Acute Care Nurse Practitioner SOAP NOTE

Type: SOAP NOTE

Subject: Acute Care Nurse Practitioner

Subject area: Nursing

Education Level: College

Length: 3 pages

Referencing style: APA

Preferred English: US English

Spacing Option: Double

Title: SOAP NOTE LOOK TO INSTRUCTIONS

Instructions: this is a case scenario and you will sort through the data provided and create a comprehensive soap note. in addition, you should use the given rubric to guide your submission. case study #1 a 25-year-old woman (g1p0) at approximately 10 weeks' gestation presented for her first prenatal appointment. she reported nausea and vomiting for the past week. she is not able to tolerate liquids and bland solid foods. she had no significant medical or surgical history and no known drug allergies. she reported no other issues or concerns vital signs: temperature, 98.7°f; heart rate, 86 beats/min; blood pressure, 110/80 mm hg; upon physical examination – unremarkable physical exam case study #1 rubric subjective (s) 5pts - chief complaint - history of present illness - ros - past medical hx - past surgical hx - social hx - family hx - recent travel objective (o) 5 pts - vital signs - labs / imaging - head to toe assessment - any other pertinent objective data assessment (a) 5 pts - primary diagnosis listed first - any secondary diagnoses - include at least three differentials plan (p) 5 pts each - treatment plan - address each diagnosis provided - implementation - teaching - address referral and follow up - health promotion and disease prevention include at least 2 references/ treatment guidelines

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SOAP NOTE

Name

Professor

University

Course Title

Due Date

SOAP NOTE

Age: 25 years 

Gender: Female

Subjective 

Chief Complaint: “I have been experiencing nausea and vomiting for the past week. Additionally, I am not able to tolerate liquids bland solid foods”

HPI: She has no significant medical history and no known drugs. 

Past Surgical History: She has no past surgical history 

Social History: Her has no social history

Family History: She has no family history

Recent Travel Objectives: She has not travelled recently. 

 General: This 25-year-old is experiencing nausea and vomiting. 

Objective 

Vitals: 

Temperature: 98.7 degrees (F)

Heart Rate: 86 Beats/ Min

Blood Pressure: 110/80 mmHg

Physical Exam Findings: 

Integument 

Skin: The Client skin has a uniform color with no blemishes. Her skin also has no foul odor. 

Hair: The client’s hair is thick, silky and evenly distributed. 

Nails: The client have light brown nails with a smooth and intact epidermis. When conducting Blanch Test, the nails return to normal in less than 4 seconds. Collectively, there were no signs of infection and infestation on the skin, hair and nails. 

Head

Head: The head is rounded, symmetrical and normocephalic 

Skull: No masses and depressions when the skull is palpated 

Face: The face is smooth with a uniform consistency.

Eyes and Vision

Eyebrows: The eyebrows are symmetrical aligned 

Eyelashes: The eyelashes appear equally distributed and curled outwards 

Eyelids: No discoloration. No presence of discharge. 

Eyes: The Bulbar is transparent with few capillaries evident 

The sclera appears white 

Palpebral conjunctiva is shiny, smooth and pink

No presence of edema or tearing of lacrimal gland

Cornea is transparent, shiny and smooth. 

The Pupils are black and of equal sizes. 

The client can see objects in the periphery when looking straight ahead (peripheral visual field)

When testing Extraocular Muscle; both eyes of the client coordinate moving in unison.

Ears and Hearing

The auricles are symmetrical with the same facial skin color. They are also mobile and firm. 

Nose and Sinus 

Nose: The nose is symmetric, straight and uniform. No presence of discharge 

Mouth: The lips are uniformly pink, moist and with symmetry. Has a smooth texture compared to the skin.

Teeth and Gums: No discoloration of the enamels, and no retraction of gums. 

The tongue is centrally positioned with pink color and slightly rough.

The uvula of the client is centrally positions (in the midline of the soft palate)

Neck

The neck muscles are equal in size

No presence of palpating in the lymph nodes 

The trachea is placed in the midline of the neck

The thyroid glands are not visible during inspection but the ascend during swallowing. 

Thorax, Lungs and Abdomen 

Lungs/ Chest: The chest wall is intact. The client manifested rhythmic and effortless respirations. The spine of the client was vertically aligned. 

Heart: No visible pulsations on both the aortic and pulmonic areas. 

Abdomen: The client’s abdomen has uniform color with a symmetric contour. The jugular vein is not visible 

Extremities 

They are symmetrical in size and length 

Muscles: The are firm and smooth.

Bones: No presence of bone deformities, tenderness or swelling 

Joints: No swelling and tenderness of joints

Mental Status 

Language: Can express in both speech and sign 

Orientations: She is up to date including understanding date and time 

Attention Span: Able to answers questions appropriately. 

Level of Consciousness: Expressed normal levels of consciousness. 

Motor Function.

Gross Motor and Balance: Has an upright posture and steady gait. 

Standing on one foot with eyes closed: Maintained Stance for at least five second.

Heel toe walking: Maintain heal toe walking along a straight line.

Heel walking: She is able to heel walk 

Fine motor tests for upper extremities 

Finger to nose test: Able to rhythmically touch the nose

Alternating supination and pronation of hands-on knees: She is able to alternately supinate and pronate hands at a rapid pace.

Fine motor test with lower extremities 

Pain sensation: She is able to discriminate between sharp and dull sensations. 

Laboratory Data: No data reported. 

Imaging results: No image results reported. 

Other diagnostic data: No other diagnostic data.

Assessment

Early stages of Pregnancy 

Diagnosis/ Differentials 

Pertinent Positives:

1. Nausea with vomiting.
2. Food aversions.

Pertinent Negatives:

1. Increased urination.
2. Fatigue.

Other Differential Diagnosis:

Stomach Flu (Gastroenteritis)

Pertinent Positives:

1. Nausea with or without vomiting.
2. Food aversions.

Pertinent Negatives:

1. Diarrhoea
2. Stomach Pain or Cramping
3. Fever.
4. Headache and body aches.

Intestinal blockage

Pertinent Positives:

1. Nausea with or without vomiting.
2. Food aversions.

Pertinent Negatives:

1. Severe Abdominal Pain
2. Pass wind 
3. Passing stool

Assessment 

Early Pregnancy 

Considering they pertinent positive above, a diagnosis of Early Pregnancy is applicable. The 25-year-old presented with an onset of symptoms including nausea with vomiting with food aversions. Review of both the system and signs and symptoms, she may have symptoms related to early pregnancy. 

Treatment and Implementation Plan:

1. Encourage the patient to eat before or as soon as they feel hungry. Therefore, a dietary change should be primary intervention (Jin & Bergese, 2020). 
2. The patient should also be encouraged to consume aromatic fluids to be helpful in reducing of nausea (Fejzo et al., 2019).
3. The Patient will be administered with Pyridoxine (Vitamin B6) monotherapy with a dosage of 10 to 25 mg orally every six to eight hours (Tsakiridis et al., 2019).

.  

Education/Screening/Follow-up

1. Return for follow-up with symptoms worsen 
2. Supportive measures for easy symptom relief. 

References

Fejzo, M. S., Trovik, J., Grooten, I. J., Sridharan, K., Roseboom, T. J., Vikanes, Å., ... & Mullin, P. M. (2019). Nausea and vomiting of pregnancy and hyperemesis gravidarum. Nature reviews Disease primers, 5(1), 1-17.

Jin, Z., Gan, T. J., & Bergese, S. D. (2020). Prevention and treatment of postoperative nausea and vomiting (Ponv): A review of current recommendations and emerging therapies. Therapeutics and Clinical Risk Management, 16, 1305. 

Tsakiridis, I., Mamopoulos, A., Athanasiadis, A., & Dagklis, T. (2019). The management of nausea and vomiting of pregnancy: synthesis of national guidelines. Obstetrical & Gynecological Survey, 74(3), 161-169.