Portfolio of Dalya Tobea



University MSN/NP Program 42386250Clinical SOAP Note Format GeriatricsDalya Tobea SOAP Note #4 Pt. Initials: J. A, Female Age: 68 DOB: 05/12/1948(S)Annual ExamHPI: NAMedical Hx: Depression. Hyperlipidemia. Arthritis. GERD. Seasonal allergies. Last physical and mammogram was a year ago. Last colonoscopy was 8 years ago and pt states she is not required for another scope for two more years. Last eye exam was 9 months ago. Pt denies performing monthly breast exams. Pt is up to date on all immunizations. Surgical Hx: Hysterectomy in 1982. Social Hx: Pt’s spouse passed 4 years ago from MI. Pt has 6 adult children. Pt lives with her adult son and daughter-in-law with five grandchildren and a pet rabbit. The house is a two-story, requiring the pt walk up/down 12 flights of stairs frequently. Pt denies exercising. Pt carriers Medicare insurance. Advance directive on file. Pt denies recreational drugs abuse, smoking, or drinking alcohol. Pt attends church weekly, which is a place where she finds spiritual and emotional support. Hobbies include reading and playing games with her grandchildren. Pt denies being exposed to toxins or traveling. Pt denies any abuse/safety concerns. Pt is not sexually active. Family Hx: Father-HTN, Hyperlipidemia. Mother- Lung CA Adult son- GERD Adult daughter-DM type 2Meds: Lipitor 40 PO daily. Nexium 40 mg PO daily. Zyrtec 10 mg PO daily prn. Flonase 2 sprays each nostril BID prn. Hydrocodone 5mg/325 mg PO TID PRN. Allergies: PCN-rashROSGeneral: Denies fever and chills. Pt feels fatigued and tired but no more than her usual state of fatigue. Reports decreased energy to perform daily chores and slight increase feelings of hopelessness since last visit 6 months ago as a close friend recently passed away. Denies suicidal or homicidal ideation. HEENT: Denies HA, head injuries, dizziness, blurring/double vision. Pt wears glasses. No post-nasal drip. Pt denies tinnitus. Denies nosebleeds, hoarseness, or sore throat. Scalp is non-tender. No sinus tenderness present on palpation on the frontal and maxillary sinuses.Skin: Denies rash, itching, or pigment/mole changes.Respiratory: Denies SOB, sputum, cough, wheezing, night sweat, or being exposed to TB. Denies dyspnea on exertion. Cardio: Denies chest pain or palpitation. Denies swelling or cool extremities.GI: Denies vomiting or nausea. Pt reports indigestion typically while eating sour/spicy foods a couple of times a month. Pt has BM every 5-6 days which are solid brown firm consistency. Denies blood in stools. GU: Denies flank pain, urgency, dysuria, or nocturia. Kidneys are non-tender. Diet: Denies weight loss or poor appetite. Last 24 diet recall includes- Breakfast: Coffee, bagel with cream cheese Lunch- 1 serving of fruit, ham sandwich, and sprite Dinner- 3-4 bites of mashed potatoes with gravy, meatloaf and coke. Endocrine: Denies heat/cold intolerance. No goiter or pain. No change in skin texture. No heart palpitations or anxiety.Breast: Denies pain, tenderness, lumps or discharge. MS: Denies or swelling/heat in joints. Pt c/o joint pain in bilateral knees 3/10 with movement. Pt feels fatigued at the end of the day possibly related to the flight of stairs at home. Neuro: Denies fainting. No seizure history, weakness, strokes, or HA. Psych: Denies suicidal/homicidal ideations. Denies anxiety at this time. Pt feeling a little depressed because a close friend passed away, which also brought back memories of her husband’s passing. Patient has history of depression, but refuses medications as she does not want to increase her medication regimen. (O)Vital signs: T: 97.4 P: 90 RR 13 BP: 104/76 HT: 5’3” WT 117lbs BMI: 20.7 Pain: 3/10, arthritis pain all over joints with movementConstitutional - Pt is a 68-year-old Caucasian female. Pt is dressed appropriately. Pt appears well. Mood and affect are appropriate. Pt has good posture with stable gait. HEENT: Head is normcephalic without head trauma. Hair is fine gray color. It is clean with even distribution. No masses palpated. Facial features symmetric. Trachea is midline without tug. No JVD or carotid bruits noted. PERRLA. Sclera is white, conjunctivae is pink without discharge. Red reflex is present. EOM intact. No nystagmus present. Septum is midline, nares patent bilaterally. Thyroid is non-palpable. No lymphadenopathy in head or neck. Nasal turbinates’ pink and moist. Lips are symmetry with tongue midline and mobile. Uvula rises with ah. No postnasal drip present. TM is pearly gray without effusion in bilateral ears. Weber test and Rinne test are negative for hearing loss. CN VIII intact utilizing whisper test. Skin: Skin is thin, fragile with mild tenting on skin turgor. No edema or lesions noted. Skin color is pink.Respiratory: Lungs are clear bilaterally. AP is 2:1. No accessory muscles are used. Respirations are unlabored and even. Resonant present on percussion. Tactile fremitus present. Thoracic expansion is symmetric. Diaphragmatic excursion is 5 cm. Cardio: No lifts or thrills present. S1, S2 regular without gallops, murmurs, or snaps. No clubbing or cyanosis. Carotid, brachial, and femoral pulses are + 2 bilaterally. PMI palpated, no heave. No edema noted.GU: Urethra is pink and midline. No discharge noted from Bartholin and Skene glands. No lesions noted. Small amount of mucous present. MS: ROM is strong and equal bilaterally without swelling. Posture is good and aligned. Gait is stable with full ROM throughout all joints. No heat or edema present in any joints. Crepitus noted in bilateral knees. Muscle strength intact throughout with 3+ in reflexes. Light and firm touch present. No tenderness present with palpation at the lower back muscles. No pain present on hip extension. Neuro: Cranial nerves 2-12 are intact. Romberg test negative. Rapid alternating movements, and finger to nose test are within normal limits without ataxia. Deep tendon reflexes are +2 bilateral biceps, triceps, and knees. No tremors or unilateral weakness noted. Sensory system intact in bilateral upper & lower extremities as demonstrated utilizing the light touch, temperature, and pain techniques.Breast: Skin texture is smooth. Areolae is round. Nipples are everted without discharge. No lumps/masses noted. Axillary, supraclavicular, and infraclavicular are nonpalpable.Abdomen: Pt has active bowel sounds in all four quadrants. No lesion, masses, tenderness, or bruits noted. Contour is flat and symmetry. No distention. Tympany sound is present on percussion of abd. Liver span is 4 cm. Spleen is nonpalpable. No ascites present. Femoral pulses are +2 bilaterally. Inguinal lymph nodes are nonpalpable Psych: Orientation is intact. Good short term memory (diet recall) Pt is dressed appropriately. well. Good thought process and content. (A)Geriatric Assessment Tools (See Appendix A)Geriatric Depression Scale- Based on the patient results utilizing this screening, patient does not have depression. Clock Drawing Test- Pt scored 1 which means she perfectly followed the directions therefore no cognitive deficit was present.Get-up and Go Test- Pt was asked to change positions and as she did, no abnormal or deviation was noted during the transition. The results conclude that the pt is not at risk for fallingInstrumental Activities of Daily Living- Pt scored 3 from the range of 0-8. The lower the scores, the high level of dependence. Pt is able to move around, however, since she does not own a car therefore she relies on her family to take her shopping for groceries and supplies. She does not perform housekeeping or preparing meals as her daughter-in-law prefers to take care of these manners. Encouraged the pt to perform ADLS independently, depend on family as needed. This allows the pt to not only be fully functioning, but to also allow pt to gain strength performing tasks such as cleaning. Medication Fall Risk-Pt takes Hydrocodone which is on the list of medications that can increase falls by causing sedation. Pt denies symptoms of light-headedness or loss of balance. Educated pt to report to provider immediately if symptoms occur and take medication as prescribed. Advised pt to wear nonskid socks and be aware of carpet as it contributes to falls.Nutritional Health Assessment-Pt scored 2 which concludes that she is not at risk for any nutritional deficit. Pt admits to eating the same types of food elements every week. Educated pt to eat a variety of fresh fruits, vegetables, and lean meat. Avoid processed foods and refined sugars. Drink 6-8 glasses of water daily. Dx: Hyperlipidemia ICD 10 E78.5Depression ICD F33.9GERD ICD K21.9Allergic rhinitis ICD J30.1 Arthritis ICD E03.9Differentials: NAPLast LDL results were 120 mg/dL about 6 months ago. Recheck Lipid Panel, CBC, CMP, T3, T4, and UA as part of annual visit. The approximate cost for all the ordered tests will be seventy-five dollars.Pt admits to feeling depressed, especially since the passing of a close friend. Pt refuses antidepressants or referral to psychiatrist as she believes she does not need treatment at this time. Pt exhibited no signs of depression on the Geriatric Depression Scale Tool. Pt admits to having a strong support group from her family and church. Pt denies being suicidal. F/U in 3 months to reassess depression or as needed. Pt is on Nexium daily. No complaints at this time. F/U prn.Pt is on Zyrtec 10 mg PO daily prn. Flonase 2 sprays each nostril BID prn. No complaints at this time. F/U prn.Pain is controlled with hydrocodone. Refill prescription per pt request (cost $299 for 90 tabs). Tylenol or NSAIDS does not ease joint pain. Encouraged pt to perform Tai Chi or exercises to assist with joint pain. Educated pt to take medication as prescribed. If patient starts to feel dizzy or lightheaded after administration of medications, then call office to reevaluate medication to prevent falls. F/U in 1 month for refill. Health Promotion- Pt will need an annual exam next year. She will need a colonoscopy in two years as recommended by her GI. She will need an eye exam in 3 months, encouraged pt to make an apt now. Nurse will schedule an apt for mammogram within the next couple of weeks. Educated pt on how to perform breast self-exams and the importance of the exam. Encouraged pt to start exercising a couple of times a week as it is beneficial to health. Tai Chi can strengthen joints and ease arthritis pain. Educated pt to eat a well-diverse healthy diet of vegetables, fruits, and lean meats. Avoid processed food and refined sugar. Pt is not drinking adequate water as noted during the diet recall; pt needs to drink 6-8 glasses of water daily. Informed pt that NP is always available to her if she becomes suicidal. Encouraged pt to talk and discuss her feelings with close family and friends. Support group pamphlet provided to pt. NONPF Domains and CompetenciesIndependent Practice Competencies- Creates a climate of patient-centered care to include confidentiality, privacy, comfort, emotional support, mutual trust, and respect. I treated my patient with respect. I knocked on the door before entering, greeted the pt by her name with a handshake before introducing myself. I allowed the pt to feel safe and comfortable in the exam room by obtaining her history before I performed the physical exam. When I assessment private areas, I informed the patient to ensure trust.Independent Practice Competencies-Preserves the patient’s control over decision making by negotiating a mutually acceptable plan of care. Pt refused antidepressants in the past. The patient, my preceptor, and I agreed that as long as the pt is not suicidal then no medication is needed at this time. Pt does have a strong support system which provides her comfort. Practice Inquiry Competencies- Applies clinical investigative skills to improve health outcomes. I utilized the geriatric assessment tools to improve the patient’s health outcomes. We educated my patient that hydrocodone can cause falls in the elderly as a result of the Medication Fall Risk therefore caution should be taken when the medication is consumed. APPENDIX AReferenceButtaro, M. T., Trybulski, J., Bailey, P. P., & Sandberg-Cook, J. (2013). Primary care: a collaborative practice. Missouri, St. Louis: Elsevier Mosby.Domino, J. F., Baldor, A. R., Golding, J., Stephens, B. M., Maloney, M., & Ceci, L. (Eds.). (2016). The 5-minute clinical consult standard 2016. Pennsylvania, Philadelphia: Wolters Kluwer.Morey, C. M., Schmader, E. K., & Park, L. (2015) Physical activity and exercise in older adults. Uptodate. ................
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