Soap Note -Gastroesophageal Reflux Disease
Soap Note -Gastroesophageal Reflux Disease
Soap observe about persistent Disease in these case I chosen: Gastroesophageal Reflux Disease.
I connect an instance to make easier your work. Please put 2 references between 2015 to 2019.
EXAMPLE:
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PATIENT INFORMATION
Title: Mr. W.S.
Age: 65-year-old
Intercourse: Male
Supply: Affected person
Allergic reactions: None
Present Drugs: Atorvastatin tab 20 mg, 1-tab PO at bedtime
PMH: Hypercholesterolemia
Immunizations: Influenza final 2018-year, tetanus, and hepatitis A and B four years in the past. Soap Note -Gastroesophageal Reflux Disease
Surgical Historical past: Appendectomy 47 years in the past.
Household Historical past: Father- died 81 doesn’t report info
Mom-alive, 88 years previous, Diabetes Mellitus, HTN
Daughter-alive, 34 years previous, wholesome
Social Hx: No smoking historical past or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
SUBJECTIVE:
Chief complain: “complications” that began two weeks in the past
Symptom Assessment/HPI:
The affected person is 65 years previous male who complaining of episodes of complications and on three totally different events blood strain was measured, which was excessive (159/100, 158/98 and 160/100 respectively). Affected person seen the issue began two weeks in the past and generally it’s accompanied by dizziness. He states that he has been underneath stress in his office for the final month. Soap Note -Gastroesophageal Reflux Disease
Affected person denies chest ache, palpitation, shortness of breath, nausea or vomiting.
ROS:
CONSTITUTIONAL: Denies fever or chills. Denies weak spot or weight reduction. NEUROLOGIC: Headache and dizzeness as describe above. Denies adjustments in LOC. Denies historical past of tremors or seizures.
HEENT: HEAD: Denies any head damage, or change in LOC. Eyes: Denies any adjustments in imaginative and prescient, diplopia or blurred imaginative and prescient. Ear: Denies ache within the ears. Denies lack of listening to or drainage. Nostril: Denies nasal drainage, congestion. THROAT: Denies throat or neck ache, hoarseness, problem swallowing.
Respiratory: Affected person denies shortness of breath, cough or hemoptysis.
Cardiovascular: No chest ache, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
Gastrointestinal: Denies stomach ache or discomfort. Denies flatulence, nausea, vomiting or
diarrhea. Soap Note -Gastroesophageal Reflux Disease
Genitourinary: Denies hematuria, dysuria or change in urinary frequency. Denies problem beginning/stopping stream of urine or incontinence.
MUSCULOSKELETAL: Denies falls or ache. Denies listening to a clicking or snapping sound.
Pores and skin: No change of coloration equivalent to cyanosis or jaundice, no rashes or pruritus.
Goal Information
CONSTITUTIONAL: Very important indicators: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’four”, Wt 200 lb, BMI 25. Report ache Zero/10.
Basic look: The affected person is alert and oriented x three. No acute misery famous. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to individual, place, and time. Sensation intact to bilateral higher and decrease extremities. Bilateral UE/LE energy 5/5. Soap Note -Gastroesophageal Reflux Disease
HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visible acuity and extraocular eye actions intact. No nystagmus famous. Ears: Bilateral canals patent with out erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly grey with sharp cone of sunshine. Maxillary sinuses no tenderness. Nasal mucosa moist with out bleeding. Oral mucosa moist with out lesions,.Lids non-remarkable and acceptable for race.
Neck: supple with out cervical lymphadenopathy, no jugular vein distention, no thyroid swelling or plenty.
Cardiovascular: S1S2, common price and rhythm, no murmur or gallop famous. Capillary refill < 2 sec.
Respiratory: No dyspnea or use of accent muscular tissues noticed. No egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on auscultation. Soap Note -Gastroesophageal Reflux Disease
Gastrointestinal: No mass or hernia noticed. Upon auscultation, bowel sounds current in all 4 quadrants, no bruits over renal and aorta arteries. Stomach smooth non-tender, no guarding, no rebound no distention or organomegaly famous on palpation
Musculoskeletal: No ache to palpation. Lively and passive ROM inside regular limits, no stiffness.
Integumentary: intact, no lesions or rashes, no cyanosis or jaundice.
Assessment
Important (Major) Hypertension (ICD10 I10): Given the signs and hypertension (156/92 mmhg), labeled as stage 2. As soon as the natural reason behind hypertension has been dominated out, equivalent to renal, adrenal or thyroid, this analysis is confirmed.
Differential analysis:
Ø Renal artery stenosis (ICD10 I70.1)
Ø Persistent kidney illness (ICD10 I12.9)
Ø Hyperthyroidism (ICD10 E05.90) Soap Note -Gastroesophageal Reflux Disease
Plan
Prognosis relies on the scientific analysis via historical past, bodily examination, and routine laboratory assessments to evaluate danger components, reveal identifiable causes and detect target-organ harm, together with proof of heart problems.
These fundamental laboratory assessments are:
· CMP
· Full blood depend
· Lipid profile
· Thyroid-stimulating hormone
· Urinalysis
· Electrocardiogram
Ø Pharmacological remedy:
The remedy of selection on this case can be:
Thiazide-like diuretic and/or a CCB
· Hydrochlorothiazide tab 25 mg, Preliminary dose: 25 mg orally as soon as each day.
Ø Non-Pharmacologic remedy:
· Weight reduction
· Nutritious diet (DASH dietary sample): Food plan wealthy in fruits, greens, complete grains, and low-fat dairy merchandise with decreased content material of saturated and trans l fats
· Lowered consumption of dietary sodium: <1,500 mg/d is perfect aim however at the least 1,000 mg/d discount in most adults Soap Note -Gastroesophageal Reflux Disease
· Enhanced consumption of dietary potassium
· Common bodily exercise (Cardio): 90–150 min/wk
· Tobacco cessation
· Measures to launch stress and efficient coping mechanisms.
Training
· Present with diet/dietary info.
· Each day blood strain monitoring at house twice a day for 7 days, maintain a file, carry the file on the following go to together with her PCP
· Instruction about medicine consumption compliance.
· Training of doable issues equivalent to stroke, coronary heart assault, and different issues.
· Affected person was educated on target of hypertension, in addition to warning indicators and signs, which may point out the necessity to attend the E.R/U.C. Answered all pt. questions/considerations. Pt verbalizes understanding to all
Observe-ups/Referrals
· Analysis with PCP in 1 weeks for managing blood strain and to judge present hypotensive remedy. Pressing Care go to prn.
· No referrals wanted right now. Soap Note -Gastroesophageal Reflux Disease
References
Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Scientific Seek the advice of 2017 (25th ed.). Print (The 5-Minute Seek the advice of Collection).
Codina Leik, M. T. (2014). Household Nurse Practitioner Certification Intensive Assessment (2nd ed.). ISBN 978-Zero-8261-3424-Zero Soap Note -Gastroesophageal Reflux Disease
