Soap_Note week 3 nsg6020
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School
South University, Savannah *
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Course
6020
Subject
Medicine
Date
Jan 9, 2024
Type
docx
Pages
6
Uploaded by CommodoreWildcat314
Name:
JR
Date: 3/07/2014
Time: 0825
Age: 54
Sex: Male
SUBJECTIVE
CC:
“I feel congested and I have been coughing since Wednesday”
HPI
: Patient states the problem started Wednesday evening as a runny nose which became congested during the night. Patient has decreased appetite since then and reports constant headache and joint pain especially at night. These symptoms are relieved by cough medicine and Motrin. The patient has high blood pressure that is treated with Norvasc and Lisinopril. He had hernia repair two years ago.
Medications:
Lisinopril and Amlodipine 10 mg for hypertension
PMH: Hypertension
Allergies: No known allergy
Medication Intolerances: None
Chronic Illnesses/Major traumas. Hypertension
Hospitalizations/Surgeries. Hernia repair in 2014
Family History.
Grandmother and grandfather had hypertension. Mother has diabetes and father has hypertension
Social History
. The patient has a Bachelor’s degree in accounting and manage a local fast food restaurant. He exercise at least twice a week and live with his wife and his four children. He stopped smoking 25 years ago and drinks a glass of wine occasionally, he states he does not feel totally safe due to occasional robberies in his neighborhood.
ROS
General Patient denies any weight loss but states he has had fever for the past two nights
Cardiovascular
Patient denies any chest pain or palpitations
but reports occasional feet edema sometimes after his shifts
Skin
No rashes, bruising, bleeding or skin discolorations, noted on patient’s body
Respiratory
Cough along with rhonchi and crackle noted during auscultation
Eyes
No visual changes or loss of vision. Corrective lenses, and glasses
Gastrointestinal
No abdominal pain, constipation eating disorders, abdominal distension or any other abnormality noted
Ears
Abundant ear wax noted in patient’s ears
Genitourinary/Gynecological
Patient reports Urgency, frequency. He was
recently diagnosed with enlarged prostate
Nose/Mouth/Throat
Patient denies sore throat any nose bleed and sinus problems. His wisdom teeth are missing
Musculoskeletal
Patient denies any back pain, joint swelling
or any other musculoskeletal problems
Breast
No bumps masses and discharge noted. Breast asymmetrical
.
Neurological
Patient denies any history of seizure, Syncope, transient paralysis, weakness, and
paresthesia, black out spells.
Heme/Lymph/Endo
Patient denies any bruising, blood transfusion night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance
Psychiatric
Patient denies any difficulty sleeping, depression or suicidal ideation
OBJECTIVE
Weight 160 lbs BMI 24
Temp 98.4
BP 126/78
Height 5ft 7
Pulse 72
Resp 18
General Appearance
Patient is a 54 years old African American Male, appears fit well dressed and healthy. He
was alert and oriented X4, calm and answered all questions appropriately
.
Skin
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Skin is appropriate for ethnicity, warm, dry, clean and intact. No rashes, bruises or skin lesions noted.
HEENT
Head is normocephalic, atraumatic and with no lesions; hair evenly distributed. Pupils are
equals and reactive. Ear canals are patent although abundant wax noted. No redness noted. Bilateral tympanic membranes are pearly grey with positive light reflex; Nasal mucosa pink and normal No septal deviation. Neck is asymmetric with Full range of motion; Oral mucosa pink and moist. wisdom teeth missing
Cardiovascular
No leg swelling noted during examination. S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill less than 3 seconds. Pulses 2+ throughout.
Respiratory
Symmetric chest wall. Respirations regular; Rhonchi and crackle to auscultation bilaterally
.
Gastrointestinal
Abdomen flat; Bowel sound active in all 4 quadrants. Abdomen soft, non-tender. Breast
No bumps masses and discharge noted. Breast asymmetrical
. Genitourinary
Bladder is non-distended; no further examination done due to patient’s refusal. Patient states he has been diagnosed with prostates enlargement and was on Flomax. Patient also reports urinary urgency, especially at night
Musculoskeletal
Patient has Full ROM in all 4 extremities during examination. Neurological
Patient’s speech is clear. Good tone. Posture is erect. Balance stable; Gait is stable with no apparent problems
.
Psychiatric
Patient is alert and oriented, well dressed and healthy. He is calm and answered all questions appropriately. Maintains eye contact. Speech is clear and of normal rate and cadence; he answered questions appropriately and was very pleasant during examination
Lab Tests
CBC
Blood Chemistry
Special Tests
Chest X-ray
ASSESSMENT FINDINGS AND PLAN
o
Diagnosis: Pneumonia
o
Differential diagnosis
Bronchitis
Influenza
Chronic Obstructive Pulmonary Disease (COPD)
Bronchiectasis
o
Plan:
Zithromax 500 mg x 6day
Amoxicillin 875 mg BID x 10 Days
Rocephin 1 G IM Q 24 hours x 2 days
o
Follow up in two weeks
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