Assignment: Nursing soap note on a 72 year-old female with abdominal pain

Assignment: Nursing soap note on a 72 year-old female with abdominal pain

Assignment: Nursing soap note on a 72 year-old female with abdominal pain

Nursing soap note on a 72 year-old female with abdominal pain

 SOAP NOTE

ID: Rogers Miller, DOB 1/2/1949, a Caucasian male was admitted at the emergency department with abdominal pain.

ORDER A CUSTOMIZED, PLAGIARISM-FREE Assignment: Nursing soap note on a 72 year-old female with abdominal pain HERE

Good News For Our New customers . We can write this assignment for you and pay after Delivery. Our Top -rated medical writers will comprehensively review instructions , synthesis external evidence sources(Scholarly) and customize a quality assignment for you. We will also attach a copy of plagiarism report alongside and AI report. Feel free to chat Us

CC: the elderly patient was diagnosed with acute abdominal pain.

HPI: The identified patient is a 72-year old female with noteworthy complaints about abdominal pain. The patient reported constant, severe abdominal pain experienced in the upper left quadrant of her abdomen as well as the right shoulder blade. Accompanied by Nausea, the pain experienced by the identified patient is worsened by eating due to the excessive bloating and gas (Reed & Malik, 2018).  Whilst the use of Rolaids, aspirin and amlodipine proved instrumental in reducing the pain, it persistent nature of the pain requires further intervention. On a likert scale of 10, the patient rates the pain experienced as a 7.

Allergies: No known drug allergies

PHM- no substantial PMH

Childhood:

Surgical:

Medications:

Vaccinations: affirms use of COVID-19 vaccine

Family History: father died of cancer, mother died of diabetes and her younger brother had had his kidney removed 5 years ago.

Social history: Divorced, and living with a domestic helper.

ROS- feart of eating, fatigue, immobility and reduced appetite

General: weight change due to reduced food consumption

Eyes: blurred vision

Ears/Nose/mouth/throat: no hearing problem, infection.

RESPIRATORY: breathing difficulties, persistent shortness of breath, positive for sore throat, running nose

CARDIOVASCULAR: chest discomfort, fever, nausea and chest pains

MUSCUSKELETAL: reports of muscle stiffness, joint pain, back pain, abdominal discomfort

NEUROLOGICAL: headache dizziness, malignancy

PSYCHIATRY: Denies psychiatric history

C/V: affirms mild chest pains, palpitations.

PULMONARY: wheezing, dyspnoea and negative haemoptysis

NEUROLOGICAL: vomiting, constipation, constant focal weakness/numbness, urinary tract infections.

LYMPHATICS: existence of swollen lymph nodes in neck

IMMUNOLOGY: history of seasonal allergies to environmental pollutants and pollen. Affirms frequent illness starting from age 50.

ENDOCRINOLOGIC: reports of heat intolerance

O

Vital Signs BP 125/40     P70 bpm      R 18 breaths      T 99.1 ̊ F

The patient is sociable, accommodative and optimistic.

Skin: pale in colour, and the existence of rashes, lesions and nails with cyanosis.

HEENT:

No Jaundice identified in sclera eyes. No bruits, thyromegaly and nick supple.

Cardiac: no gallops and murmurs. Regular heart rhythm and rate

Pelvic and breast examinations performed by a primary care practitioner in the last 6 months.

Musculoskeletal/ extremities: No clubbing or edema or cyanosis. 2+ dorsalis and radial pulses. Complete range of motion in her hands, shoulders, ankles, knees, elbows without bodily swelling or pain tenderness. The patient is not diagnosed with scapular tenderness (Reed & Malik, 2018).

Flanking and redness between f3-4 and 2-3 toes

Neuro: Gait normal, Romberg normal. Strength 4/4 bilateral lower and upper extremities.

Thorax and lungs: pneumonia, lung inflammation next to the diaphragm

A:

Differential diagnoses: 1. adnominal pain, a possible warning sign of gall stone disease and severe chronic constipation

P:

Less likely possibilities include gastritis, hepatitis, heart disease and/or peptic ulcer illness. The workup will encompass a full blood count, a sonogram of the RUQ         , an EKG and liver chemistries. Constant monitoring and communication with the patient is key throughout the treatment program (Morales, 2018). An assessment of the airway, circulation, breathing, and vital signs is fundamental in responding to a patient with acute abdominal pain. The provision of appropriate and tailored treatment and improved patient outcomes demands a comprehensive analysis of the severity of the disease based on historical facts, physical examination, diagnostic work-up as well as timely consultation with relevant geriatric and/or surgery specialists (Reed & Malik, 2018).

References

Morales, E. A. (2018). Abdominal pain in the elderly: Mini review. MOJ Gerontology & Geriatrics, 2(4). https://doi.org/10.15406/mojgg.2018.03.00131

Reed, A., & Malik, T. M. (2018). Chronic abdominal pain in the elderly: Ischemic pain. Oxford Medicine Online. https://doi.org/10.1093/med/9780190271787.003.0018

SOAP Note Week Three
ID: Mickey Mouse, DOB 1/1/2000, age 20, white Hispanic male presents to the clinic unaccompanied and appears to be a reliable historian.
S:
CC: “Cough, runny nose, and sore throat x 7 days”
HPI: New Asian male patient 28 yo presents to the clinic unaccompanied, complaining of non-productive cough, runny nose and sore throat x 7 days (1/7/2020). Currently somewhat controlling symptoms with Dayquil and Nyquil. Cough mild, worsened when laying flat. Highest temp at home 99 degrees. Patient wondering if he needs antibiotics. Rates pain in throat as 4/10, described as “aching, swallowing makes it worse”, relieved by Dayquil/nyquil. Denies headache, denies sick contacts or recent travel. Denies feeling worse outdoors or seasonally. He is a reliable historian
PMH:
Allergies: No known drug allergies. Strawberries (rash).
PMH: seasonal allergies
Childhood: Asthma until high school, chickenpox at age 2
Surgical: Tonsillectomy (1998), Wisdom Teeth Removal (2005)
Medications: None
Vaccinations: received childhood vaccines, Last flu shot given Oct 2019.
Denies psychiatric history.
Social History:
Denies tobacco/e-cigarette use. Admits to occasional once every 2-3 months alcohol use – last drink
2 months ago, Engaged, works in IT, Hobbies include archery.
Family History:
Diabetes II (Mother)
HTN (Older sister – 42 years old)
Dementia (Maternal Grandmother)
ROS:
General: No weight change, weakness, fatigue, fevers..
Eyes: no vision change, corrective lenses, pain redness, excessive tearing, double vision, blurred vision, or blindness.
EarsNose/Throat/mouth: no hearing change, tinnitus, earaches, infection, discharge. POSITIVE FOR RHINORHEA. No sinus pain or epistaxis. POSITIVE FOR SORE THROAT, HOARSE VOICE. No bleeding gums, dentures, sore tongue, dry mouth. Last dental exam 4 months ago.
C/V: Denies chest pain, palpitations.
Pulmonary: POSITIVE FOR NON-PRODUCTIVE COUGH, negative hemoptysis, dyspnea, wheezing, pleuritic pain
Neuro: No headache dizziness, focal numbness/weakness, nausea, vomiting.
Lymph: Denies swollen lymph nodes in neck.
Allery/immunology: Denies seasonal allergies or allergy to pets, pollen or other. Denies frequent illness.
O:
VS: T – 98 P – 80 R – 16 BP – 128/72 O2 sat – 99% – 4/10 pain in throat. Wt: 205 Ht: 72 in BMI: 27.8
Skin: Natural in color, warm, smooth and dry. Good skin turgor, no lesions, rashes, ecchymosis or moles. Nails without clubbing or cyanosis.
HEENT:
Ears: pinna clean, no exudate noted. TM intact and pearly gray with cone of light bilat.
Nose: nasal mucosa pink and moist. Inferior turbinates slightly reddened bilat. Nares patent bilat. No sinus pain upon palpation. Septum midline.
Throat: oral mucosa pink and moist, tongue mobile without lesions, tonsils absent. Posterior pharynx with erythema but no cobblestone appearance.
Neck: non-tender cervical area, no lymph nodes palpable. Non-enlarged thyroid palpated. Trachea midline.
Neuro: Alert and oriented x 4.
Cardio: RRR. Crisp S1 S2 without clicks or murmurs.
Thorax and lungs: Thorax is symmetric with good expansion. Respirations are even and unlabored. No use of accessory muscles, stridor, grunting, or nasal flaring. Lungs CTA Bilaterally.

A:
Differential DDX: INCLUDE AT LEAST 3 DIFFERENTIALS
Viral pharyngitis – as evidenced by sore throat, cough, no fever
Strep Throat – not as likely; no fever and 7 days duration, age not as consistent with this dx
Allergic rhinitis – no report of sx increasing with outdoor activity or exposure to allergens, sx with sore throat are less likely for allergies.

DX: Viral pharyngitis

P:
In house throat swab for rapid strep – negative.
Continue to rest and drink lots of fluids (Cash & Glass, 2017).
Continue OTC Dayquil/Nyquil PRN per directions on the box – Safe dosing discussed, sedation may occur with Nyquil, avoid driving or operating heavy machinery after taking.
Encourage tea with honey and lemon to help with cough and sore throat.
Gargle with warm salt water 2-3 times a day for 30 sec, swish and spit.
Do not drink alcohol while taking these medications.
Cover mouth when coughing, do not drink after other people (Cash & Glass, 2017).
Return to office in 3-4 days if symptoms do not improve, worsen, or get better and then again get worse (Cash & Glass, 2017).
Call 911 or go to ER for trouble breathing or any other emergent concern.

References:

Cash, J. & Glass, C. (2017). Family practice guidelines. New York, NY. Springer.

Stead, W. (2019). Symptomatic treatment of acute pharyngitis in adults. In L. Kunnis
(Ed.). UpToDate Retrieved February 12, 2020 from:
https://www.uptodate.com/contents/symptomatic-treatment-of-acute-pharyngitis-
in-adults