Soap note -Gastroesophageal Reflux Disease


Soap music encircling continuous  Disease in these instance I selected: Gastroesophageal Reflux Disease.

 I fasten an in to fabricate past lenient your composition. Please put 2 references betwixt 2015 to 2019.


EXAMPLE:

  

PATIENT INFORMATION

Name: Mr. W.S.

Age: 65-year-old

Sex: Male

Source: Patient

Allergies: None

Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime

PMH: Hypercholesterolemia

Immunizations: Influenza conclusive 2018-year, tetanus, and hepatitis A and B 4 years ago.

Surgical History: Appendectomy 47 years ago.

Family History: Father- died 81 does not rumor instruction

 Mother-alive, 88 years old, Diabetes Mellitus, HTN

Daughter-alive, 34 years old, healthy

Social Hx: No smoking narrative or unfair offal use, interrupted alcoholic beverage decay on gregarious celebrations. Retired, widow, he lives fantastical.

SUBJECTIVE:

Chief complain: “headaches” that inaugurated two weeks ago

Symptom analysis/HPI:

The unrepining is 65 years old manly who irritable of episodes of summitaches and on 3 unanalogous occasions lineage constraining was measured, which was lofty (159/100, 158/98 and 160/100 respectively). Unrepining noticed the total inaugurated two weeks ago and sometimes it is accompanied by dizziness. He states that he has been beneath urgency in his compositionattribute for the conclusive month.

Patient denies chest abstinence, palpitation, scantiness of inspiration, abomination or vomiting.

ROS:

CONSTITUTIONAL: Denies flush or chills. Denies faintness or urgency missing. NEUROLOGIC: Headache and dizzeness as narrate aggravate. Denies diversifys in LOC. Denies narrative of tremors or seizures. 

HEENT: HEAD: Denies any summit defective, or diversify in LOC. Eyes: Denies any diversifys in anticipation, diplopia or blurred anticipation. Ear: Denies abstinence in the ears. Denies missing of hearing or drainage. Nose: Denies nasal drainage, congeries. THROAT: Denies throat or neck abstinence, hoarseness, awkwardness absorption.

Respiratory: Unrepining denies scantiness of inspiration, cough or hemoptysis.

Cardiovascular: No chest abstinence, tachycardia. No orthopnea or paroxysmal nocturnal

dyspnea.

Gastrointestinal: Denies abdominal abstinence or unpleasantness. Denies flatulence, abomination, vomiting or

diarrhea.

Genitourinary: Denies hematuria, dysuria or diversify in urinary quantity. Denies awkwardness starting/stopping drift of urine or intemperance.

MUSCULOSKELETAL: Denies falls or abstinence. Denies hearing a clicking or snapping investigate.

Skin: No diversify of coloration such as cyanosis or jaundice, no rashes or pruritus.

Objective Data

CONSTITUTIONAL: Vital signs: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on locality air, Ht- 6’4”, Wt 200 lb, BMI 25. Rumor abstinence 0/10.

General appearance: The unrepining is babandon and oriented x 3. No intelligent diurgency musicd. NEUROLOGIC: Alert, CNII-XII grossly pure, oriented to idiosyncratic, attribute, and season. Sensation pure to bilateral excellent and inferior extremities. Bilateral UE/LE power 5/5.

HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no sensibility. Eyes: No conjunctival introduction, no icterus, visual acuity and extraocular eye movements pure. No nystagmus musicd. Ears: Bilateral canals indisputable extraneously erythema, edema, or exudate. Bilateral tympanic membranes pure, pearly frosty after a while hard cone of scanty. Maxillary sinuses no sensibility. Nasal mucosa lively extraneously bleeding. Oral mucosa lively extraneously lesions,.Lids non-remarkable and after a whilehold for career.

Neck: sycophantic extraneously cervical lymphadenopathy, no jugular humor distention, no thyroid protuberance or majorityes.

Cardiovascular: S1S2, formal rate and rhythm, no babble or gallop musicd. Capillary refill < 2 sec.

Respiratory: No dyspnea or use of abettor muscles observed. No egophony, whispered pectoriloquy or material fremitus on palpation. Inspiration investigates confer-upons and apparent bilaterally on auscultation.

Gastrointestinal: No majority or hernia observed. Upon auscultation, bowel investigates confer-upon in all impure quadrants, no bruits aggravate renal and aorta arteries. Abdomen balmy non-tender, no enriching, no reverberate no distention or organomegaly musicd on palpation

Musculoskeletal: No abstinence to palpation. Active and negative ROM after a whilein typical limits, no stiffness.

Integumentary: pure, no lesions or rashes, no cyanosis or jaundice.

Assessment 

Essential (Primary) Hypertension (ICD10 I10): Given the symptoms and lofty lineage constraining (156/92 mmhg), classified as grade 2. Unintermittently the radical principle of hypertension has been unwavering out, such as renal, adrenal or thyroid, this personality is grown.

Differential personality:

Ø Renal artery stenosis (ICD10 I70.1)

Ø Continuous family ailment (ICD10 I12.9)

Ø Hyperthyroidism (ICD10 E05.90)

Plan

Diagnosis is domiciled on the clinical evaluation through narrative, tangible probation, and order laboratory tests to assess abandon factors, unearth identifiable principles and unmask target-organ mischief, including testimony of cardiovascular ailment.

These basic laboratory tests are:

· CMP

· Complete lineage count

· Lipid profile

· Thyroid-stimulating hormone

· Urinalysis

· Electrocardiogram

Ø Pharmacological treatment: 

The treatment of valuable in this instance would be:

Thiazide-like diuretic and/or a CCB

· Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally unintermittently daily. 

Ø Non-Pharmacologic treatment

· Urgency missing

· Healthy fare (DASH fareary exemplar): Fare opulent in income, vegetables, perfect grains, and low-fat dairy products after a while stunted resigned of saturated and trans l fat

· Stunted intake of fareary sodium: <1,500 mg/d is optimal view but at lowest 1,000 mg/d contraction in most adults

· Enhanced intake of fareary potassium

· Formal tangible essence (Aerobic): 90–150 min/wk

· Tobacco cessation

· Measures to quit urgency and conducive coping mechanisms.

Education

· Provide after a while nutrition/dietary instruction.

· Daily lineage constraining monitoring at settlement twice a day for 7 days, tend a proceedings, induce the proceedings on the next mark after a while her PCP

· Instruction encircling medication intake yielding. 

· Education of potential complications such as pat, disposition onset, and other totals.

· Unrepining was educated on series of hypertension, as courteous as admonition signs and symptoms, which could betray the deficiency to watch the E.R/U.C. Answered all pt. questions/concerns. Pt verbalizes beneathstanding to all

Follow-ups/Referrals

· Evaluation after a while PCP in 1 weeks for managing lineage constraining and to evaluate running hypotensive therapy. Urgent Care mark prn.

· No referrals deficiencyed at this season.

References

Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Clinical Consult 2017 (25th ed.). Print (The 5-Minute Consult Series).

Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.). ISBN 978-0-8261-3424-0