UOPX Material - University of Phoenix



University of Phoenix Material

Sample SOAP Note

CC: Dizziness and nocturia x 2

S: Patient comes in today with complaints of dizziness. This started approximately 2 days ago, is present at all times, and is described as a spinning sensation. It is worse with head movement and improved when still. Symptoms are associated with nausea and vomiting, but patient denies headache, syncope, near-syncope, or visual changes. Patient has also had nocturia for the last 3 weeks, which has disturbed his sleep. He states getting up twice at night to urinate a moderate amount, but has had no increase in daytime urination. This nocturia is aggravated by increased fluid intake and alleviated by avoiding fluids after 6 p.m. There are no associated symptoms. He denies any hesitancy, dysuria, hematuria, or decreased urine stream.

O: WT 250 BP 148/98 P 88 T 98.6. Glucometer in the office is 260 (nonfasting). Patient is a middle-aged, slightly obese male that appears in no acute distress. Neuro: PERLLA with CN I-CNXII normal bilaterally. TM intact bilat with no erythema. No sinus tenderness noted. Nares red with no drainage noted. Throat no erythema or tonsilar enlargement/exudates. No nystagmus noted with EOMs intact. Lungs are CTA with good and equal bilateral breath sounds and equal chest expansion. Normal A/P diameter. Heart RRR with no murmur, rub, or extra heart sounds. PMI is nondisplaced, S1 and S2 are audible and regular. Penis is circumcised with no urethral irregularities noted. Patient has two testicles, both descended with no lesions or irregularities palpated. Prostate exam shows normal +1 boggy-feeling prostate with no lumps or irregularities.

A: 386.11 Benign Positional Vertigo

788.43 Nocturia, suspect DM

401.9 Hypertension, not controlled

272.4 Dyslipidemia

Comprehensive Office Visit – CPT Code: 99214

|Differentials |Unsupported information |

|TIA |No neurological abnormalities to support this |

|Sinusitis |No fever, physical exam does not support |

|Arrhythmia |Pulse regular, symptoms aggravated with movement and are not even|

| |related |

|Plan |Rationale and EBP/supporting documentation |

|Attempt Canalith repositioning maneuver in office |Epley maneuver is suggested first-line treatment for BPV and has |

| |been shown to be 70% effective (Fife et al., 2008). |

|Teach patient Epley maneuver for home use |By teaching patients correct procedure, they may get relief of sx|

| |more rapidly. |

|Meclizine 25 mg TID-QID PRN dizziness #45 with 0 refills |American College of Audiologist suggests meclizine as second-line|

| |tx for BPV. It is indicated for BPV (PDR, 2008). |

|OGTT or fasting BS this week |ADA recommends screening for DM in someone with nocturia (ADA, |

| |2009). |

|Urine analysis |Consider a UTI as a differential. |

|Reinstruct on the importance of diet and exercise |American Task Force on Healthy Americans suggests this (AHRQ, |

| |2008). |

|Home BP monitoring for 2 weeks, results to office |According to AHA, diagnosis for HTN should include monitoring |

| |ambulatory BPs (White, 2006). |

|Suggest no fluids after 6 p.m. |To help with symptoms of nocturia |

|Referral for colonoscopy |Task force recommendation for anyone over 50 (AHRQ, 2008) |

|Follow up in 1 week |Need to reevaluate symptoms and review lab testing. |

References

Agency for Healthcare Research and Quality. (2008). Guide to clinical preventive services, 2009.

Retrieved from

American Diabetes Association. (2009). Summary of revisions for the 2009 clinical practice recommendations. Retrieved from

Fife, T. D., Iverson, D. J., Lempert, T., Furman, J. M., Baloh, R. W., Tusa. R. J., … Gronseth, G. S. (2008). Practice parameter: Therapies for benign paroxysmal positional vertigo (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology, 70(22) 2067–2074. Retrieved from

Physicians’ Desk Reference. (2008). Meclizine. Retrieved from

White, W. (2006). Expanding the use of ambulatory blood pressure monitoring for the diagnosis and management of patients with hypertension. Retrieved from

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