Soap Note: Hypertension

  

Follow these guidelines for APA. This is maternity note ,please adapt to advance primary care

References in APA have to be within a 5-year range.

Make sure you include Psych History as well and also Genitourinary system.

 

Semester:

SpringCourse:MSN5700C Advanced Practice in Primary Care IPreceptor:ARENCIBIA, ALEXEISClinical Site:AMERICAN CARE (SOUTH TAMPA)Setting Type:

Patient Demographics

Age:

74 years

Race:

Black or African American

Gender:

Male

Insurance:

Medicare

Referral:

Nutritionist

Clinical Information

Time with Patient:

40 minutes

Consult with Preceptor:

15 minutesType of Decision-Making:Moderate complexityReason for Visit:Follow-up (Routine)Chief Complaint:HTN follow upType of HP:ComprehensiveSocial Problems Addressed:Emotional
Prevention
Nutrition/Exercise
Substance Abuse
 

Procedures/Skills (Observed/Assisted/Performed)

Physical Assessment – Physical Assessment (Perf)
General Skills – EKG (Perf)
General Skills – Vital Signs (Perf)
ICD-10 Diagnosis Codes#1 – I10 – ESSENTIAL (PRIMARY) HYPERTENSION#2 – E66.9 – OBESITY, UNSPECIF

Medications

# OTC Drugs taken regularly:

1# Prescriptions currently prescribed:2# New/Refilled Prescriptions This Visit:1Types of New/Refilled Prescriptions This Visit:
Cardiology – Antilipids
Cardiology – Calcium channel blockers
Adherence Issues with Medications:
Caretaker failure
Financial concerns
Forgetfulness
 

Other Questions About This Case

Patient’s Primary Language:EnglishSmoking Assessment:HistoryAdvanced Directive:Yes, on file

Packs per day:

Dyspareunia.

Student:(19-SM0627)

Miami Regional University.

Day of encounter:

10

/06/2020

Preceptor name:

Clinical Site: G & G Medical Center

Instructor:

SOAP Note # 5 Dyspareunia

10

Demographic Information

Encounter Date: 10/06/2020 Patient initials: D.G

Age: 45 y/o Race: Hispanic Gender: Female

Insurance: Ambetter Information Source: Patient

SUBJECTIVE

Chief complaint: “I feel pain during intercourse”

History of present illness (HPI): Patient 45 years old Hispanic female, came to the clinic and complains intense pelvic pain during intercourse. Patient is crying during interview and she said that is not the first time that this occurs. She has had the same problem since then, she has been without a partner for a year, now she has a new partner four months ago and she is very sad because she is afraid of losing him. Patient denies vaginal discharge, bleeding, burning when urinating or fever. Menarche was at the age of 10 and was sexually active since the age of 18 yrs.

Allergies: Iodine.

Medication History: No medication Family History

Mother Alive 66 y/o /Hypothyroidism

Father Alive: 70 y/o/Positive Hx: HTN 1 Brother Alive 47 HTN

Son Alive 20 y/o Healthy

Negative Hx for Cancer, Dead for CV event, Genetical disease

Patient History

Past medical History (PMH): Negative for Chronic Disease

Genetical History: Negative Infection History: Negative Menstrual History:

Age of menarche: 12 years

LMP: 09/14/2020

Menses Monthly: Yes

Frequency: 7-9 Days Q/ 28 days

Menarche: 11 y/o

On Contraception Tx: No

Current method of contraception being used: Condom but expresses some discomfort with the mentioned method.

Hormone replacement Therapy: none

Menopause: N/A

Fertility: No difficulty conceiving.

Sexual history: Denies history of sexual dysfunction but around 10 years ago felt the same situation.

Obstetric History

Total Preg.

Full Term

Premature

Ab Induced

Ab Espontan

Ectopic

Multiple

Living

3

1

0

1

1

0

0

1

Date: 08/09/2000

GA week 40.1

Weigh 7.1

Sex Male

Deliver Vaginal

Complic No

Hospitalization: No previous hospitalization.

History of mental illness/personality disorders: None.

Physical trauma/falls: No reported during the last twelve months.

Surgeries: Denies past surgical procedures. No previous gynecologic surgeries.

Exposure: Patient is living in an apartment and does not complaint of any financial difficulties, she is working like a cashier with sedentary life. No knows HIV exposure during the last year. No blood transfusions or other blood components or tissues have been received. No identified environmental exposure to asbestos, radiations, or any other chemical substances. No exposure to the sunlight during the regular daily activities.

Immunizations: Vaccines updated (Flu Vaccine: 12/15/2019).

Exercise: Usually no practices exercise.

Diet: Patient does not follow a specific diet. The diet is rather rich in carbohydrate, vegetables, and proteins.

Social History: Patient is well socially integrated, non-smoker, does not consume alcohol frequently. Consume coffee at least three times a day. Denies using illegal drugs. She is working in a Shop (cashier). Lives with her parents and her son 20 y/o. She describes her home dynamic, functional and happy.

Educational level: High school completed.

Sexual Behavior: Patient is heterosexual and has not a stable sex partner at the present.

Last annual physical exam: 11/21/2019

Screening:

Pap smear: 12/15/2019: Negative HIV /STD Test: 12/15/2019Negative

Monthly Breast Self-examination: Yes Mammogram: 12/23/2019 Normal

Bone density: N/A

Colon cancer Screening: N/A Skin cancer Screening: 12/15/2019

REVIEW OF SYSTEMS:

Systemic: No fever reported. Denies fatigue or weight loss.

HEENT. Head: No history of trauma, no complaining of headache. No sinus pain or any other facial pain is stated.

Neck: Denies pain or stiffness. No swollen glands in the neck. Eyes: Denies blurring vision, double vision, redness, or eye discharge. Oto-laryngeal: Denies change in hearing, ringing in ears, pain, or discharges from external auditory canal. Denies watery nose discharge, congestion, or nasal bleeding. Denies bleeding gums. No hoarseness.

Cardiovascular: Denies chest pain, palpitation, or edema on the lower extremities. No varicosities or history of DVT.

Respiratory: Denies shortness of breath, cough, or wheeze. No complaints of chest congestion.

Gastrointestinal: Denied appetite problems. No dysphagia. Denies heartburn or bleeding. No complaints of flatulence. Denies nausea or vomiting. Denies hematochezia. No diarrhea or constipation. Last bowel movement: 10/06/2020.

Genitourinary: Denies changes in urinary habits, normal urinary frequency, denies urgency, nocturia or hematuria. Denies history of kidney stones, flank pain, cloudy urine, or bad smell.

Gynecological: the menstrual period normal, with moderate flow every month. No accompanying symptoms, painful on the lower abdomen the two first days as usual relieve with application of warm compresses and Tylenol. Denies vaginal discharge. Complains intense pelvic pain during intercourse with deeper entry.

Breast: No mass noted, no fulness sensation, pain or discharge reported. No prior history of breast biopsy, lesions, pain, or discharge.

Endocrine: Denies hot or cold intolerance, polyuria, or polyphagia. Denies thyroid problems. Hematologic: Denies anemia, bruising, adenomegaly, unusual bleeding, petechiae, left upper quadrant or bone pain.

Musculoskeletal: No history of falls reported, denies weakness, muscular pain, swollen or any other inflammatory symptoms in the joints. Denies joint pain, limited ROM, difficulty walking or trouble reaching above head.

Neurological: Denies loss of memory, seizures, seizures or fainting lightheadedness, facial pain, gait imbalance or changes in LOC. Denies tremors, muscle weakness, numbness, tingling or sleeping disturbances.

Psychological: Patient states no changes in mood, denies anxiety, depression, or insomnia. Denies low self-esteem, feeling sad, social isolation or attention deficit, no change in thought patterns. Enjoyment of activities is sometime interrupted during the pain.

Integumentary: Denies pruritus, bruises, or rash. No new nevus. Denies history of contusions, lacerations, burns or history of skin cancer.

OBJECTIVE:

Physical Exam

Vitals Signs: Temp (Axillary): 96.7 0F. BP-sitting L: 120/75 mmHg (BP cuff size: Regular). Pulse Rate-Sitting: 78 bpm. (regular rhythm). RR: 18 per min. Height 5”4”, Weight: 141 lbs. BMI: 24.2Kg/m2 (normal). Oxygen Saturation: 98 %. Pain Scale/Rate: 3/10.

General appearance: Patient in not apparent acute distress, speaks fluent, coherent, alert and oriented x3. Well hydrated, well nourished.

Head: Normocephalic, symmetric head, no signs of trauma. Normal sinuses, maxillary and frontal to palpation.

Neck: No visible mass. No lymphadenopathy noted. Thyroid in the middle, no palpable. No palpable masses or tenderness, trachea is midline. No JVD.

Eyes: No strabismus observed during exploration, normal extraocular muscles function, no discharge from the eyes, sclera is white, conjunctiva pink. PERRLA.

Ears: Normal tragus and external canal. Meatus are normal. No swollen or reddened. Bilateral tympanic membranes were intact and pearly gray with light reflex. No erythematous, scarred or hemorrhage. No pus or serous exudate. No hearing loss on bilateral whisper test.

Nose: No external deformities of the nose. Nasal mucosa moist and pink with clear drainage, septum midline. Nasal turbinate no erythematous, no swollen. No sinus tenderness.

Oral Cavity: Oral mucosa moist and pink. No lesions suggestive of malignancy or infections. Normal gums and palate, no bleeding or hypertrophy. Good hygiene, no caries or abscess detectable to single inspection, normal dentition.

Pharynx: Moist and pink, no presence of plaques or exudate. Absence of tonsils. No petechias, no strawberry tongue. Normal pharynx and uvula to inspection, gag reflex presents and unaltered.

Lymph Nodes: No adenomegaly detected along the ganglion’s chains.

Chest: Symmetric chest wall, follow up the breading movement.

Lungs: Respirations are regular, equal, and unlabored with symmetrical chest expansion. No cyanosis or nasal flaring observed. Normal breath sounds to palpation, unremarkable percussion. Lung sounds clear to all lung fields. No wheezing, stridor, crackles, or rhonchi noted.

Cardiovascular: Normal chest wall, absence of orthopnea, collateral circulation or edema on lower extremities, no clubbing or cyanosis observed. No pericardial friction rub heard. Regular rate and rhythm, heart sounds of S1 and S2, no bruits, murmurs found to auscultation, no extra heart sounds, PMI at 5th intercostal space, midclavicular line. No pericardial friction rub heard. No gallops, murmurs, or opening snaps. Carotid, apical, radial femoral and pedal pulses present and strong, capillary refill 2 seconds.

Abdomen: Inspection: Symmetric, is watched flat, nondistended, no visible masses, few vertical striaes present.

Auscultation: Bowel sound active in all 4 quadrants. No bruits. Palpation: soft, no pain when palpating, no involuntary guarding or rebound tenderness observed, no signs of peritoneal irritation, no palpable masses. No hepatomegaly or splenomegaly. Percussion: Normal.

Genitourinary: Bimanual palpation does not reveal signs of enlarged kidneys. Costovertebral angles do not reveal tenderness. No palpable or percussed bladder.

Gynecological: Patient positioned lying supine on the office examination table with the knees flexed, and with the feet in supporting stirrups.

Inspection: Normal general appearance of the external genitalia, adequate hair

distribution. Scar of a previous medio-lateral right episiotomy. No presence of caruncle and other findings to inspect the urethra, erythematous and mild swelling to labia majora and vaginal introit. No vesicular lesions observed at this moment. No perineal lesions. Vagina: Atrophic labia with decrease rugae, pale pink, Small amount of thin, clear non-odorous discharge noted. No evidence of prolapse.

Palpation: Mild discomfort with exam, painful. Mild vaginal tenderness. Free of masses to bilateral adnexal area. No ovary enlargement. No palpable Bartholin’s gland.

Speculum exam for Vagina and cervix.: Painful introduction to vaginal canal. Vaginal walls free of masses, no bleeding. Cervix: pink, non-friable without lesion or mass. No discharge appearing from cervical oz.

Bimanual exam: Unremarkable vagina, cervix, uterus, and adnexal exam. No signs of pregnancy.

Pregnancy test done, negative result.

Breast: Inspection: Bilaterally symmetrical breast, no changes in color, no irregularity observed. No Ulceration of the skin or area of thickening noted. No observable convex skin

changes. No evidences of retraction phenomena.

Palpation: Right/Left breast, no palpable mass on any of the four quadrants. No enlargement of axillary or supraclavicular nodes are palpated

Endocrine: She had no goiter, no ophthalmopathy, no hyperhidrosis, no tremor.

Hematologic: No adenomegaly found. No spleen/liver palpable.

Musculoskeletal: Normal gait. No muscular atrophies observed, no evident deformities, no stiffness observed, range of motion within normal limited, normal joints. Fingers, feet, and toes are normal. Spine without deformity.

Neurologic: AAOx3. Keeps adequate communication ability, no concentration or attention deficit noted during the exploration. Normal gait and balance observed. Sensation intact. Normal motor activity. Deep tendon reflexes symmetrical and equal bilaterally. Normal function of all cranial nerves (from I to XII). Bilateral UE/LE strength 5/5.

Psychiatric: Patient is euthymic, with normal level of mood, language, and communication. The affect was normal just sad because of the current situation.

Integumentary: No observable diaphoresis. No discoloration presents, absence of cyanosis in skin, lips, no suspicious nevi, good turgor on examination. Hair: Normal distribution according to the gender and age. No hair loss in the lower extremities was observed.

Nails: Pink with normal appearance, absence of cyanosis in nails. No clubbing of the fingers. No lesions.

ASSESSMENT:

Dyspareunia (ICD-10 N94.10). Patient’s symptoms are consisting with a diagnosis with recurrent genital pain associated with sexual activity. Dyspareunia is painful sexual intercourse due to medical or psychological causes. It can affect a small portion of the vulva or vagina or be felt all over the surface. (Al-Abbadey, Liossi, Curran, Schoth, Graham, 2016).

Dyspareunia is not exclusively due to lack of lubrication or vaginismus and is associated with distress or interpersonal difficulty. May be the result of organic, emotional, or psychogenic causes. It could be primary in these cases present throughout one’s sexual history with potential relationship between primary dyspareunia and vaginismus, low libido, and arousal disorders. Secondary arising from some specific event or condition (e.g., menopause, drug) More than 50% of all sexually active women will report dyspareunia at some time. (Domino, F., 2020).

Superficial dyspareunia: pain at, or near, the introitus or vaginal barrel associated with penetration.

Deep dyspareunia: pain after penetration located at the cervix or lower abdominal area. (Merck Manual)

Differential diagnosis

1. Pelvic Inflammatory Disease (ICD 10 N73.9). Pelvic inflammatory disease is a term for infection of the female reproductive organs such as ovaries, fallopian tubes, uterus, cervix, or vagina, characterized by abdominal pain, dysuria and dyspareunia. Most common causes are STD’s (gonorrhea and Chlamydia), foreign device such as IUD and abortion. The patient in this case complained of dyspareunia intense pelvic pain during intercourse but denies vaginal yellowish discharge or dysuria which leads us to a diagnosis of PID. (Al-Abbadey, Liossi, Curran, Schoth, Graham, 2016).

2. Acute cystitis (ICD 10 N30.01). Is the infection of the bladder, or of the urethra and sign and symptoms include bacteriuria, frequency, urgency, suprapubic pain and or hematuria. It is defines as an invasion of microorganism to the bladder. Women tend to get infections more often than men because their urethra is shorter and closer to the anus. This patient denies symptoms like dysuria, frequency, urgency or hematuria, her complaint is pain during sexual relation. (Al-Abbadey, Liossi, Curran, Schoth, Graham, 2016).

3. Vaginal irritation (ICD-10 N98.8). Due to pain during intercourse and not complaint vulvar irritation by the patient ruled out due to the absence of etiology in this case.

PLAN:

Diagnostic tests ordered to support the diagnosis:

Lab test:

· Complete blood count (CBC) with differential to search for evidence of infection

· Erythrocyte sedimentation rate (ESR)

· Urinalysis (UA)

· Abdominal ultrasonography

· Smear, Wet mount examination for infectious agents.

· Pap smear (Cytopathology cervical/vaginal)

Pharmacological treatment:

The goal of pharmacotherapy is to treat sexual pain:

· Ibuprofen 800 mg 1-tab P.O TID as needed for pain.

Non-pharmacologic treatment:

· Avoid chemical irritants such as douches and deodorant tampons.

· Avoid stress

· Healthy food (High in fiber)

· Exercises

· Sitz baths may relieve the pain.

· Perineal massage.

Patient education:

Educate the patient and the parent regarding the nature of problem, reassure both that there are solutions to the problem.

Emotions are deeply intertwined with sexual activity, so they might play a role in sexual pain. Emotional factors include: Psychological issues. Anxiety, depression, concerns about your sexual abuse, fear of intimacy or relationship problems can contribute to a low level of arousal and a resulting discomfort or pain. Stress is other problems that provoke that situation. This can contribute to pain during intercourse. It can be difficult to tell whether emotional factors are associated with dyspareunia. Initial pain can lead to fear of recurring pain, making it difficult to relax, which can lead to more pain.

Delay sexual relation until symptoms clear or resolves.

Balance diet and avoid constipation, practice exercises regularly.

Follow-up/Referrals:

Follow-up: Next office visit will be in 1 week for re-evaluation and lab report.

Referrals: Referral mental health/counseling.

References

Domino, F. J., Barry, K., Baldor, R. A., & Golding, J. (2020). 5-Minute clinical consult 2021. Lippincott Williams & Wilkins. 306-307.

The Merck manual of diagnosis and therapy. (2011). Merck.

Al-Abbadey, M. Liossi, C. Curran, N. Schoth, D.E. Graham, C.A. (2016). Treatment of Female Sexual Pain Disorders: A Systematic Review. J Sex Marital Ther. 42 (2):99-142.

Miami Regional University

Date of Encounter:
06/18/2020

Student Name:
LWC

Preceptor:
Silvio Planas APRN

Clinical Site: Gynecology and More INC.

Clinical Instructor: Kirenia Santiuste

Soap Note # 6

Main Diagnosis: Allergic Rhinitis

PATIENT INFORMATION

· Name: TJ

· Age: 28

· Gender at Birth: Female

· Gender Identity: Female

· Source: Patient

· Allergies: allergies to dust, cats and Penicillin

· Current Medications: Albuterol 90mcg, 1-2 puff qid inhaler PRN when symptoms occur.

· PMH: Asthma

· Immunizations: Up to Date, Refused Influenza vaccination this year due to COVID-19 National Pandemic

· Preventive Care: Avoid allergens, Good house hygiene, Regular exercising, annual checkups.

· Surgical History: Appendicitis.

· Family History: 1st relatives Asthma, Mother and grandparents High blood pressure, Father died on car accident DM.

· Social History: Alcohol drinker 2 cups or rum weekly. Preferred hobby Netflix and sport tv programs.

· Sexual Orientation: Female Preference

· Nutrition History: Low Sodium Diet

Subjective Data:

· Chief Complaint: “I have sore throat and itchy, itchy eyes and runny nose”

· Symptom analysis/HPI: Patient has been with those symptoms for a week, the runny nose and eye itchy are the same but the sore throat got worse lately, the discharge is clear. There is tenderness around the nose. The Symptoms improve drinking water and some drops throat lozenges. Denies fever, no nasal blockage, no chills.

Review of Systems (ROS)

·
General: Fatigued, Generalized Weakness.

·
HEENT:
Runny nose, eyes itchy, sore throat, difficult swallowing, blurred vision when reading, no double vision., denies block nose and no bleeding.

·
Neck: Denies neck pain, able to rotate his neck laterally and in and upward position

·
Lungs
: No cough, shortness of breath, PND, or orthopnea

·
Cardiovascular:
No pressure, squeezing, tightness, heaviness or aching about the chest, neck, axilla or epigastrium

·
Breast:
Denies any pain or lumps

·
GI:
Denies Abdominal Pain

·
Female genital
: Denies dysuria, frequency and urgency when urinating

·
GU
: Denies dysuria, no frequency and urgency when urinating

·
Neuro:
No burning or tingling, sensation present in all quadrants

·
Musculoskeletal:
No joint pain no restriction motions.

·
Activity & Exercise
: no habits of exercise.

·
Psychosocial:
anxious about the disease.

·
Derm:
denies any rash, bums or recent lesions.

·
Sleep/Rest
: more than 6 hours a day but with difficult to breath.

Objective Data/Physical Exam

· BP 141/82 TPR 99.1 HT 170 cm WT. BMI 30.1 O2: 99%

·
General:
Well-groomed, appropriate posture and gait, normal affect, obesity

·
HEENT
: Tenderness frontal and right maxillary sinus, Weber and Rinne test intact, cranial nerves intact, no hearing loss, vision left eye 20/20 right eye 20/40. whitish discharge noted from the nose. Edema and erythema of nasal mucosa, uvula and Tonsils, redness noted. Halitosis presents.

·
Neck
: thyroid gland intact no nodules no lymphadenopathy noted

·
Pulmonary:
lungs clear to auscultation, no adventitious sound throughout the lungs

· Cardiovascular: no abnormal heart sounds normal physiologic S1/S2 present, normal PMI

·
Breast:
no bumps or lesions

·
Abdomen:
no abdominal distention, no pain on percussion or palpation, active bowel sounds any signs of liver or spleen enlargement

·
Rectal:
Refuse assessment

·
Male genital
: Denies discharge, dysuria, pyuria, pain that radiates to the groin

·
Neuro:
Cranial nerves intact, no cerebellar dysfunctions, alert x4

·
Derm
: Acanthosis nigrins around the neck, papules, comedones on the face

·
Psych
: anxious about disease process

ASSESSMENT

Main Diagnosis:

· Allergic Rhinitis

Differential diagnosis:

· Infectious Rhinitis

· Rhinitis Medicamentosa

· Influenza

· Seasonal allergic.

· Asthma

PLAN:

Labs and Diagnostic Test to be ordered:

· CBC with Differential (pending results)

· Rapid Strep Test done in office (positive in office)

· Influenza Swab (negative in office)

· Covid -19 Swab (pending results)

Education

· Avoid exposure to known allergens

· Frequent hand washing

· Monitoring signs of complication such as fever, change of discharge color, change of senses of smell and taste, nose bleeding.

· Take medications as prescribed.

Non-Pharmacologic treatment:

· Drink plenty of Fluids

Pharmacological treatment:

· Loratadine 10 mg po daily

· Saline nasal drop qid

· Ibuprofen 600mg qid PRN for pain

Follow-ups/Referrals

· Follow up in 2 week. Office

· will call you when lab work is available.

· No referrals needed at this time.

References

Barbara Bates a Guide to Physical Examination

Buttaro, T. et al. (2017). Primary care: a collaborative practice. St. Louis, MO: Elsevier.

Gupta, N., Singh, R., & Saxena, R. K. (2019).

Porter, R. S. (2018). The Merck manual: of diagnosis and therapy. Rahway: Merck Sharp & Dohme Corp. 246 (2080-2080)

Webmd.com