What was your primary diagnosis and why?
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Comprehensive SOAP Note
NURS 6531N- 20
Practicum Experience Assignment 3#
Patient name- BR Age- 68 Sex- Black female
Chief Complaint (CC): “I am having blurred vision and headaches and sometimes they make me nauseated”. I recently was placed on a different blood Pressure medication two weeks ago.
History of Present Illness (HPI): This is a 68yr. old black female presenting to the clinic with complaints of headaches with blurred vision and nausea for two week. Patient states she experienced low-grade fever that morning. Patient states she was placed on Lisinopril 20mg PO daily.
Medications: Zantac 75mg PO daily, Lisinopril 20mg PO daily,ASA 81 mg PO daily, Advair 50mg PRN
Past Medical History (PMH): Ashma , HTN, Arthritis
Past Surgical History (PSH): Appendectomy ten years ago
Immunization History: Immunizations up-to-date to age.
Significant Family History: Both parents are no longer living and both had HTN. Patient has one younger brother with HTN.
Lifestyle: Retired and lives on Social security .
REVIEW OF SYSTEMS:
General: Alert with complaints of fatigue due to nausea
Respiratory: Denies any shortness of breath or cough
Cardiovascular/Peripheral Vascular: Denies chest pain or any other heart symptoms
Musculoskeletal: Some Joint pain in the mornings .
HEENT: Blurred vision.
Psychiatric: Anxious related to disease process
Skin: Denies any skin issues, rash or lesions
Gastrointestinal- complaints of off and on Nauesa
Hematologic: Denies bruising
Endocrine: Denies polydipsia, polyuria, polyphagia
Neuro- Denies any loss in memory, seizures.
GU- Denies difficulty or pain in urinating.
Vital signs: T 98.4 F, BP 140/101, P- 101, R- 22, SPO2 98 % room air.
General: 68-year-old female, alert oriented,
Neurological – No abnormal positioning, movements or facial asymmetry.
HEENT: PERLA, Atraumatic, normocephalic, no redness in eyes, no nose bleed, moist mucous membrane, no oral ulcers, no sore throat or tonsillitis, no ear discharge.
Neck: No carotid bruit or JVD, swollen lymph nodes noted, no stiffness, supple, symmetrical, no adenopathy, no tenderness/mass/nodules.
Chest/Lungs: Unlabored respiration, Breath sounds clear bilaterally.
Cardiovascular- Regular rate and rhythm. S1 and S2 normal. No murmur, rub, or gallop. Thorax symmetrical
Chest wall- No tenderness or deformity.
Skin: warm and dry, no rashes or lesions, color, texture, decreased skin turgor
Abdomen- mild tenderness- abdomen. Nondistended, protuberant. Normoactive bowel sounds on all four quadrants, no masses, no organomegaly.
Genitourinary- No suprapubic tenderness. No costovertebral angle tenderness.
Musculoskeletal- No joint swelling, No skeletal deformity.
Peripheral/ vascular- Extremities normal, 2+ dorsalis pedis pulses bilaterally. No peripheral edema or cyanosis.
1.PROVIDE 3# List them from highest priority to lowest priority,
2.What was your primary diagnosis and why?
3.Description of Health History-
4.Patient Problem/Plan Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management including alternative therapies?
5.Diagnostic tests; For a patient with HNT
6.Conclusion Reflection notes: What would you do differently in a similar patient evaluation?
• Buttaro, T. M., Trybulski, J., Polgar Bailey, P., & Sandberg-Cook, J. (2013). Primary care: A collaborative practice (4th ed.). St. Louis, MO: Mosby.
o Part 11, “Evaluation and Management of Cardiovascular Disorders” (pp. 487–611)
This part explores diagnostics of cardiovascular disorders, including how to differentiate between normal and abnormal test results. It also examines how patient history and physical exams contribute to differential diagnoses for cardiovascular disorders.
• Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Mosby.
o Chapter 26, “Recording Information”
This chapter outlines the components of SOAP notes and provides guidelines for writing SOAP notes after patient examinations. Please note: You should have this textbook in your personal library, as it was the required text in NURS 6511: Advanced Health Assessment & Diagnostic Reasoning.
• Gagan, M. J. (2009). The SOAP format enhances communication. Nursing New Zealand, 15(5), 15.
Retrieved from the Walden Library databases.
This article outlines the four parts of SOAP notes and examines the importance and effectiveness of SOAP notes in clinical settings.
• National Heart Lung and Blood Institute. (2002). Primary prevention of hypertension: Clinical and public health advisory from the National High Blood Pressure Education Program. Retrieved from http://www.nhlbi.nih.gov/files/docs/resources/heart/pphbp.pdf
This article reviews factors that impact the patient education of hypertension. Hypertension prevention and intervention methods are also explored.
• American Heart Association. (n.d.). Retrieved November 28, 2012, from http://www.heart.org/HEARTORG/
• Drugs.com. (n.d.). Retrieved November 28, 2012, from www.drugs.com
• Institute for Safe Medication Practices. (n.d.). Retrieved November 28, 2012, from http://www.ismp.org/
• Million Hearts. (n.d.). Retrieved November 28, 2012, from http://millionhearts.hhs.gov/index.html
• WebMD. (2012). Medscape. Retrieved from http://www.medscape.com/
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