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SOAP Note # 1 Name: Karen MeltonInitials: R.A.Age: 50 DOB: 5/23/64 LMP: N/A(S) CC: Patient here for routine monthly pain medication refill. Complain of right hip “popping” 2 weeks ago and has had increased pain since then. HPI: Character: Sharp at times but mostly throbbingOnset: 2 weeks ago while walking in Wal-Mart Location: Right hip Duration: 2 Weeks agoSeverity: 10/10Pattern: ConstantAssociated: Movement worsens pain; pain medication diminishes pain to a 6/10 which patient states is a tolerable pain level. Patient states he also has chronic pain in lumbar region due to DDD and in left hip due to avascular necrosis that rates a 10/10 but also improves to a 6/10 with medication use. Medical Hx: Avascular necrosis in bilateral hips, DDD, DJD, COPD w/emphysema, Anemia unspecified, Duodenal ulcer, HTN Surgical Hx: Total right hip replaced 5/2013, Hernia repair 1/2013, Appendectomy 1968 Social Hx: Alcohol abuse- stopped drinking approx. 10 years ago, smokes 1-2 packs a day. Married. Family Hx: Father with HTN. Mother with hypothyroidism and COPD. Meds/Allergies: Proair HFA inhale 2 puffs every 4-6 hrs prn for shortness of breath. Protonix 40mg po qd for duodenal ulcer, Lisionpril 20mg po qd for HTN, Percocet 10mg po QID for pain. NKDAROS: General: Denies fatigue HEENT: Denies headaches, visual changes, sore throat, hoarseness, hearing loss, or ear pain Respiratory: Denies shortness of breath but states that he has taken Proair 2 x’s a day every day for a few months now due to shortness of breath Cardio: Denies chest pain, shortness of breath, or heart palpitations GI: States BM’s qd, denies abdominal pain or discomfort. Patient states scar on abdomen due to appendectomy at age 14 GU: Denies urinary frequency, dysuria, polyuria Diet: Regular diet Endocrine: Denies heat or cold intolerance MS: States limited range of bilateral lower extremities; stiffness and pain with standing and walking. Patient states he can only walk for short distances before the pain reaches a 10/10 but he says he will not use a motorized chair in Wal-Mart. States scar on right hip that extends from right hip to outer mid thigh due hip arthroplasty in 2013. Neuro: Denies confusion or memory loss, head or neck injury, dizziness, tremors Psych: Denies depression, anxiety, suicidal or homicidal ideation.Vital signs: T-97.9f P-88 R-16 BP-140/80 HT-5”10 WT-220 BMI- Pain-10/10Constitutional – Patient alert, oriented and well groomed. Walked in with straight cane in right hand. Patient appears uncomfortable sitting in chair grimacing and sitting with weight on left hip.HEENT- Head: Normocephalic; no apparent trauma. Eyes: PERRLA bilaterally. Ears: TM’s translucent bilaterally with minimal cerumen noted. Skin is smooth and intact. Nose: External skin smooth and intact; mucosa smooth and intact without edema. Mouth/teeth/gums- mucous membranes pink and intact without lesions. No caries or inflammation of the gums noted.Throat/neck- mucosa without inflammation, tonsils are without exudates or hypertrophy. Uvula rises midline. Neck is without lesions or bruits and thyroid is without deviation and is non tender /non enlarged Respiratory- Respirations are even and unlabored; lung sounds clear but diminished to auscultation in bilateral upper and lower lobes. Cardio: Heart rate and rhythm are regular with no murmur or gallops noted GI: Bowel sounds normo-active in all four quadrants. No visible pulsations noted. No masses or tenderness noted upon palpation. Scare noted vertically from umbilicus to pubus. GU: Not assessed Endocrine: Not assessed MS: Right hip mobility was limited with internal and external rotation noted at 20 degrees. The patient guarded the area and grimaced with pain with any movement. Dislocation of the replaced hip was not noted upon palpation.Strenglth of upper and lower extremiteies was 5/5 however this assessment caused the patient extreme pain. ROM was intact however again these movements cause an increase in pain. Patient is able to ambulate with increased pain, a limp the right side and uses a straight cane. Neuro: Not assessed Psych: Not assessed(A)Dx: (include ICD 9 code - )(list as many diagnoses as indicated) Diagnosis: Complex regional pain syndrome post arthroplasty of the hip pending x-ray results. Differentials: 1 Complex regional pain syndrome post arthroplasty of the hip- ICD-9 code 355.712 Acquired hip dislocation - ICD-9 code 835.003 Osteoarthritis- ICD-9 code- 715.15 (P)(Include costs of tests, medications, etc. – can find resources for this at ; , )– Preventive care/Pt. Education: Prescribed Advair 250/50 inhale 1 puff two times a day every day for maintenance therapy for COPD. Rinse mouth after every use due to the potential of oral candidiasis infection. Call if you have worsening shortness of breath, increased heart rate, or skin rash. $5.00 is the cost to the patient at this clinic. The cost if a patient is uninsured without assistance is $ 271.45.The patient had a Flu vaccine 12/14. Patient has never had a pneumonia vaccine. Recommended pneumonia vaccine this visit due to COPD, but patient stated he will get it from Walgreens because it is $25.00 the compared to $35.00 at this clinic.Follow-up instructions/Pt. Education: Refill Percocet 10mg po qid for 120 tablets. $5.00 is the cost to the patient at this clinic. The cost if a patient is uninsured without assistance is $197.00. Apply ice to area for 15- 20 min 2 to 3 times per day. Rest and reposition as need to reduce pain. Also educated patient to walk as much as he can in Wal-Mart but then consider getting a motorized cart when pain increases so the pain can be controlled. Take pain medicine as directed X-ray of anterior/posterior pelvis and lateral hip to rule out dislocation. The cost of the x-ray for this patient is $ 140.00. The cost of an x-ray for a patient without insurance or assistance is $ 350.00- $460.00.Follow up in one month unless problems continue or worsen. If x-ray is abnormal we will call patient for an appointment.Discuss how you addressed at least 3 NONPF competencies during this visit. (See NONPF competency list)1) B. Management of Patient Illness 1. Analyzes and interprets history, including presenting symptoms, physical findings, and diagnostic information to develop appropriate differential diagnoses.2) A. Health Promotion/Health Protection and Disease Prevention 1. Differentiates between normal, variations of normal, and abnormal findings.3) B. Management of Patient Illness 5. Formulates an action plan based on scientific rationale, evidence-based standards of care, and practice guidelines. What I wish I had done differently: I wish I were more fluid and systematic in my verbal and physical assessment, and the documentation.Difference of opinion with the preceptor: I reported my findings, diagnosis, and plan to the preceptor prior to implementing the plan. The preceptor went in to assess the patient and he determined that I was correct in my assessment and the plan which was then implemented.What I will do differently next time: With this particular patient situation, I would not change my approach. I did make some quick reference physical assessment notes on the note pad I use to help with a more fluid assessment and documentation. What I learned from this experience: I learned that it is necessary to look over medications, labs, and other diagnostics tests to ensure that they are being performed per guidelines. ?I also learned that is important to question patients about other disease processes even if they appear stable and are not being seen for them. I saw a patient that was being seen for pain medication refill only. ?He also had a diagnosis of COPD but did not appear in any distress. I reviewed his medications and found that he was on ProAir. I asked him how often he was using his rescue inhaler and he said twice a day every day. I question why he was using it that often and he stated shortness of breath as the reason. Bilateral upper and lower lungs sounds were diminished. ?I recommended he be placed on Advair 250/50 twice a day. ................
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