work due ASAP

69 years old female .

Height

CC: “I have been having chest pain” HPI: it started about 5 days ago. Medications:

Allergies:No durg allergies. No food or environmental allergies . PMH: High blood pressure, high cholesterol, heart murmur/ aortic stenosis, and heart disease/ coronary artery disease. PSH: gallbladder removed 20 years

11 years ago I had surgery to get my mouth for dentures. OB/GYN Hx: Personal/Social Hx: Immunizations: Family Hx

ROS

· General: denies weight changes, weakness, fatigue, or fever.

· Skin: denies rashes, lumps, sores, itching, dryness, changes, etc.

· HEENT: Denies HA, head injury, dizziness, and lightheadedness. Eyes: Denies eye pain, redness, excessive tearing, double or blurred vision spots, flashing lights, and the use of eyeglasses or contact lenses.

· Ears: Denies ear pain, tinnitus, vertigo, discharge, and use of hearing aids.

· Nose and Sinuses: Denies frequent colds, nasal stuffiness, drainage, itching, nosebleeds, and sinus pain. Mouth and Throat: Denies bleeding gums, sore throat, dry mouth, hoarseness .

· Neck: Denies swollen glands, goiter, lumps, pain, or stiffness.

· Breasts: Denies rashes, ulcerations, dryness, flaking, excessive sweating, and changes in moles.

· Respiratory denies Not experiencing difficulty in breathing, coughing, or wheezing

· Denies cough, dyspnea, increased sputum production, hemoptysis, snoring, and wheezing.

· Cardiovascular: Patient Has high blood pressure/o chest pain.

· PS 0/10 at the moment, but PS 6/10 when it happens.

· Denies chest pain, palpitations, orthopnea, PND, edema, intermittent claudication, leg cramps, and varicose veins.noted to have heart murmurs

· Gastrointestinal: Denies trouble swallowing, N/V, indigestion, abdominal pain, constipation, diarrhea, blood in stool, and hemorrhoids. Last BM yesterday, appearance usual for patient.

· Peripheral vascular:

· Urinary: Denies dysuria, urgency, nocturia, burning w/ urination, incontinence, flank pain, suprapubic pain, hernias, ulcerations, drainage, and hematuria. Has no concerns about STIs.

· Genital:

· Musculoskeletal: denies back, joint pain, or muscle stiffness.

· Psychiatric: Denies paresthesia, tremor, seizures, and gait/strength/balance/coordination changes. Denies problems with memory or speech.

· Neurological: Denies paresthesia, tremor, seizures, and changes in gait/strength/balance/coordination. Denies problems with memory or speech.

· Hematologic: Denies easy bruising or bleeding, pallor, and past transfusions.

· Endocrine: Denies excessive sweating, heat or cold intolerance, and increased hunger.

Physical Exam Vital Signs. Ht/Wt/BMI

SOAP OUTLINE

 

Problem Statement

 

 

General: General state of health, posture, motor activity and gait. Dress, grooming, hygiene. Odors of body or breath. Facial expression, manner, affect and reactions to people and things. Level of conscience.

· SKIN: Erythematous dry pruritic rash covering flexor surface of left elbow w/ superficial abrasions from scratching; no edema, drainage, or heat present. Otherwise, exposed skin is smooth and free of lesions, bruising, tattoos, and piercings. Several nevi were noted on the forearms and forehead. Hair thinning at crown and temples. No facial hair. Nails trimmed and in good condition.

· HEENT: Head: Normocephalic, atraumatic. No masses, lesions, or scalp tenderness.

·

· Eyes: Visual acuity not examined at this visit. Visual fields full by confrontation. Conjunctivae clear, sclera white. EOM intact, equal convergence, no nystagmus. Disc margins are sharp without hemorrhages or exudates, with no A-V nicking.

· Ears: Whisper test negative. Canals clear with average hair distribution, no erythema or edema. TM’s pearly gray landmarks and cones are in usual positions. Weber midline. AC > BC. Nose/Sinuses: Mucosa pink, moist without lesions or drainage. Nasal septum midline without perforation.

·

· Mouth/Throat: Lips and gums pink, moist without lesions. Teeth in good condition with evidence of cavity filling on bilateral lower molars. The tongue is pink and moist, midline without lesions. Salivary glands are non-palpable/non-tender. Uvula midline rises with vocalization. Oropharynx pink and moist, no exudate. Tonsils absent. Jaw opens and closes smoothly.

·

· Neck: Full ROM w/o pain. Trachea midline.

· Chest/Lungs: Thorax symmetric with good excursion. Rate regular and unlabored. No accessory muscle use. Lung sounds clear and equal bilat. Diaphragmatic expansion symmetrical. No chest wall lesions, masses, or tenderness. Resonant in all lung fields. Nail beds pink w/o clubbing.

· Heart/Peripheral Vascular: Regular rate/rhythm w/o clicks, gallops, rubs, S3, S4, Carotid upstrokes brisk pulses 2+ bilat w/o bruit. Noted with high BP.C/O chest pain 6/10 with walking and no pain at rest. Noted to have heart murmurs.

· Abdomen: Obese, soft, symmetrical, w/o masses, lesions, or hernia. Bowel sounds normoactive x4 quadrants. Resonant w/ gastric tympany. No tenderness or rigidity on light and deep palpation. No renal/aortic/iliac bruits. Liver edge is smooth and palpable, 1 cm below RCM. Spleen and kidneys not examined. No CVA tenderness.

· Genital:

· Musculoskeletal: Full active ROM of all joints w/o pain, swelling, or deformity. Strength 5+ throughout. No tremor. Gait smooth with increased side-to-side sway.

· Neurological: Right-hand dominant. Alert and cooperative. Thoughts are coherent and oriented to person, place, and time. Cranial nerves II-XII intact. Good muscle bulk and tone, strength 5/5 throughout. Rapid alternating movement of fingers performed w/o difficulty. Light touch, position, sense, and vibration intact. Patellar reflexes 2+ bilateral. Romberg negative.

· Psych: Affect bright and appropriate.

 

· • ASSESSMENT •

 

1) Diagnose

 

 

differential diagnosis – do 3 differential diagnosis

· Name each one in order of importance

· Explain what it is, what causes it, usual presenting symptoms and how they differ with this patient’s current symptoms. If it is caused by a viral or bacterial pathogen, tell me which one is usual cause.

· Include how you ruled out the diagnosis as primary

· Provide citations to support your decision-making

 

 

 

1) 2) 3)

 

 

Testing

· Testing

· Therapy needed (medications and non-medication). Include name/dose/frequency and

duration of therapy for Rx and OTC medications.

· Specialist referral(s) or consults

· Patient education on disease and medication, counseling on lifestyle modifications

· Follow up: include specific time frame for follow-up as well as red flags for immediate recheck

· Include citation for treatment guideline used

 

 

 

Treatment plan

 

Medication

 

· Medication should include prescription medications as well as OTC medication you are recommending. For both Rx and OTC you must include: name, dose, frequency, duration of therapy and if PRN medication it must include an indication (ie pain, vomiting, dizziness, etc)

· Non-medicationtherapyincludesitemssuchassplinting,homephysicaltherapy,TENS unit, cold or heat therapy, etc. Include specifics such as type of splint, type of therapy, how often and how long to use the therapy.

 

 

 

 

 

 

Patient education

Education on disease. What is it, what is the expected course

• Education on medication. What is it and what are usual side effects. Include any black box warnings

• Education on lifestyle modifications with included goals Exercise=what type, how often Weight loss or gain=goal BMI Diet=2 gm sodium, low cholesterol/saturated fats etc

 

 

 

Follow up

 

Include specific time frame for follow up • Include specific red flags for immediate recheck

HEALTH PROMOTION

Review existing diagnoses and whether any changes need to be made? For example: HTN- is it controlled based on VS today? Do any changes need to be made on existing medication plan? Depression: is it controlled on current medication?

Did I include needed preventative care based on my patient’s age and risk factors? o Preventative care includes all recommended health screening exams based on age, sex, risk factors. You can find a list at USPSTF Website.

Social Determinants of Health (SDOH) • This should review the following 5 elements

· 1) Patient’s ability to access care

· 2) Patient’s ability to pay for care

· 3) Patient’s education level

· 4) Patient’s social support

· 5) Safety of the patient’s environment

 

• Reference list