NSG 6440 Week 2 soap Note Essay

NSG 6440 Week 2 soap Note Essay

NSG 6440 Week 2 soap Note Essay

SUBJECTIVE
CC:
“I cannot feel the toes in my left foot, and I Have a numbness, sort of a tingling feeling in my right foot.”
HPI: Use the OLDCART acronym
He reports that about a month ago, he started feeling numbness in his left foot. The symptoms were of gradual onset. Over time the patient noticed he could not feel his left foot toes, and a few days ago, he developed numbness and a tingling sensation in his right foot. At first, he thought it was due to the cold weather, but when it did persist, he thought it was due to his decreased activity. The patient reports that the character of the symptoms was numbness and a tingling sensation. During the illness, the patient reports that the presentation is worsened by cold and relieved by rest. The symptoms have no specific time as they are constantly there. J.D. reports that the symptoms are moderately severe and have reduced his life quality as he can not feel when hurt.
Medications: (list with the reason for med )

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Metformin 500 mg P.O. twice a day with meals (Diabetes Mellitus type 2; as an adjunct therapy to diet and exercise for the promotion of glycemic control)
PMH (list the approximate year of Dx of the disease or when the surgical procedure was performed)
Allergies: denies any food and drug allergies
Medication Intolerances: Denies
Chronic Illnesses/Major traumas: D.M. type 2 (2019)
Hospitalizations/Surgeries: Appendectomy (2015)
Family History (list immediate family, age, disease, and whether he is dead or alive)
His mother (67), father (69), brother (40), sister (45) and sons (15 and 10), and 5-year-old daughter are healthy. His paternal grandfather passed away from diabetes, and his paternal grandmother and maternal grandparents are alive, but he does not know their ages. The majority of relatives are overweight.
Social History
Occupation: University graduate, Works as a branch manager for a local production company,
Marital status: Married to one wife
Living situation: he lives with his wife and children in his company’s staff quarters.
Social habits: I had a history of alcoholism but went to rehabilitation over twenty years ago. Denies using illegal drugs and smoking.
Spirituality: Does not go to church
Leisure patterns: like to watch movies
Sleep patterns: states that he gets 8 hours of sleep every night
Nutrition: He is on a diet as prescribed by a dietician for his diabetes mellitus. Has recently lost weight significantly
ROS (Start each sentence with words such as “Denies, admits, complains, reports, “do not use the words “No, positive for, negative for.” Do NOT list physical exam findings here. If the body system not assess, write “Non-Contributory.”
General
Admits to having lost weight significantly. Denies fever, fatigue, chills, and weakness. Reports a decreased sensation in the toes on the left foot and numbness and tingling feeling in the heel of his right foot. Cardiovascular
Denies chest pain, discomfort, or awareness of the heartbeat.

Skin
Reports that he does not have a rash or itch Respiratory
Denies having a cough, sputum, or a feeling of shortness of breath
Eyes
Denies double vision or impaired eyesight Gastrointestinal
Denies anorexia, diarrhea, nausea, or vomiting
Ears
Denies having hearing loss Genitourinary/Gynecological
Reports dysuria and polyuria
Nose/Mouth/Throat
Denies having a sore throat or a runny throat Musculoskeletal
Reports no muscle, joint, or back pain and stiffness
Breast
Denies any enlargement of breasts Neurological
Denies headache, dizziness, ataxia, or syncope. Reports no change in bowel movement
Heme/Lymph/Endo
Denies bleeding and bruising and does not report any enlarged lymph nodes. No report of heat or cold intolerance or sweating Psychiatric
Denies anxiety or desperation.
OBJECTIVE– this is where you document physical exam findings, do NOT use the word NORMAL to record a finding, and instead, explain what normal is. For example, the gait is not normal; the gait is steady. If the body part is not assessed, then type “Deferred.”
Weight 91 kg BMI 29.4 Temp 98 F BP 130/85 mmHg
Height 5′ 8.” Pulse 68 bpm Resp 17 bpm
General Appearance
Warm, dry skin without discoloration or pallor, proper reactions, cooperation; seems anxious but does not show signs of immediate discomfort.
Skin
Skin is warm, pink, and supple, without any lesions.
HEENT
Head: A normocephalic with normal hair distribution. Atraumatic.
Eyes: PERRLA, EOMI, the conjunctiva is white, the red reflex is present, and there are no hemorrhages in the retina.
Ears: The tragus has no erythema, effusion, or discomfort. The tympanic membrane is translucent in both ears.
Nose: patent with no crusting or discharge in the bilateral nares, erythema, or swelling of the turbinates.
Throat: Moist mucus membranes, No pharyngeal erythema, no ulcers, no oozing from the tonsils, the uvula and tongue are middle lines, and the gag reflex is sensitive.
Cardiovascular
Regular rate and rhythm. The apex beat is at the 5th intercostal area. On auscultation, S1and S2 heard. No murmurs or added sounds on auscultation. The lower extremities are cold and non-edematous. There are no varicose veins. There are no bruits in the femoral or abdominal vessels. The pulses in the peripheries are present, brisk, and symmetric.
Respiratory
The chest is symmetrical with good expansion. There is equal and bilateral air entry. Resonant on percussion. Breath sounds are vesicular no wheezes, rales, or rhonchi.
Gastrointestinal
The abdomen is mildly distended, moving with respiration, without obvious masses, scares, or color changes; warm to the touch, soft and non-tender, with no organomegaly on palpation, and present bowel sounds in all quadrants.
Breast
Deferred
Genitourinary
Deferred
Musculoskeletal
There are no abnormalities in the joints. Positive ROM in the ankles, hands, knees, wrists, elbows, and shoulders. The patient walked slowly with a wide-based posture. Walking with both heels and toes intact. The spinal column did not have kyphosis, lordosis, or scoliosis; he could extend and rotate it. SLR is negative, Patrick’s test is negative, and crossed SLR is negative. The knee extensors, ankle plantar flexors, invertors, and dorsiflexion all worked well. There is no tenderness in a CVA.
Neurological
The left foot is less sensitive to light touch and pinpricks, and the right ankle’s reflexes are decreased. Cranial nerves I–XII are all intact. Both muscle mass and tone are excellent. Power in all muscle groups is rated 5/5 throughout. Point-to-point movements and quick alternating movements are still evident. A steady gait. Romberg negative, intact stereognosis, light touch, location feeling, pinprick, and vibration. Reflexes 2+ and symmetric, with normal plantar reflexes.
Psychiatric
Oriented to person, place, and time. The patient had a normal mood and affect. A coherent thought process and was relaxed and cooperative. No signs of anxiety or depression were noted.
Lab Tests (lists any tests ordered and status of the test, if a rapid test was done at the office, list the results)
Hb A1C levels (evaluation of glycemic control)
Special Tests (List any imaging study or special test ordered and the status of the test, if the result is available, write the result)
Diagnosis
Differential Diagnoses with ICD 10 codes (these are Dx you considered but then ruled out)
• peripheral arterial disease I73.9: Peripheral arterial disease, brought on by decreased circulation in the lower limbs, is a danger for people with diabetes (Zemaitis et al., 2022). the condition, which is prevalent in diabetes individuals, may be the source of the patient’s presentation, including the left ankle’s diminished reflexes.
• Lumbar radiculopathy M54.16 is an injury restricted to nerve roots of lumbar spines that can result in leg pain that is piercing, burning, or stinging, as well as reduced sensation in the legs, with numbness, tingling, and more severe scenarios, weakness of the muscles (Dydyk et al., 2021). J.D.’s symptoms of tingling and numbness in the feet could be brought on by lumbar radiculopathy, which is nerve root compression in the lower back.
• Tarsal tunnel syndrome G57.50: refers to neuropathy caused by an entrapment that happens when the structures in the tarsal tunnel are pressed together (Kiel & Kaiser, 2021). It is also tibial nerve dysfunction or neuralgia. However, the patient has only reported numbness and tingling sensation, not pain.
Diagnosis with ICD 10 Code
• Peripheral diabetic neuropathy E11.40: P.N. patients typically feel tingling, numbness, and burn in their extremities (Bodman & Varacallo, 2022). The client’s history of type 2 diabetes and complaints of loss of sensation, numbness, and tingling in the feet are in tandem with diabetic peripheral neuropathy.
• CPT Code/Office visit code:
Plan/Therapeutics
o Plan:
 Further testing
Nerve conduction studies ad electromyography were ordered to evaluate peripheral neuropathy
 Medication
Pregabalin 75mg/day
 Education
Patients should be taught well how to check their blood sugar levels and look for ulcers, wounds, or broken skin on their feet daily.
The healthcare provider tells them what to eat and when to take their medicines (Bodman & Varacallo, 2022).
They should be told how drinking and smoking can cause peripheral neuropathy and given the plan to quit if needed.
Also, the patient should not wear shoes that do not fit right.
 Non-medication treatments
The patient might need to be reassured and told what is happening. It is important to check in every so often. With better blood sugar control, paresthesias and dysesthesias may disappear in a year.
 Follow Up:
Come back if there is no improvement in the symptoms after a week. Return sooner if they get hurt in the feet or if they develop painful symptoms.
 Referral
To a podiatrist for education on foot care
 When to seek emergency care
In case of any injury to the feet, despite the magnitude
Evaluation of patient encounter;
I evaluated the patient and informed my preceptor of my findings, which included several vital positives on the ROS and physical examination. Both the diagnosis and the suggested course of treatment benefited from my efforts.
Weaknesses: I have to get better at managing my time.
Strengths: I have increased my physical exam abilities, am competent, and can speak with patients independently.
Reflection: In retrospect, I believeNSG I am getting better at collecting relevant data and doing precise physical examinations. For once, it seems like everything is coming together for me.

References
Bodman, M. A., & Varacallo, M. (2022). Peripheral diabetic neuropathy. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK442009/#:~:text=Peripheral%20neuropathy%20(PN)%20encompasses%20a
Dydyk, A. M., Khan, M. Z., & M Das, J. (2021). Radicular back pain. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK546593/#:~:text=Lumbar%20radiculopathy%20is%20a%20self
Kiel, J., & Kaiser, K. (2021). Tarsal tunnel syndrome. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK513273/#:~:text=The%20tarsal%20tunnel%20syndrome%20is
Zemaitis, M. R., Boll, J. M., & Dreyer, M. A. (2022). Peripheral arterial disease. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430745/#:~:text=Peripheral%20arterial%20disease%20(PAD)%20is

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SOAP NOTE
SUBJECTIVE
CC:
“My back hurts”.
HPI: (Use OLDCART)
She reports feeling pain in her lower back that started yesterday while at work. Last night she went to sleep as usual, when she woke up this morning she was in a lot of pain and was very stiff. The pain is described as a 7/10 on the pain scale, feels like burning. Pt states pain is worse in the R lumbo-sacral area. Pain radiated to her R buttock. It hurts her to stand up or to find a comfortable position. Pain worsens after bending or lifting. Her back hurts even at rest, but gets worse with movement. Taking Tylenol 500mg 2 caplets with no relief of the pain. Denies hx of UTI symptoms; Denies vaginal discharge or dyspareunia; denies change in bladder or bowel habits; denies weight loss or fever. Denies hx of previous back pain, injury or trauma. States she works as a cashier at the grocery store where she stands most of the day. Yesterday was her second day of working over time at work and she thinks since she works standing up, this might have cause for her to feel pain in her lower back. Denies muscle weakness, paresthesia, loss of sensations, and no severe or progressive neurological deficit in lower extremity.
Medications: (list with reason for med )
Tylenol Extra Strength 500 mg Caplets, 2 tabs q4-6 hr for back pain with no relief
Metformin 500mg 1 PO QD for Type 2DM
Lisinopril 10mg 1 po QD for HTN
PMH
Allergies: NKDA, denies food allergies
Medication Intolerances: Denies
Chronic Illnesses/Major traumas: HTN (2016), Type 2 NIDDM (2017)
Hospitalizations/Surgeries: Appendectomy (2001)
Family History
States her parents (mother 59, father 63), siblings (sister 34, brother 27) and daughter- 4y/o are healthy and both sets of grandparents are alive and live in Colombia (doesn’t know age or if they have any medical problems).
Social History
General: Born and raised in Cali, Colombia, moved to the US with her parents when she was 17 years old.
Marital status: Single Mom of a 4-yr/old girl. Ex-husband not involved financially or physically in care of child.
Living situation: Parents live 100 miles away. One brother in town; sees brother seldom. Mrs. B has a few close friends. Pt sates she is in debt “way over head”. No health insurance benefits. Considers herself a strong and independent woman.
Children: One 4-yr/old daughter who is healthy
Occupation: Works at a local grocery store as a cashier. She stands most of the day in her job. Sees job only as a means of providing income for her and her daughter.
Leisure Patterns: Pt states she doesn’t have time to “relax”.
Social habits: Denies smoking or alcohol consumption. Does not exercise.
Spirituality: No church involvement but states that she believes in God.
Nutrition: Pt states her appetite has increased owing to “stress”, craves chocolate, eats what she wants, no special diet. Has not experienced any changes on her weight.
Sleep Patterns: States that she usually gets about 7 hrs of sleep every night.
ROS
General
States there have not been any changes in the past 5 years. He has been wearing the same size of clothes for the past 5 years. Denies weakness, fatigue, or fever.
Head: Denies headache, head injury, dizziness, or lightheadedness. Cardiovascular
States she was just recently diagnosed with HTN, takes Lisinopril every night, states she checks her BP at least once a week when she goes to the grocery store and it is always below 130/80. Denies any troubles with her heart, rheumatic fever, or heart murmurs. Denies having chest pain or discomfort, palpitations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, or edema. Has never had EKG done.
Skin
Reports dryness of the skin, especially on his hands, legs and feet. Denies rashes, lumps, sores, itching, and changes in color. Denies changes in his nails or hair. Denies changes in size or color of moles. Respiratory
Denies cough, sputum, hemoptysis, dyspnea, wheezing, or pleurisy. Has not had a Chest X Ray done. Denies having asthma, bronchitis, emphysema, pneumonia, or tuberculosis.
Eyes
Denies any changes in her vision. Does not use glasses. Last eye exam 2 years ago (Oct/15). Denies any pain, redness, excessive tearing, double or blurred vision, spots, specks, flashing lights, glaucoma or cataracts. Gastrointestinal
Denies trouble swallowing, heartburn, changes in appetite, or nausea. States she has bowel movements every other day normally, the stools are small, brown and formed. Denies pain or bleeding with defecation. No changes in bowel habits. Denies black or tarry stools, hemorrhoids, constipation, or diarrhea. Denies abdominal pain, food intolerance or excessive belching or passing gas. Denies jaundice, live, or gallbladder trouble. Denies Hepatitis. Does not remember if she has received Hep B vaccine.
Ears
States she doesn’t have any hearing problems. Denies tinnitus, vertigo, earaches, infection, or discharge. Denies use of hearing aides. Genitourinary/Gynecological
Goes to the bathroom 4 or 5 times a day. Denies polyuria, nocturia, urgency, burning or pain during urination. Denies hematuria, urinary infections, kidney or flank pain, kidney stones, urethral colic, suprapubic pain, or incontinence. No changes in bladder habits.
Menarche at age 13. States she gets her period approx. q 28 days and it lasts about 5 days. Flow heavier on the first 2 days. Denies bleeding between periods. LMP: September 4th. Denies PMS. Denies any vaginal discharge, dyspareunia, itching, sores, lumps, or STDs. G1 P1, spontaneous vaginal delivery at 39 weeks. Denies any complications with her pregnancy. Denies use of birth control methods. Not sexually active at the moment. Has had one partner in the past 5 years. Denies exposure to HIV infection or STDs.
Nose/Mouth/Throat
Pt states she gets occasional allergies and colds that cause her to have stuffiness and discharge. Denies hay fever, nose bleeding, or sinus trouble. Throat: States her teeth are yellow and sometimes her gums would bleed. Denies use of dentures. Last dental examination 2 yrs ago (Oct/15). Denies sore tongue, frequent sore throats or hoarseness. Denies having dry mouth or excessive thirst.
Neck: Denies swollen glands, goiter, lumps, pain, or stiffness in the neck. Musculoskeletal
Denies muscle weakness, paresthesia, loss of sensations, no severe or progressive neurological deficit in lower extremity. No Hx of cancer, or risk factors for spinal infection (no IV drug abuse, UTI, Immune suppression). Pt reports feeling lower back pain that started yesterday while at work that is worse in the R lumbo-sacral area. Pain radiates to her R buttock. Pt states it hurts to stand up or find a comfortable position. States her back hurts even at rest, but pain gets worse when she moves. Pain worsens after bending or lifting. Denies other muscle or joint pain, stiffness, arthritis or hx of gout. Denies fever, chills, rash, anorexia, weight loss or weakness.
Breast
Denies lumps, pain, discomfort or nipple discharge. Neurological
Denies changes in mood, attention or speech. Denies changes in orientation, memory, insight, or judgment. Denies headaches, dizziness, vertigo, fainting, blackouts, seizures, weakness, paralysis, numbness or loss of sensation, tingling or pins and needles, tremors or other involuntary movements.
Heme/Lymph/Endo
Denies anemia, easy bruising or bleeding, and past transfusions. Denies excessive thirst and hunger. Denies thyroid trouble, heat or cold intolerance, excessive sweating, polyuria or changes in shoe size. Denies weight changes or fever.
Periferal Vascular: Pt states she has a few spider veins that look like bruises, she got them during the pregnancy. Denies leg cramps, varicose veins, past clots in veins, swelling in calves, legs or feet. Pt states there have not been any changes in the color of her fingertips or toes during cold temperatures/weather. Denies any swelling or tenderness. Psychiatric
Denies nervousness, tension, mood changes, depression, or memory changes.
OBJECTIVE
Weight 120lbs BMI 20 Temp 98 F BP 114/74
Height 67” Pulse 89 Resp 20
General Appearance
Skin warm and dry w/o discoloration or pallor, A/O x 3, appropriate responses, cooperative, appears concerned w/o signs of acute distress.
Skin
Skin is warm, pink and supple, no lesions noted.
HEENT
Normocephalic, PERRLA, EOMs intact, fundoscopic: red reflex present, no nicking or hemorrhage. TM intact bilaterally, pearly with + light reflex. Nares patent, neck supple. Pharynx: swallows w/o difficulty, no erythema; Neck: thyroid non palpable, no carotid bruits.
Cardiovascular
Carotid upstrokes are brisk, w/o bruits. The PMI is tapping, 7cm lateral to the midsternal line in the 5th intercostal space. S1 louder than S2 on auscultation. No murmurs or extra sounds. Extremities are warm and w/o edema. No varicosities or stasis changes. Calves are supple and nontender. No femoral or abdominal bruits. Brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial pulses are 2+ , brisk, and symmetric.
Respiratory
Thorax is symmetric with good expansion. Lungs resonant. Breath sounds vesicular; no rales, wheezes, or ronchi.
Gastrointestinal
Abdomen is flat with active bowel sounds in all four quadrants. It is soft and non-tender; no masses or hepatosplenomegaly. No CVA tenderness.
Breast
Deferred
Genitourinary
Deferred
Musculoskeletal
No joint deformities. Positive ROM in hands, wrists, elbows, shoulders, knees and ankles. Gait/Posture: Flexed forward at 15º, walked slowly with a wide based stance, and grimaced with movement. Heel and toe walking intact. Spinal column: No kyphosis, scoliosis or lordosis; unable to extend or rotate. Lateral movement: bilaterally to 20º. All attempts at ROM produced pain. Right paravertebral muscle spasm noted in lumbar area. Straight leg raise (SLR) negative, Patrick test negative, crossed SLR negative. No noted major motor weakness on knee extension, ankle plantar flexors, evertors, dorsiflexors. No CVA Tenderness.
Neurological
Cranial nerves II to XII intact. Good muscle bulk and tone. Strength 5/5 throughout. Rapid alternating movements and point to point movements are intact. Gait stable. Pinprick, light touch, position sense, vibration, and stereognosis intact, Romberg negative. Reflexes 2 + and symmetric with plantar reflexes down going.
Psychiatric
Alert, relaxed and cooperative. Thought process is coherent. Oriented to person, place and time.
Lab Tests
None ordered today.
Special Tests
None ordered today.
Diagnosis
Diagnosis:
1. Acute lumbosacral strain (M54.5)
Differentials:
1. Acute lumbosacral pain (M54.5): Minimal discomfort initially followed by increased pain and stiffness 12-36 hrs later, SLR, crossed SLR, heel and toe walking were intact. No muscular weakness or loss of sensation. DTRs were equal and not depressed. Babinski negative. Spasm noted in paravertebral muscles.
2. Herniated lumbar disc (M51.2): Pain in buttocks.
3. Sciatica (M54.3): Pain in back/buttocks.
4. Possible vertebral Fx (S32.009A): Low back pain.
Plan/Therapeutics
Plan:
Diagnostic: No tests needed at this time
Therapeutic: Pharmacological:
D/C OTC Tylenol. Start Ibuprofen 600mg 1 po q8h x 7 days then PRN for pain. Robaxin 500mg 1 po QAM, 2 po QHS x 2 weeks then 1 po Q8H PRN for back pain.
Non-pharmacological:
Local application of ice may help initially to decrease pain, apply cold pack for 20 minutes q2-3 hours while awake. After 2-3 days, either heat or ice may be applied. No bed rest indicated. Take 3-7 days off work (her job would increase stress on her back), or perform other duties until the symptoms abate.
Patient Education:
1. Avoid jerky, hurried movements when lifting
2. Lift with legs by straddling the load; bend knees to pick up load; keep back straight (do not bend back)
3. Keep objects close to the body at navel level when lifting
4. Avoid twisting, bending, reaching while lifting
5. Avoid prolonged sitting
6. Change positions often while sitting
7. A soft support belt for the back, armrests to support some body weight, a slight reclining chair may make sitting more comfortable
8. Firm mattress/bed board, lying supine with hips and knees flexed on pillows is beneficial when sleeping
9. May return to work in 4-8 days
10. As soon as she returns to regular activities (in 2 weeks), aerobic conditioning exercises such as walking, swimming, stationary biking, or even light jogging may be recommended to avoid debilitation.
Referral: None
Follow-Up: Come back if the pain does not improve by 50% in 24-48 hrs. Return to the office in 7-10 days. Return sooner if neurological symptoms worsen or bowel/bladder dysfunction occurs.
Evaluation of patient encounter:
I was able to assess the patient independently and then later present the case to my preceptor by providing her with the pertinent positive on the ROS and on the physical exam findings. I participated in the Dx selection and in the treatment plan.
Weaknesses: I must by managing my time. It took me almost 45 minutes to work on this case.
Strengths: I have improved my physical exam skills, I feel confident and comfortable interacting with patients on my own.
Reflection: I feel like I am improving with collecting enough information and with performing focused physical exams. I feel like everything is starting to fall in the right place.

References:
Bickley, L. (2007). Bates’ Guide to Physical Examination & History Taking (9th Edition), Lippincott, Williams and Wilkins Publishers
National Guideline Clearinghouse. (2008). Management of Acute Low Back Pain. Retrieved November 10, 2008 from http://www.guideline.gov/summary/summary.aspx?doc_id=12491&nbr=006422&string=back+AND+pain
Uphold C, Graham M. Clinical Guidelines in Family Practice. 4th ed. Gainesville, Fl: Barmarrae Books Inc; 2003:370-376.