughly discussed with the patient. Pt is aware of the hazards and agrees to try to manage his hypertension. Pt also agrees to take drugs on a regular basis.
Follow-up: 2-3 days for lab results if symptoms worsen go to the nearest ER
Referrals: None at the moment
Evaluation of patient encounter: Answer the following questions:
I talked to the patient and enquired about their symptoms and past health conditions. The patient was open to sharing information and gave me permission to assist them with their health issues. We spoke about their signs and symptoms and past health, and I treated them with their consent. Before administering any medical care, it was essential to engage the patient in open dialogue, pay close attention to what they had to say, and obtain their consent. I consider myself adept at communicating self-care strategies, available treatments, and challenging medical ideas to patients in a straightforward and succinct manner.
Every patient engagement, I know as a nurse practitioner, is an opportunity for me to develop both professionally and personally. I've learnt the value of thorough data gathering and targeted physical examinations via successful consultations. These encounters have taught me the value of thorough evaluations, which enable me to know my patients better and offer the best treatment. I am able to continuously advance my abilities and knowledge in providing patient-centered care since every patient interaction is a chance for learning.
References: You need at least three current journal/clinical guidelines references (published within the last 5 years) to support your treatment plan. Do not use your textbooks for treatment plans. Format according to APA.
Bozkurt B, Coats AJ, Tsutsui H, et al. Universal definition and classification of heart failure: a report of the Heart Failure Society of America, Heart Failure Association of the European
Society of Cardiology, Japanese Heart Failure Society and Writing Committee of the Universal Definition of Heart Failure. J Card Fail. 2021 Apr 1;27(4):387-413.
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Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain: a report of the American College
of Cardiology/American Heart Association joint committee on clinical practice guidelines. Circulation. 2021 Nov 30;144(22):e368-e454.
Law YM, Lal AK, Chen S, et al. Diagnosis and management of myocarditis in children: a scientific statement from the American Heart Association. Circulation. 2021 Aug 10;144(6):e123-35.