Soap Note For Patient With Psoriasis
Complete the template attached (See File 1) according to the example (See File 2 )
It is mandatory that you respect the information requested in the template
You should not modify the template. The titles and subtitles will be verified
Dont write in the first person
Dont copy and pase the questions.
Answer the question objectively, do not make introductions to your answers, answer it when you start the paragraph
3) It will be verified by Turnitin and SafeAssign
4) Minimum 5 references not older than 5 years
Purpose: create soap note for patient with Psoriasis
Create a clinical case of a patient diagnosed with Psoriasis. Based on the case you created, complete the Template.
Miami Regional University
Date of Encounter:
Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension)
Name: Mr. DT
Gender at Birth: Male
Gender Identity: Male
Allergies: PCN, Iodine
· Atorvastatin tab 20 mg, 1-tab PO at bedtime
· ASA 81mg po daily
· Multi-Vitamin Centrum Silver
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
Chief Complaint: “headaches” that started two weeks ago
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
GASTROINTESTINAL: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or
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.
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.
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,ical 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).
· Renal artery stenosis (ICD10 I70.1)
· Chronic kidney disease (ICD10 I12.9)
· Hyperthyroidism (ICD10 E05.90)
Labs and Diagnostic Test to be ordered:
· Complete blood count (CBC)
· Lipid profile
· Thyroid-stimulating hormone (TSH)
· Urinalysis with Micro
· Electrocardiogram (EKG 12 lead)
· Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily.
· Lisinopril 10mg PO Daily
· 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.
· 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 up appointment 1 weeks for managing blood pressure and to evaluate current hypotensive therapy.
· No referrals needed at this time.
Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).
Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Clinical Consult 2017
(25th ed.). Print (The 5-Minute Consult Series).
Click here to ORDER an A++ paper from our MASTERS and DOCTORATE WRITERS
Your assignment woes end here!
Who We Are
We are a professional custom writing website. If you have searched for a question and bumped into our website just know you are in the right place to get help in your coursework.
Do you handle any type of coursework?
Yes. We have posted over our previous orders to display our experience. Since we have done this question before, we can also do it for you. To make sure we do it perfectly, please fill our Order Form. Filling the order form correctly will assist our team in referencing, specifications and future communication.
Is it hard to Place an Order?
ORDER NOW FOR AN ORIGINAL PAPER ASSIGNMENT
1. Click on the “Order Now” on the main Menu and a new page will appear with an order form to be filled.
2. Fill in your paper’s requirements in the “PAPER INFORMATION” section and the system will calculate your order price/cost.
3. Fill in your paper’s academic level, deadline and the required number of pages from the drop-down menus.
4. Click “FINAL STEP” to enter your registration details and get an account with us for record-keeping and then, click on “PROCEED TO CHECKOUT” at the bottom of the page.
100% Reliable Site. Make this your Home of Academic Papers.
SCORE A+ WITH HELP FROM OUR PROFESSIONAL WRITERS: ORDER NOW FOR AN ORIGINAL PAPER ASSIGNMENT
Always Order High-Quality Academic Papers from HERE
5. From there, the payment sections will show, follow the guided payment process and your order will be available for our writing team to work on it.
We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so that it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium.
Looking for a Similar Assignment? Order a custom-written, plagiarism-free paper
Your assignment woes end here!