TITLE: NASAL FRACTURE
EXAMPLE: SOAP NOTE
  
Soap Note # Main Diagnosis ( Exp: H&P Note #3 DX: Hypertension)
Student Name
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor: Dr. Rafael Camejo
  
Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension)
PATIENT INFORMATION
Name: Mr. DT
Age: 68-year-old
Gender at Birth: Male
Gender Identity: Male
Source: Patient
Allergies: PCN, Iodine
Current Medications: 
· Atorvastatin tab 20 mg, 1-tab PO at bedtime
· ASA 81mg po daily
· Multi-Vitamin Centrum Silver
PMH: Hypercholesterolemia
Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.
Preventive Care: Coloscopy 5 years ago (Negative) 
Surgical History: Appendectomy 47 years ago.
Family History: Father- died 81 does not report information
 Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social History: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
Sexual Orientation: Straight
Nutrition History: Diets off and on, Does not each seafood 
Subjective Data:
Chief Complaint: “headaches” that started two weeks ago
Symptom analysis/HPI:
The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month. Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.
Review of Systems (ROS)
CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures. 
HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.
RESPIRATORY: Patient denies shortness of breath, cough or hemoptysis.
CARDIOVASCULAR: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
GASTROINTESTINAL: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or
diarrhea.
GENITOURINARY: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.
MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound.
SKIN: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.
Objective Data:
VITAL SIGNS: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 2/10.
GENERAL APPREARANCE: The patient is alert and oriented x 3. No acute distress noted. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5.
HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without lesions,. Lids non-remarkable and appropriate for race.
Neck: supple without cervical lymphadenopathy, no jugular vein distention, no thyroid swelling or masses.
CARDIOVASCULAR: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary refill < 2 sec.
RESPIRATORY: No dyspnea or use of accessory muscles observed. No egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on auscultation.
GASTROINTESTINAL: No mass or hernia observed. Upon auscultation, bowel sounds present in all four quadrants, no bruits over renal and aorta arteries. Abdomen soft non-tender, no guarding, no rebound no distention or organomegaly noted on palpation
MUSKULOSKELETAL: No pain to palpation. Active and passive ROM within normal limits, no stiffness.
INTEGUMENTARY: intact, no lesions or rashes, no cyanosis or jaundice.
ASSESSMENT:
Main Diagnosis
Essential (Primary) Hypertension (ICD10 I10): Given the symptoms and high blood pressure (156/92 mmhg), classified as stage 2. Once the organic cause of hypertension has been ruled out, such as renal, adrenal or thyroid, this diagnosis is confirmed (Codina Leik, 2015). Diagnosis is based on the clinical evaluation through history, physical examination, and routine laboratory tests to assess risk factors, reveal identifiable causes and detect target-organ damage, including evidence of cardiovascular disease (Domino et al,. 2017).
Differential diagnosis:
Ø Renal artery stenosis (ICD10 I70.1)
Ø Chronic kidney disease (ICD10 I12.9)
Ø Hyperthyroidism (ICD10 E05.90)
PLAN:
Labs and Diagnostic Test to be ordered:
· CMP
· Complete blood count (CBC)
· Lipid profile
· Thyroid-stimulating hormone (TSH)
· Urinalysis with Micro
· Electrocardiogram (EKG 12 lead)
Pharmacological treatment: 
· Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily. 
· Lisinopril 10mg PO Daily
Non-Pharmacologic treatment: 
· Weight loss
· Healthy diet (DASH dietary pattern): Diet rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced content of saturated and trans l fat
· Reduced intake of dietary sodium: <1,500 mg/d is optimal goal but at least 1,000 mg/d reduction in most adults
· Enhanced intake of dietary potassium
· Regular physical activity (Aerobic): 90–150 min/wk
· Tobacco cessation
· Measures to release stress and effective coping mechanisms.
Education
· Provide with nutrition/dietary information.
· Daily blood pressure monitoring log at home twice a day for 7 days, keep a record, bring the record on the next visit with her PCP
· Instruction about medication intake compliance. 
· Education of possible complications such as stroke, heart attack, and other problems.
· Patient was educated on course of hypertension, as well as warning signs and symptoms, which could indicate the need to attend the E.R/U.C. Answered all pt. questions/concerns. Pt verbalizes understanding to all
Follow-ups/Referrals
· Follow up appointment 1 weeks for managing blood pressure and to evaluate current hypotensive therapy.
· No referrals needed at this time.
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
NOTE: PLEASE APA FORMAT OF THE REFERENCE, AND ORIGINAL
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dentify what issues may arise with the prescriptive authority of controlled substances and how you may avoid these situations?
Whenever there is a prescriptive authority of controlled substances, there is likely to be an abuse of the same by drug administrators. This has been demonstrated by the case of Heather Alonso, who was an advanced practice registered nurse (APRN) and used her position to prescribe controlled substances under the Medicare drug program. Nurse practitioners are not supposed to prescribe schedule 2 drugs since there is a high potential that they will be abused. Such issues mainly arise when medical practitioners compromise their practice and administer highly controlled substances contrary to rules and regulations, mainly because they receive hefty payments for the same.
To control the administration of controlled substances, the first step that must be taken is to ensure that a diagnostic workup is conducted (Young, 2018). The diagnostic workup will enable physicians to properly diagnose a patient before administering any drug. In the case of Heather Alonso, many of the patients were not being reviewed hence leading to prescriptions being administered wrongly. The second step that must be taken is to utilize prescription databases and obtain a medical history of the patient. The database will give information on whether the patient has received medication from multiple doctors. Screening for drug seeking is also necessary as it will enable one to establish if the patient is genuine or they are just abusing drugs.  Also, states can revamp their prescription drug monitoring programs (PDMP) which will have better standards for monitoring the administrati0n of controlled drugs (Perrone & Nelson, 2012). All the drugs which fall under schedule 2-5 are monitored. This will enable the states to understand whether stricter control and surveillance is needed. Through the PDMP, surprise audits can be done at the premises of drug administrators to check whether the necessary guidelines are being followed.This will lead to better monitoring and control when it comes to administration of controlled substances.
References
Young, J. (2018).Best Practices When Prescribing Controlled Substances. Retrieved from https://www.psychologytoday.com/us/blog/when-your-adult-child-breaks-your-heart/201806/best-practices-when-prescribing-controlled
Perrone, J., & Nelson, L. S. (2012). Medication reconciliation for controlled substances—an “ideal” prescription-drug monitoring program. New England Journal of Medicine, 366(25), 2341-2343.
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Prior to beginning work on this discussion, please read Chapters 8, 12, and 13 in DSM 5 Made Easy: The Clinician’s Guide to Diagnosis; Chapter 2 in Turning Points in Dynamic Psychotherapy: Initial Assessment, Boundaries, Money, Disruptions and Suicidal Crises; Chapter 5 in The Psychiatric Interview: Evaluation and Diagnosis; all required articles; and review the PSY645 Fictional Sociocultural Case Studies document. One of the most important aspects of developing competence in psychopathology is to be as honestly and completely aware as possible of your personal attitudes toward people who have mental health conditions. Through this awareness, we are better able to challenge our own biases and prejudicial views in order to be more open to the findings within scholarly research.For your initial post in this discussion, choose one of the three case studies from the PSY645 Fictional Sociocultural Case Studies document, and write a detailed description of your uncensored personal observation of the patient depicted. Describe at least one theoretical orientation you would use to conceptualize your view of the patient’s problem and how it may have developed. Identify the issues you might focus on in treatment with this patient. Be sure to identify within your post which of the three case studies you have chosen.
Guided Response: Review several of your colleagues’ posts, and respond to at least two of your peers by 11:59 p.m. on Day 7 of the week. You are encouraged to post your required replies earlier in the week to promote more meaningful interactive discourse in this discussion. Examine your colleague’s initial post, and formulate a possible response. Research a minimum of two peer-reviewed articles that support the views presented in your response. Compose a response that uses a sociocultural perspective to assess the validity of your colleague’s observation and his or her proposed direction of treatment.  
Outline any biases or prejudicial views you observe in your colleague’s post which may affect their conceptualization of the patient’s problems. Remember that your colleague is being open and honest regarding his or her personal views; therefore, your task is to provide persuasive information to encourage your colleague to adopt a view that is supported by peer-reviewed literature. Pay close attention to the tone of your response to ensure your colleague will not become defensive when reading it. Be sure to use at least two peer-reviewed sources to support your statements.Continue to monitor the discussion forum until 5:00 p.m. Mountain Standard Time (MST) on Day 7 of the week and respond to anyone who replies to your initial post. 
Carefully review the Discussion Forum Grading Rubric for the criteria that will be used to evaluate this Discussion Thread.The post Addressing and Confronting Bias and Prejudice first appeared on Nursing School Essays.

The role of the microsystem in shaping children’s effortful control is important and parents play a critical role. After reading the text and viewing the “Life at 3: Bad Behavior” video, address the following: 

What would you recommend to a parent who asks you what he or she can do to promote his or her preschool child’s self-regulation skills?
Now turning to the mesosystem, identify examples of influences on the child’s effortful control you can share with the parent.  
Provide examples of influences on children’s effortful control that you have observed in your own family and other families who are close to you.  

Guided Response:  Your initial post should be at least 250 words in length.The post week 3 discussion question 2 first appeared on Nursing School Essays.