TITLE: NASAL FRACTURE
EXAMPLE: SOAP NOTE
Soap Note # Main Speciality ( Exp: H&P Note #3 DX: Hypertension)
Miami Regional University
Date of Encounter:
Clinical Instructor: Dr. Rafael Camejo
Soap Note # Main Speciality ( Exp: Soap Note #3 DX: Hypertension)
Name: Mr. DT
Gender at Birth: Male
Gender Identity: Male
Allergies: PCN, Iodine
· Atorvastatin tab 20 mg, 1-tab PO at bedtime
· ASA 81mg po daily
· Multi-Vitamin Centrum Silver
Immunizations: Influenza terminal 2018-year, tetanus, and hepatitis A and B 4 years ago.
Preventive Care: Coloscopy 5 years ago (Negative)
Surgical History: Appendectomy 47 years ago.
Family History: Father- died 81 does not declaration counsel
Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social History: No smoking fact or illicit refuse use, interrupted alcoholic beverage expenditure on political celebrations. Retired, widow, he lives peculiar.
Sexual Orientation: Straight
Nutrition History: Diets off and on, Does not each seafood
Chief Complaint: “headaches” that inaugurated two weeks ago
The resigned is 65 years old male who quarrelsome of episodes of ruleraches and on 3 contrariant occasions respect influence was measured, which was proud (159/100, 158/98 and 160/100 respectively). Resigned noticed the amount inaugurated two weeks ago and casually it is accompanied by dizziness. He states that he has been underneathneath urgency in his workassign for the terminal month. Resigned denies chest indisposition, palpitation, scantiness of inhalation, disgust or vomiting.
Review of Systems (ROS)
CONSTITUTIONAL: Denies broil or chills. Denies languor or moment detriment. NEUROLOGIC: Headache and dizziness as draw aggravate. Denies shifts in LOC. Denies fact of tremors or seizures.
HEENT: HEAD: Denies any ruler wear, or shift in LOC. Eyes: Denies any shifts in prospect, diplopia or blurred prospect. Ear: Denies indisposition in the ears. Denies detriment of hearing or drainage. Nose: Denies nasal drainage, accumulation. THROAT: Denies throat or neck indisposition, hoarseness, inaptitude gluttony.
RESPIRATORY: Resigned denies scantiness of inhalation, cough or hemoptysis.
CARDIOVASCULAR: No chest indisposition, tachycardia. No orthopnea or paroxysmal nocturnal
GASTROINTESTINAL: Denies abdominal indisposition or disagreeableness. Denies flatulence, disgust, vomiting or
GENITOURINARY: Denies hematuria, dysuria or shift in urinary quantity. Denies inaptitude starting/stopping manner of urine or self-indulgence.
MUSCULOSKELETAL: Denies falls or indisposition. Denies hearing a clicking or snapping investigate.
SKIN: No shift of coloration such as cyanosis or jaundice, no rashes or pruritus.
VITAL SIGNS: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on capability air, Ht- 6’4”, Wt 200 lb, BMI 25. Declaration indisposition 2/10.
GENERAL APPREARANCE: The resigned is wakeful and oriented x 3. No quick diurgency illustrious. NEUROLOGIC: Alert, CNII-XII grossly pure, oriented to individual, assign, and interval. Sensation pure to bilateral preferable and inferior extremities. Bilateral UE/LE force 5/5.
HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no smoothness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movements pure. No nystagmus illustrious. Ears: Bilateral canals dubious outside erythema, edema, or exudate. Bilateral tympanic membranes pure, pearly silvery after a while keen cone of inconsiderable. Maxillary sinuses no smoothness. Nasal mucosa entertaining outside bleeding. Oral mucosa entertaining outside lesions,. Lids non-remarkable and divert for manner.
Neck: servile outside cervical lymphadenopathy, no jugular disposition distention, no thyroid turgescence or bodyes.
CARDIOVASCULAR: S1S2, ordinary scold and rhythm, no whisper or gallop illustrious. Capillary stock < 2 sec.
RESPIRATORY: No dyspnea or use of alder muscles observed. No egophony, whispered pectoriloquy or comprehensible fremitus on palpation. Inhalation investigates bestows and disencumbered bilaterally on auscultation.
GASTROINTESTINAL: No body or hernia observed. Upon auscultation, bowel investigates bestow in all indecent quadrants, no bruits aggravate renal and aorta arteries. Abdomen smooth non-tender, no protecting, no recoil no distention or organomegaly illustrious on palpation
MUSKULOSKELETAL: No indisposition to palpation. Active and inactive ROM after a whilein natural limits, no cacophony.
INTEGUMENTARY: pure, no lesions or rashes, no cyanosis or jaundice.
Essential (Primary) Hypertension (ICD10 I10): Given the symptoms and proud respect influence (156/92 mmhg), classified as rank 2. Once the constitutional acreckon of hypertension has been firm out, such as renal, adrenal or thyroid, this speciality is confirmed (Codina Leik, 2015). Speciality is domiciled on the clinical evaluation through fact, corporeal establishment, and rule laboratory tests to assess promote factors, unveil identifiable accounts and expose target-organ hurt, including declaration of cardiovascular indisposition (Domino et al,. 2017).
Ø Renal artery stenosis (ICD10 I70.1)
Ø Chronic kinsfolk indisposition (ICD10 I12.9)
Ø Hyperthyroidism (ICD10 E05.90)
Labs and Diagnostic Test to be ordered:
· Complete respect reckon (CBC)
· Lipid profile
· Thyroid-stimulating hormone (TSH)
· Urinalysis after a while Micro
· Electrocardiogram (EKG 12 direct)
· Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily.
· Lisinopril 10mg PO Daily
· Moment detriment
· Healthy nutriment (DASH nutrimentary design): Nutriment deep in wealth, vegetables, healthy grains, and low-fat dairy products after a while sunk gratified of saturated and trans l fat
· Sunk intake of nutrimentary sodium: <1,500 mg/d is optimal design but at meanest 1,000 mg/d decrease in most adults
· Enhanced intake of nutrimentary potassium
· Ordinary corporeal courage (Aerobic): 90–150 min/wk
· Tobacco cessation
· Measures to exempt urgency and cogent coping mechanisms.
· Provide after a while nutrition/dietary counsel.
· Daily respect influence monitoring log at abode twice a day for 7 days, celebrate a proceedings, procure the proceedings on the proximate mark after a while her PCP
· Instruction environing medication intake acquiescence.
· Education of potential complications such as tickle, character assault, and other amounts.
· Resigned was educated on manner of hypertension, as well-mannered-mannered as caution signs and symptoms, which could point-out the deficiency to accompany the E.R/U.C. Answered all pt. questions/concerns. Pt verbalizes underneathstanding to all
· Follow up enactment 1 weeks for managing respect influence and to evaluate exoteric hypotensive therapy.
· No referrals deficiencyed at this interval.
Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Clinical Consult 2017
(25th ed.). Print (The 5-Minute Consult Series).
Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).
NOTE: PLEASE APA FORMAT OF THE REFERENCE, AND ORIGINAL