Reason given by the patient for seeking medical care “in quotes”

Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness.

Allergies:

Medication Intolerances:

Chronic Illnesses/Major traumas

Hospitalizations/Surgeries

“Have you every been told that you have:  Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.”

lung disease, heart disease, htn, cancer, TB, DM, or kidney disease.

Education level, occupational history, current living situation/partner/marital status, substance use/abuse,

ETOH, tobacco, marijuana.  Safety status

Weight change, fatigue, fever, chills, night sweats,  energy level

Chest pain, palpitations, PND, orthopnea, edema

Delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles

Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB

Corrective lenses, blurring, visual changes of any kind

Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools

Ear pain, hearing loss, ringing in ears, discharge

Urgency, frequency burning, change in color of urine.

Contraception, sexual activity, STDS    Fe: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx

  Male: prostate, PSA, urinary complaints

Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain

Back pain, joint swelling, stiffness or pain, fracture hx, osteoporosis

SBE, lumps, bumps or changes

Syncope, seizures, transient paralysis, weakness, paresthesias, black out spells

HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance

Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx

Skin is brown, warm, dry, clean and intact. No rashes or lesions noted.

Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes:  PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation.

Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules.

Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.

Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.

Abdomen obese; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly.

Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin.

Bladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT.

Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness.  No adnexal masses or tenderness. Ovaries are non-palpable.

(Male:  both testes palpable, no masses or lesions, no hernia, no uretheral discharge. )

(Rectal as appropriate:  no evidence of hemorrhoids, fissures, bleeding or masses—Males: prostrate is smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm).

Full ROM seen in all 4 extremities as patient moved about the exam room.

Speech clear. Good tone. Posture erect. Balance stable; gait normal.

Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.

Urinalysis – pending

Urine culture – pending

Wet prep – pending

o    1- o    2- o    3-

Diagnosis (Final)

o

▪  Further testing

▪  Medication

▪  Education

▪  Non-medication treatments

Chief Complaint (CC)

“My chest hurts and I feel short of breath”

In patient’s own words. Identity and reliability of informant if patient is not informant.

History of Present Illness (HPI)

Onset:  2 days ago

Location:   sternal chest pain radiating across chest

Duration:  present upon awakening from sleep.  Has been present daily

Characteristics:  dull aching pain.  Sometimes it is a sharp pain

Associated S/S:  increased pain with upper body movement, lying down and taking a deep breath.  Feels short of breath when walking but not laying down.  Had a head cold about 2 weeks ago.  Denies fever, chills, cough, runny nose, nasal congestion, rhinitis, nausea, chest wall trauma, and vertigo

Relieving/Aggravating Factors:  Tylenol 500 every 6 hours helped to decrease pain.  Moist heating pad helps to decrease pain.

Timing:  acute onset; intermittent pain

Severity:  pain is 6 out of 10 and decreases to 2 out of 10.  The pain is always present

FBS 115 this morning before eating.  She states they have been running no higher than 140 pre-meal.

Remember to turn the above information into a narrative…

44y/o female presents with a 2 day history of substernal chest pain radiating across the chest. The pain is rated at 2/10 and is present upon waking, described as aching with episodes of sharpness dependent on positioning. Pain is worse with upper body movements, lying down and deep breathing. Associated symptom of shortness of breath with walking. No other associated symptoms reported. Has taken Tylenol 500mf every 6 hours with some relief. In addition, moist heating pad has helped to decrease pain.

For EACH component of the Chief Complaint include all elements (OLDCARTS). Include pertinent positives from the review of systems as they relate to the HPI

Past Medical History (PMH)

Diabetes Mellitus, Diagnosed 2006

Hypertension, 2007

Hyperlipidemia, 2008

GERD, 2021

Influenza B, 2010

Depression (situational r/t death of father, 2012)

Tobacco abuse, started smoking 20 years ago

Acute appendicitis, age 18

Acute cholecystitis, 2010

Colon Cancer, 2014

In chronological order: Current/Past medical problems with date of onset

Past Surgical History (PSH)

Appendectomy, age 18

Cholecystectomy, 2010

Exploratory lap, 2015 for abdominal pain, normal findings

Hospitalized for small bowel resection, colon cancer 2014

Liposuction of abdomen, May 2019

In chronological order: Surgeries and Procedures with date performed and outcome

OB/GYN history

(if applicable)

Gravida 2 Para 2, A 0

LMP:  10 years ago, menopausal

Last PAP:  March 2019, normal findings

Last Mammogram:  Marsh 2019, normal findings

Hx of STD:  negative history of STD

Gravida/Para. Last menstrual period.  Last PAP w/ results. Last Mammogram w/ results.  History of STD

Immunization status

Childhood immunizations completed include smallpox, diphtheria, tetanus, pertussis, polio (OPV), measles, mumps, rubella

Active case of chicken pox, age 8

TdaP, 2017

Pneumovax, 2018

Influenza vaccine contraindicated due to egg allergy

Age specific immunizations, list and describe any history of reactions

Medications

Lisinopril 20mg 1 tablet by mouth once a day for essential HTN

Atorvastatin 20mg 1 tablet by mouth at bedtime for hyperlipidemia

Tylenol Extra Strength, 2 tablets by mouth every 6 hours as needed for pain

Pepcid 20mg 1 tablet by mouth twice a day as needed for GERD

Current medications: include medication name, dose, route, frequency, duration, and reason for taking

Allergies

Allergy to eggs – rash, childhood

Allergy to ACE inhibitors – angioedema, 2010

Not allergic to environment or latex

Medications, Foods, Environmental, Latex and  how allergy is manifested

Family History (FH)

Paternal GF:  deceased age 78 from car accident, CAD, CABG, DM2

Paternal GM:  deceased age 50 from AMI, breast CA

Maternal GF:  living age 85, prostate CA under hospice care

Maternal GM:  deceased age 84 natural causes, hypothyroidism

Father:  living age 68, DM2, Essential HTN, CVA

Mother:  living age 64, essential HTN

Brother:  living, age 42, essential HTN

Sister:  living, age 38, healthy without chronic disease

Daughter (adopted): living age 10, healthy without chronic disease

Blood relatives:  Age, living/deceased, medical problems, Include grandparents, parents,

siblings, and children

Psychosocial or Social History (SH)

Divorced heterosexual female who is not currently in a sexual relationship

1 child – daughter who was adopted at birth

Denies use of illegal or recreational drugs

Drinks 1-2 beers every weekend for at least 20 years

Does not exercise regularly

Eats fast food meals at least 1-2 times per day

Cigarette smoker for 20 years, 1 pack per day.  Not interested in cessation

MSN prepared registered nurse and works as FNP in primary care office

Southern Baptist who does not attend church regularly due to work schedule

Stressors include being single parent with young daughter

Pt. profile (sexual orientation, marital status, children), Lifestyle risk factors (illicit drug use, smoking/pack year, exercise) , Employment history, Education, Religion – beliefs, Cultural history, Support System, Stressors, Driving

Nutritional Screening

when applicable

Screened using Nestle’s Nutritional Screening Tool

Score is 1 of 10 which indicates adequate nutritional status

Area of deficiency was only eating 2 meals per day (skips breakfast)

Report findings from a nutritional screening tool you used to interview patient

Advanced Directives

Has a written Advanced Directive with DPOAHC.  There is not a copy on the chart

She wants her mother to make medical decisions if incapacitated

Wants to have CPR and be placed on ventilator should cardiopulmonary arrest occur

Report patient wishes and initials of decision-maker/relationship of DPOAHC

Episodic visits should include ROS and Physical Exam only for body systems relevant to the complaint

Review your differential diagnosis list and be sure to include all body systems which will adequately evaluate the differential diagnosis

Typically, only negatives are reported in the ROS.section.

Positives should be reported in the HPI.

Episodic SOAP note should have 3-5 elements addressed in the pertinent body system

Comprehensive SOAP note should have 5-8 elements addressed in the pertinent body system

Constitutional

General statement by the patient (reported symptoms that do not fit one system but often affect overall status)

Skin

Cardiovascular

Denies radiation of chest pain into jaws or arms, palpitations, racing heart,

Respiratory

Negative for hemoptysis, wheezing, productive cough, exposure to TB

Gastrointestinal

Denies abdominal pain, nausea, vomiting, heartburn, waterbrash.  Chest pain does not occur in relation to meals.

Not needed for this concern (chest pain)

Musculoskeletal

Denies muscle weakness, neck or shoulder pain, and tremors

Neurological

Denies numbness, tingling, loss of movement or sensation, vertigo

Psychiatric

Denies anxiety, depression, suicidal or homicidal thoughts

Endocrine

Denies increased thirst, hunger, unexplained weight loss or gain,

Hematologic /Lymphatic

Denies hemoptysis, swollen nodes, and fever

Denies recurrent infections, use of immunosuppressants, and low blood cell counts

Avoid describing findings as “normal”, “WNL”, “appropriate”, “intact”.  Instead describe what you found on evaluation

Episodic SOAP note should have 3-5 elements addressed in the pertinent body system

Comprehensive SOAP note should have 5-8 elements addressed in the pertinent body system

Constitutional

XX year old XXX female in no acute distress.  Speech clear and appropriately answers questions.  Good historian.

General description of patient including age, gender, nutritional status, habitus, attention to grooming, state of cooperativeness/demeanor, overall picture of wellness/distress

Vital Signs

Bp 135/74.  Pulse 82.  Respirations 20  Temp 98.7 orally.Pulse ox on room air is 97%  Height 66 inches.  Weight 227 lbs.  BMI 36.6

Temperature, Pulses (apical and radial), Respirations, BP (Postural PRN), Ht, Wt, BMI

Skin

Skin pink with rebound less than 2 seconds.  Capillary refill brisk in fingers bilaterally.Herpetic rash absent to chest, torso, abdomen, and flank.

HEENT

Eyes:  PERRLA. 

Ears:  TM’s pearly gray bilaterally without effusion.  Light reflex @5 on right and @7 on left

Nose:  Nares patent bilaterally.  Turbinates pale without exudate or polyps.

Throat:  Pharynx without redness or irritation.  Dentition does not show erosions

Neck

Negative lymph node swelling at anterior and posterior cervical chains as well as infra and supraclavicular areas.

Respiratory

Chest is tender to palpation along 2^nd to 5^th costochondral joints at the sternum bilaterally.  The pain is reproducible with deep breath and when patients rotates chest.  Breath sounds are clear bilaterally and cough is not productive.  Chest is symmetrical with bilateral chest rise.  Chest percussion negative for consolidation.

Cardiovascular

Regular S1 and S2 without gallop or murmur.  PMI located midclavicular line at 5^th ICS.  Radial and pedal pulses are 2+ bilaterally.  Negative homan’s sign bilaterally.  Peripheral edema absent bilateral lower extremities

Breast

Not needed

Abdomen

Abdomen soft, non-tender throughout.  Positive bowel sounds x4 quadrants.  Liver and spleen not palpable.  Negative rebound on light and deep palpation.

GYN

if applicable

Not needed

Prostate if applicable

Not needed

Rectal

Not needed

Including frailty evaluation if applicable

Non-tender to palpation at cervical spine, bilateral clavicles, and shoulders.  Neck and shoulders with full active ROM.  Gait steady without imbalance

Neurological

Alert, oriented to name, place, and date.  Deep tendon reflexes 2+ at radialis and Achilles. 

(Mental Status, Cranial nerves, Motor, Cerebellum, Motor, Cerebellum, Sensory, Reflexes)

Psychiatric

Mood is pleasant.  Demonstrates insight as evidenced by verbalization that uncontrolled hypertension can cause her kidneys to fail.  Demonstrates judgement as evidenced by compliance with taking medications.

(Minimal documentation is mood, insight, and judgement. Document findings from depression screen, Mini-mental status exam, CAGE, etc.)

Diagnostic Information

2.10.19  EKG negative for ischemia, injury, and infarct

2.2.18 Cholesterol was 250

Results of diagnostic testing conducted at the time of the visit OR previously done and being used to support the diagnosis and management plan for the current visit

for each presenting problem

Costochondritis

sternal chest pain radiating across chest, pain is reproducible with inspiration, recent respiratory infection

Pain waxes and wanes

Meds:  Pain improves with NSAID

SH: smokes 1 pack per day

PE: 

Chest pain diminishes when holding breath

Costal areas tender to touch, pain is reproducible with movement

CXR: negative for pneumonia, CHF

EKG: negative AMI

Presence of shortness of breath, absence of chest wall trauma,

PE:  Blood pressure is normal 135/74.

Lungs are clear , chest percussion negative for consolidation

Patient has costal tenderness which is 98% sensitive for inflammation as cause of pain (Blue et al, 2018)

Acute Myocardial infarction

sternal chest pain radiating across chest, shortness of breath

PMH: personal history of HTN,

FH:  family history of CAD, CVA,

SH: smokes 1 pack per day, does not exercise, eats fast foods daily

PE:  negative for …

Positive for ….

Dx:  cholesterol on Feb 2, 2018 was 250

Did not have diaphoresis, pain improves with NSAID

PMH:  BMI indicates healthy weight,  negative for CAD, AMI

PE:  Blood pressure is normal 135/74. tenderness across the anterior chest at costovertebral angles bilaterally, pain is reproducible with inspiration

Dx:  EKG negative for injury (ST changes), ischemia (change in T-wave), and infarct (Q wave changes)

Pain of angina and AMI typically is not reproducible nor does it improve with the use of NSAID.  EKG negative for findings of ischemia, injury, infarct.  (Smith et al, 2018)

sternal chest pain radiating across chest, gets worse when laying down

PMH: personal history of GERD

Meds:  Pepcid help to decrease chest pain

SH: smokes 1 pack per day, does not exercise, eats fast foods daily

PE:  negative for …

Positive for ….

Absence of heart burn, waterbrash, pain is not related to food intake, pain decreases with NSAID

PMH:  BMI indicates healthy weight,

PE:  Blood pressure is normal 135/74.

Pharynx without redness or irritation, dentition does not show erosion, abdomen soft, non-tender, positive bowel sounds

Absence of heartburn and waterbrash along with pain not related to food intake makes the likelihood of GERD diagnosis less than 10% according to Jones et al, 2018

sternal chest pain radiating across chest, shortness of breath, pain is reproducible with inspiration, recent respiratory infection

SH: smokes 1 pack per day, does not exercise, eats fast foods daily

PE: 

Negative for …

Positive for ….

HPI/ ROS:

Does not have fever, tachycardia, chills, malaise

PMH:  no history of immunosuppression

PE:  Blood pressure is normal 135/74.

Lungs are clear , chest percussion negative for consolidation

Dx:  EKG without is

Patient is not demonstrating S/S of acute infection including fever and chills and physical exam of lungs does not reveal congestion or consolidation. (Blue et al, 2018)

sternal chest pain radiating across chest, shortness of breath,

PMH:  recent liposuction of abdomen last month

SH: smokes 1 pack per day, does not exercise, eats fast foods daily

PE: 

Negative for …

Positive for ….

Pain decreases with NSAID use, does not have hemoptysis

PMH:  negative for coagulopathy

FH:  negative for coagulopathy

SH:  negative risk factors for clotting event – recent travel, use of OCP

PE:  Blood pressure is normal 135/74.

Lungs are clear , negative peripheral edema and homan’s sign bilaterally

Dx:  D-Dimer normal

(Peter & Paul, 2016)

M94

Acute costochondritis

Primary diagnosis for the visit

Additional diagnoses for the visit AND active problems from the medical history that may contribute to the diagnosis and plan for the current visit (ie DMII or HTN may impact management even if the visit is not related to these diagnoses)

Chest x-ray completed today in the office but will have to await radiology interpretation which takes 24 hours.  Chest x-ray is recommended for patients suspected of having costochondritis who are older than 35 years and/or have signs and symptoms of a coronary event (Author, Year)

include rationale with citation for each diagnostic test being ordered

Celebrex 200mg 1 tablet by mouth twice a day.  NSAIDS work to decrease inflammation of the costochondral area (Author,year)

Tylenol Extra Strength 2 tablets by mouth every 6 hours as needed for pain.  Research shows Tylenol is effective for relief of mild to moderate pain (Author, year)

If there is not improvement in pain within 24-48 hours, will consider Medrol dose pak as stronger anti-inflammatory may be needed (Author,year)

Precipitating event is likely a viral URI and patient is no longer symptomatic.  Therefore anti-infectives are not indicated (Author, year)

include rationale with citation for each pharmacological treatment ordered

Treatments:

Non-Pharmacological

Continue to apply local heat for 10 minutes every 1-2 hours as needed to discomfort.  Heat increases blood flow and makes connective tissue more flexible which will decrease joint pain and reduce inflammation (Author, year)

Avoid unnecessary exercise or activities that make the symptoms worse such as reaching up, twisting the torso, or lifting objects.  Limited activity will allow inflammation to resolve (Author, year)

Return to normal activities when they are tolerated.  As inflammation decreases, normal day to day activities are less painful and should be resumed to avoid stiffness and loss of motion (Author, year)

include rationale with citation for each non-pharmacological treatment ordered

Patient Education

Provided handout on costochondritis including symptoms and treatment plan outlined above.  Educated patient on the side effects and adverse effects of Celebrex and Tylenol.

Rationale:  Empowering patients with knowledge on how to manage and improve their own health helps to engage the patient in self-care and encourages them to take responsibility for their health (Author, date)

nclude rationale with citation for patient education

Consultations recommended with

Rationale

Referral to cardiology – Dr. Yam Lam – to continue evaluation of chest pain associated with shortness of breath.  Appointment is Tuesday June 30, 2019 at 11:15 am.

include rationale with citation for each consultation ordered.  Also include the name of the provider, area of specialty, and date/time of the appointment

Disposition

Return to office in 5 days for follow-up to evaluate patient progress and effectiveness of medications (Author, year)

Next office visit scheduled, identify the plan for follow-up, note expectations for further treatment.

Office visit E/M code

Point of care testing (urine dipstick, wet mount, x rays, etc.) and resulted IN OFFICE, and any procedures done in office

South University

Savannah GA

Patient Name ______________X.X________________    Date ___Month/Date/Year_________

Celebrex 200mg capsules

Sig:  one capsule by mouth twice a day

Disp:  #30

No refills.

Refills: __0__

Signature ______Sallie Student, RN, NP Student________________________

Includes the info that’s collected from the pt’s current  health situation. Includes: ht, wt, vs & physical findings

-Include results of point of care testing conducted at the time of the visit OR diagnostic testing previously done and being used to support the diagnosis & management plan for the current visit

This is a summary of the key symptoms & diagnosis of the pt. and a list of other likely diagnoses.

-Use correct ICD10 codes for final diagnosis.

-Final diagnosis may include any active medical problems being addressed in the patient education & treatment plan

Steps that the provider will take to treat the patient and their concerns

-Use CPT billing codes for office visit (Level of service) and for testing conducted during the office visit.  Again, make sure you identify the rationale for your patient education and/or treatment plans using current evidence-based references within the past 5 years.