Assignment Prompt & Instructions
Support doing SOAP Note for assignment
– ## SOAPnoteAssignmentNUR6282025.docx
– ## SampleAdultNotefromTyphon.docx
**## SOAPnoteAssignmentNUR6282025.docx**
## **Patient Information:**
Her Vital Signs:
o Blood Pressure: 150/90 mmHg
o Heart Rate: 88 bpm
o Respiratory Rate: 18 breaths per minute
o Temperature: 98.6°F
o Oxygen Saturation: 98% on room air
o Height: 5’5"
o Weight: 180 lbs
o BMI: 30.0
She reports feeling fatigue, but denies any weight loss or fever. Her lung sounds are clear to auscultation bilaterally. Her skin is warm and dry to touch. She denies having any headaches, vision changes or hearing loss. She denies chest pain, palpitations or edema
o Her Lab values are as follows: CBC:
WBC: 7.5 x 10^3/µL
Hemoglobin: 13.5 g/dL
Hematocrit: 40.2%
Platelets: 250 x 10^3/µL
Chem 7:
Sodium: 140 mmol/L
Potassium: 4.2 mmol/L
Chloride: 102 mmol/L
Bicarbonate: 24 mmol/L
BUN: 15 mg/dL
Creatinine: 0.9 mg/dL
Glucose: 110 mg/dL
o Liver Panel:
AST: 45 U/L (elevated)
ALT: 50 U/L (elevated)
ALP: 120 U/L
Total Bilirubin: 1.2 mg/dL
Albumin: 4.0 g/dL
o Ultrasound: Gallstones present in the gallbladder, no signs of cholecystitis.
She denies and cough. Her neck is supple, no lymphadenopathy. Her head is normocephalic, atraumatic, PERRLA, EOMI. She denies any rash, lesions, or Shortness of breath. She denies any cough, denies diarrhea or constipation. Her extremities are non-edematous with pulses +2 Bilaterally. She denies any History of anxiety or depression. She has a past Surgical History of an appendectomy
Instructions for students:
The above is scrambled information which will make up the “S” and “O” portions of the SOAP note. Read the narrative and place the information in the appropriate category/location.
Write the SOAP note exam using the information provided. You could find a sample format to help guide your write up in your course document section of
If the above narrative does not provide information for your ROS or PE then assume these bullets or categories are normal and fill in those blanks with what is normal for those sections. DO NOT LEAVE THEM BLANK. This is to be a comprehensive SOAP note.
If you feel there are other diagnostic exams necessary for this case, then indicate them in your treatment plan with the rationale.
Continue your SOAP note with your “A” making sure to include at least (3) differentials for your case.
Lastly, include all the pertinent information in your “P” Plan including (if applicable) follow up, treatment plan, referral and teaching/ education plan. Remember to consider health promotion and disease prevention.
**## SampleAdultNotefromTyphon.docx**
**Patient Demographics**
**Age:**
90+ years
**Biological Sex:**
Female
**Race:**
White, Non Hispanic
**Insurance:**
Medicaid
**Referral:**
No referral
Clinical Information
**Time with Patient:**
20 minutes
**Consult with Preceptor:**
**Type of Decision-Making:**
Low complexity
**Student Participation:**
Less than shared
**Reason for Visit:**
Episodic
**Chief Complaint:**
physical
**Encounter #:**
1
**Type of HP:**
Problem Focused
**Social Problems Addressed:**
Procedures/Skills (Observed/Assisted/Done) (Critical in
**Bold**)
ICD-10 Diagnosis Codes
**#1 -** Z00.00 – ENCNTR FOR GENERAL ADULT MEDICAL EXAM W/O ABNORMAL FINDINGS
**#2 -** Z76.0 – ENCOUNTER FOR ISSUE OF REPEAT PRESCRIPTION
**#3 -** Z68.1 – BODY MASS INDEX (BMI) 19.9 OR LESS, ADULT
CPT Billing Codes
**#1 -** 99213 – OFFICE/OP VISIT, EST PT, MEDICALLY APPROPRIATE HX/EXAM; LOW LEVEL MED DECISION; 20-29 MIN
Medications
**# OTC Drugs taken regularly:**
0
**# Prescriptions currently prescribed:**
0
**# New/Refilled Prescriptions This Visit:**
0
**Types of New/Refilled Prescriptions This Visit:**
**Adherence Issues with Medications:**
Other Questions About This Case
**Patient choice of language:**
English
**Patient is unable verbalize / speak:**
**Patient is verbal and cooperative:**
**Patient does not speak English:**
**Patient comatose / unresponsive:**
**Patient is ambulatory:**
**Maintains NP-patient relationship :**
**Participates in NP role :**
**Manages health care deliverysystems:**
**Proves culturally competent care:**
**Incorporates NP role into care:**
**Indirect :**
**Clinical Notes**
Sex: FeMale
DOB: 11/11/1928
Age: 94 Yrs
CHIEF COMPLAINT:PHYSICAL W.L
HISTORY OF PRESENT ILLNESS:Pleasant 94 year old female presents with daughter for a followup appointment and medication refill. Patient has no complaints or concerns for today's visit. States she lives alone, but near family (daughters). Patient states she walks daily using cane and right hip is feeling strong following hip surgery that took place one year ago. Denies recent illness and states her appetite is very good. She states she is compliant with her medications, Norvasc and ASA, and they are working well for her. Patient states she notices bilateral peripheral edema at the end of the day, but she elevates legs and sees improvement. She uses a walker and cane for ambulation.
MEDICAL HISTORY:Common: Essential Hypertension
SOCIAL HISTORY:
· Alcohol: Denies alcohol use
· Illicit Drugs: Caffeine usage 1 cup /day
· Smoking: Does not actively smoke tobacco and has never smoked
· Marital Status: She is widowed
· Working Status: She is currently unemployed
ACTIVE MEDICATIONS: Medication Reviewed/
**Reconciled**
Amlodipine Besylate 10mg Tablets Take 1 Tablet By Mouth Every Day
Aspirin 81MG Tablet Chewable 1 Po Q D
Norvasc 10MG Tablet 1 Po Q D
**ALLERGIES:**
· No Known Drug Allergies.
· No Known Food Allergies.
· No Known Environmental Allergies.
**VITALS:**
Weight: 107 lbs / 48.53 kg
Height: 5.4 ft BMI: 18.4BSA: 1.5
BP: 140/70
Pulse Rate: 86
BPMResp. Rate: 16 RPM
Temp: 97.5 F
Pain Scale: 0
ROS:Refer to HPI. The patient was also asked about all other systems. All other systems were reviewed and are negative
**PHYSICAL EXAM:**
Gen: Pt. is alert, oriented to place, person and time, NAD
HEENT: Normocephalic, extraocular movements intact, pupils equal and reactive to light, normal moist mucosa of nose and throat.
Chest: CTAB, no wheezes, rales and rhonchi
CVS: RRR, s1/s2
Abd: positive for BS, soft, NT/ND
Ext: no pedal edema, cyanosis/clubbing.
Neuro: II-XII cranial nerves intact, moving all four extremities, FROM, sensory/ motor intact
**ASSESSMENT**
1. Z76.0-Encounter For Issue Of Repeat Prescription
2. Z00.0 encounter for normal physical exam
3. Body mass index (BMI) 19 or less, adult(Z68.1)
Differentials- 3. Normal or high BMI, 1. prescription reaction or need to increase dose (both BP meds BP stable), 2. murmur, enlarged thyroid, adventitious breath sounds (negative assessment none of these finding found) pt declined screenings.
**PLAN:**
Z76.0-Encounter For Issue Of Repeat Prescription
Erx to designated pharmacy.
3. I10-Essential (primary) Hypertension
· Continue medication
· Keep track of the BP readings.
· Cut down coffee intake
· continue the low salt diet and exercise on a daily basis.
· Pt. advised to avoid stress.
· call us if the SBP is more than 150.
PRESCRIPTION ORDERS:Amlodipine Besylate 10MGTAKE 1 TABLET BY MOUTH EVERY DAY1 Refills # 90(Ninety),Norvasc 10MG1 po Q d1 Refills # 90(Ninety)
Body Mass Index: 18.4- eat plenty of healthy foods to maintian caloric intake
Weight: 107
Height: 64Fall Risk Screening 65 Years And Older:How many times in the past year did you fall: 0 or one fall
Confirm Patient has walker/cane or other ambulatory assistance: No
How often does it happen to you that you think you are about to fall, but manage to grab something and then don’t fall: Never or rarely have near falls
Follow up can include visit with PCP, Specialist or Physical Therapy.: Yes
**## SampleAdultNotefromTyphon.docx**
**Patient Demographics**
**Age:**
90+ years
**Biological Sex:**
Female
**Race:**
White, Non Hispanic
**Insurance:**
Medicaid
**Referral:**
No referral
Clinical Information
**Time with Patient:**
20 minutes
**Consult with Preceptor:**
**Type of Decision-Making:**
Low complexity
**Student Participation:**
Less than shared
**Reason for Visit:**
Episodic
**Chief Complaint:**
physical
**Encounter #:**
1
**Type of HP:**
Problem Focused
**Social Problems Addressed:**
Procedures/Skills (Observed/Assisted/Done) (Critical in
**Bold**)
ICD-10 Diagnosis Codes
**#1 -** Z00.00 – ENCNTR FOR GENERAL ADULT MEDICAL EXAM W/O ABNORMAL FINDINGS
**#2 -** Z76.0 – ENCOUNTER FOR ISSUE OF REPEAT PRESCRIPTION
**#3 -** Z68.1 – BODY MASS INDEX (BMI) 19.9 OR LESS, ADULT
CPT Billing Codes
**#1 -** 99213 – OFFICE/OP VISIT, EST PT, MEDICALLY APPROPRIATE HX/EXAM; LOW LEVEL MED DECISION; 20-29 MIN
Medications
**# OTC Drugs taken regularly:**
0
**# Prescriptions currently prescribed:**
0
**# New/Refilled Prescriptions This Visit:**
0
**Types of New/Refilled Prescriptions This Visit:**
**Adherence Issues with Medications:**
Other Questions About This Case
**Patient choice of language:**
English
**Patient is unable verbalize / speak:**
**Patient is verbal and cooperative:**
**Patient does not speak English:**
**Patient comatose / unresponsive:**
**Patient is ambulatory:**
**Maintains NP-patient relationship :**
**Participates in NP role :**
**Manages health care deliverysystems:**
**Proves culturally competent care:**
**Incorporates NP role into care:**
**Indirect :**
**Clinical Notes**
Sex: FeMale
DOB: 11/11/1928
Age: 94 Yrs
CHIEF COMPLAINT:PHYSICAL W.L
HISTORY OF PRESENT ILLNESS:Pleasant 94 year old female presents with daughter for a followup appointment and medication refill. Patient has no complaints or concerns for today's visit. States she lives alone, but near family (daughters). Patient states she walks daily using cane and right hip is feeling strong following hip surgery that took place one year ago. Denies recent illness and states her appetite is very good. She states she is compliant with her medications, Norvasc and ASA, and they are working well for her. Patient states she notices bilateral peripheral edema at the end of the day, but she elevates legs and sees improvement. She uses a walker and cane for ambulation.
MEDICAL HISTORY:Common: Essential Hypertension
SOCIAL HISTORY:
· Alcohol: Denies alcohol use
· Illicit Drugs: Caffeine usage 1 cup /day
· Smoking: Does not actively smoke tobacco and has never smoked
· Marital Status: She is widowed
· Working Status: She is currently unemployed
ACTIVE MEDICATIONS: Medication Reviewed/
**Reconciled**
Amlodipine Besylate 10mg Tablets Take 1 Tablet By Mouth Every Day
Aspirin 81MG Tablet Chewable 1 Po Q D
Norvasc 10MG Tablet 1 Po Q D
**ALLERGIES:**
· No Known Drug Allergies.
· No Known Food Allergies.
· No Known Environmental Allergies.
**VITALS:**
Weight: 107 lbs / 48.53 kg
Height: 5.4 ft BMI: 18.4BSA: 1.5
BP: 140/70
Pulse Rate: 86
BPMResp. Rate: 16 RPM
Temp: 97.5 F
Pain Scale: 0
ROS:Refer to HPI. The patient was also asked about all other systems. All other systems were reviewed and are negative
**PHYSICAL EXAM:**
Gen: Pt. is alert, oriented to place, person and time, NAD
HEENT: Normocephalic, extraocular movements intact, pupils equal and reactive to light, normal moist mucosa of nose and throat.
Chest: CTAB, no wheezes, rales and rhonchi
CVS: RRR, s1/s2
Abd: positive for BS, soft, NT/ND
Ext: no pedal edema, cyanosis/clubbing.
Neuro: II-XII cranial nerves intact, moving all four extremities, FROM, sensory/ motor intact
**ASSESSMENT**
1. Z76.0-Encounter For Issue Of Repeat Prescription
2. Z00.0 encounter for normal physical exam
3. Body mass index (BMI) 19 or less, adult(Z68.1)
Differentials- 3. Normal or high BMI, 1. prescription reaction or need to increase dose (both BP meds BP stable), 2. murmur, enlarged thyroid, adventitious breath sounds (negative assessment none of these finding found) pt declined screenings.
**PLAN:**
Z76.0-Encounter For Issue Of Repeat Prescription
Erx to designated pharmacy.
3. I10-Essential (primary) Hypertension
· Continue medication
· Keep track of the BP readings.
· Cut down coffee intake
· continue the low salt diet and exercise on a daily basis.
· Pt. advised to avoid stress.
· call us if the SBP is more than 150.
PRESCRIPTION ORDERS:Amlodipine Besylate 10MGTAKE 1 TABLET BY MOUTH EVERY DAY1 Refills # 90(Ninety),Norvasc 10MG1 po Q d1 Refills # 90(Ninety)
Body Mass Index: 18.4- eat plenty of healthy foods to maintian caloric intake
Weight: 107
Height: 64Fall Risk Screening 65 Years And Older:How many times in the past year did you fall: 0 or one fall
Confirm Patient has walker/cane or other ambulatory assistance: No
How often does it happen to you that you think you are about to fall, but manage to grab something and then don’t fall: Never or rarely have near falls
Follow up can include visit with PCP, Specialist or Physical Therapy.: Yes
**## SOAPnoteAssignmentNUR6282025.docx**
## **Patient Information:**
Her Vital Signs:
o Blood Pressure: 150/90 mmHg
o Heart Rate: 88 bpm
o Respiratory Rate: 18 breaths per minute
o Temperature: 98.6°F
o Oxygen Saturation: 98% on room air
o Height: 5’5"
o Weight: 180 lbs
o BMI: 30.0
She reports feeling fatigue, but denies any weight loss or fever. Her lung sounds are clear to auscultation bilaterally. Her skin is warm and dry to touch. She denies having any headaches, vision changes or hearing loss. She denies chest pain, palpitations or edema
o Her Lab values are as follows: CBC:
WBC: 7.5 x 10^3/µL
Hemoglobin: 13.5 g/dL
Hematocrit: 40.2%
Platelets: 250 x 10^3/µL
Chem 7:
Sodium: 140 mmol/L
Potassium: 4.2 mmol/L
Chloride: 102 mmol/L
Bicarbonate: 24 mmol/L
BUN: 15 mg/dL
Creatinine: 0.9 mg/dL
Glucose: 110 mg/dL
o Liver Panel:
AST: 45 U/L (elevated)
ALT: 50 U/L (elevated)
ALP: 120 U/L
Total Bilirubin: 1.2 mg/dL
Albumin: 4.0 g/dL
o Ultrasound: Gallstones present in the gallbladder, no signs of cholecystitis.
She denies and cough. Her neck is supple, no lymphadenopathy. Her head is normocephalic, atraumatic, PERRLA, EOMI. She denies any rash, lesions, or Shortness of breath. She denies any cough, denies diarrhea or constipation. Her extremities are non-edematous with pulses +2 Bilaterally. She denies any History of anxiety or depression. She has a past Surgical History of an appendectomy
Instructions for students:
The above is scrambled information which will make up the “S” and “O” portions of the SOAP note. Read the narrative and place the information in the appropriate category/location.
Write the SOAP note exam using the information provided. You could find a sample format to help guide your write up in your course document section of
If the above narrative does not provide information for your ROS or PE then assume these bullets or categories are normal and fill in those blanks with what is normal for those sections. DO NOT LEAVE THEM BLANK. This is to be a comprehensive SOAP note.
If you feel there are other diagnostic exams necessary for this case, then indicate them in your treatment plan with the rationale.
Continue your SOAP note with your “A” making sure to include at least (3) differentials for your case.
Lastly, include all the pertinent information in your “P” Plan including (if applicable) follow up, treatment plan, referral and teaching/ education plan. Remember to consider health promotion and disease prevention.
**## SampleAdultNotefromTyphon.docx**
**Patient Demographics**
**Age:**
90+ years
**Biological Sex:**
Female
**Race:**
White, Non Hispanic
**Insurance:**
Medicaid
**Referral:**
No referral
Clinical Information
**Time with Patient:**
20 minutes
**Consult with Preceptor:**
**Type of Decision-Making:**
Low complexity
**Student Participation:**
Less than shared
**Reason for Visit:**
Episodic
**Chief Complaint:**
physical
**Encounter #:**
1
**Type of HP:**
Problem Focused
**Social Problems Addressed:**
Procedures/Skills (Observed/Assisted/Done) (Critical in
**Bold**)
ICD-10 Diagnosis Codes
**#1 -** Z00.00 – ENCNTR FOR GENERAL ADULT MEDICAL EXAM W/O ABNORMAL FINDINGS
**#2 -** Z76.0 – ENCOUNTER FOR ISSUE OF REPEAT PRESCRIPTION
**#3 -** Z68.1 – BODY MASS INDEX (BMI) 19.9 OR LESS, ADULT
CPT Billing Codes
**#1 -** 99213 – OFFICE/OP VISIT, EST PT, MEDICALLY APPROPRIATE HX/EXAM; LOW LEVEL MED DECISION; 20-29 MIN
Medications
**# OTC Drugs taken regularly:**
0
**# Prescriptions currently prescribed:**
0
**# New/Refilled Prescriptions This Visit:**
0
**Types of New/Refilled Prescriptions This Visit:**
**Adherence Issues with Medications:**
Other Questions About This Case
**Patient choice of language:**
English
**Patient is unable verbalize / speak:**
**Patient is verbal and cooperative:**
**Patient does not speak English:**
**Patient comatose / unresponsive:**
**Patient is ambulatory:**
**Maintains NP-patient relationship :**
**Participates in NP role :**
**Manages health care deliverysystems:**
**Proves culturally competent care:**
**Incorporates NP role into care:**
**Indirect :**
**Clinical Notes**
Sex: FeMale
DOB: 11/11/1928
Age: 94 Yrs
CHIEF COMPLAINT:PHYSICAL W.L
HISTORY OF PRESENT ILLNESS:Pleasant 94 year old female presents with daughter for a followup appointment and medication refill. Patient has no complaints or concerns for today's visit. States she lives alone, but near family (daughters). Patient states she walks daily using cane and right hip is feeling strong following hip surgery that took place one year ago. Denies recent illness and states her appetite is very good. She states she is compliant with her medications, Norvasc and ASA, and they are working well for her. Patient states she notices bilateral peripheral edema at the end of the day, but she elevates legs and sees improvement. She uses a walker and cane for ambulation.
MEDICAL HISTORY:Common: Essential Hypertension
SOCIAL HISTORY:
· Alcohol: Denies alcohol use
· Illicit Drugs: Caffeine usage 1 cup /day
· Smoking: Does not actively smoke tobacco and has never smoked
· Marital Status: She is widowed
· Working Status: She is currently unemployed
ACTIVE MEDICATIONS: Medication Reviewed/
**Reconciled**
Amlodipine Besylate 10mg Tablets Take 1 Tablet By Mouth Every Day
Aspirin 81MG Tablet Chewable 1 Po Q D
Norvasc 10MG Tablet 1 Po Q D
**ALLERGIES:**
· No Known Drug Allergies.
· No Known Food Allergies.
· No Known Environmental Allergies.
**VITALS:**
Weight: 107 lbs / 48.53 kg
Height: 5.4 ft BMI: 18.4BSA: 1.5
BP: 140/70
Pulse Rate: 86
BPMResp. Rate: 16 RPM
Temp: 97.5 F
Pain Scale: 0
ROS:Refer to HPI. The patient was also asked about all other systems. All other systems were reviewed and are negative
**PHYSICAL EXAM:**
Gen: Pt. is alert, oriented to place, person and time, NAD
HEENT: Normocephalic, extraocular movements intact, pupils equal and reactive to light, normal moist mucosa of nose and throat.
Chest: CTAB, no wheezes, rales and rhonchi
CVS: RRR, s1/s2
Abd: positive for BS, soft, NT/ND
Ext: no pedal edema, cyanosis/clubbing.
Neuro: II-XII cranial nerves intact, moving all four extremities, FROM, sensory/ motor intact
**ASSESSMENT**
1. Z76.0-Encounter For Issue Of Repeat Prescription
2. Z00.0 encounter for normal physical exam
3. Body mass index (BMI) 19 or less, adult(Z68.1)
Differentials- 3. Normal or high BMI, 1. prescription reaction or need to increase dose (both BP meds BP stable), 2. murmur, enlarged thyroid, adventitious breath sounds (negative assessment none of these finding found) pt declined screenings.
**PLAN:**
Z76.0-Encounter For Issue Of Repeat Prescription
Erx to designated pharmacy.
3. I10-Essential (primary) Hypertension
· Continue medication
· Keep track of the BP readings.
· Cut down coffee intake
· continue the low salt diet and exercise on a daily basis.
· Pt. advised to avoid stress.
· call us if the SBP is more than 150.
PRESCRIPTION ORDERS:Amlodipine Besylate 10MGTAKE 1 TABLET BY MOUTH EVERY DAY1 Refills # 90(Ninety),Norvasc 10MG1 po Q d1 Refills # 90(Ninety)
Body Mass Index: 18.4- eat plenty of healthy foods to maintian caloric intake
Weight: 107
Height: 64Fall Risk Screening 65 Years And Older:How many times in the past year did you fall: 0 or one fall
Confirm Patient has walker/cane or other ambulatory assistance: No
How often does it happen to you that you think you are about to fall, but manage to grab something and then don’t fall: Never or rarely have near falls
Follow up can include visit with PCP, Specialist or Physical Therapy.: Yes
**## SOAPnoteAssignmentNUR6282025.docx**
## **Patient Information:**
Her Vital Signs:
o Blood Pressure: 150/90 mmHg
o Heart Rate: 88 bpm
o Respiratory Rate: 18 breaths per minute
o Temperature: 98.6°F
o Oxygen Saturation: 98% on room air
o Height: 5’5"
o Weight: 180 lbs
o BMI: 30.0
She reports feeling fatigue, but denies any weight loss or fever. Her lung sounds are clear to auscultation bilaterally. Her skin is warm and dry to touch. She denies having any headaches, vision changes or hearing loss. She denies chest pain, palpitations or edema
o Her Lab values are as follows: CBC:
WBC: 7.5 x 10^3/µL
Hemoglobin: 13.5 g/dL
Hematocrit: 40.2%
Platelets: 250 x 10^3/µL
Chem 7:
Sodium: 140 mmol/L
Potassium: 4.2 mmol/L
Chloride: 102 mmol/L
Bicarbonate: 24 mmol/L
BUN: 15 mg/dL
Creatinine: 0.9 mg/dL
Glucose: 110 mg/dL
o Liver Panel:
AST: 45 U/L (elevated)
ALT: 50 U/L (elevated)
ALP: 120 U/L
Total Bilirubin: 1.2 mg/dL
Albumin: 4.0 g/dL
o Ultrasound: Gallstones present in the gallbladder, no signs of cholecystitis.
She denies and cough. Her neck is supple, no lymphadenopathy. Her head is normocephalic, atraumatic, PERRLA, EOMI. She denies any rash, lesions, or Shortness of breath. She denies any cough, denies diarrhea or constipation. Her extremities are non-edematous with pulses +2 Bilaterally. She denies any History of anxiety or depression. She has a past Surgical History of an appendectomy
Instructions for students:
The above is scrambled information which will make up the “S” and “O” portions of the SOAP note. Read the narrative and place the information in the appropriate category/location.
Write the SOAP note exam using the information provided. You could find a sample format to help guide your write up in your course document section of
If the above narrative does not provide information for your ROS or PE then assume these bullets or categories are normal and fill in those blanks with what is normal for those sections. DO NOT LEAVE THEM BLANK. This is to be a comprehensive SOAP note.
If you feel there are other diagnostic exams necessary for this case, then indicate them in your treatment plan with the rationale.
Continue your SOAP note with your “A” making sure to include at least (3) differentials for your case.
Lastly, include all the pertinent information in your “P” Plan including (if applicable) follow up, treatment plan, referral and teaching/ education plan. Remember to consider health promotion and disease prevention.
**## SampleAdultNotefromTyphon.docx**
**Patient Demographics**
**Age:**
90+ years
**Biological Sex:**
Female
**Race:**
White, Non Hispanic
**Insurance:**
Medicaid
**Referral:**
No referral
Clinical Information
**Time with Patient:**
20 minutes
**Consult with Preceptor:**
**Type of Decision-Making:**
Low complexity
**Student Participation:**
Less than shared
**Reason for Visit:**
Episodic
**Chief Complaint:**
physical
**Encounter #:**
1
**Type of HP:**
Problem Focused
**Social Problems Addressed:**
Procedures/Skills (Observed/Assisted/Done) (Critical in
**Bold**)
ICD-10 Diagnosis Codes
**#1 -** Z00.00 – ENCNTR FOR GENERAL ADULT MEDICAL EXAM W/O ABNORMAL FINDINGS
**#2 -** Z76.0 – ENCOUNTER FOR ISSUE OF REPEAT PRESCRIPTION
**#3 -** Z68.1 – BODY MASS INDEX (BMI) 19.9 OR LESS, ADULT
CPT Billing Codes
**#1 -** 99213 – OFFICE/OP VISIT, EST PT, MEDICALLY APPROPRIATE HX/EXAM; LOW LEVEL MED DECISION; 20-29 MIN
Medications
**# OTC Drugs taken regularly:**
0
**# Prescriptions currently prescribed:**
0
**# New/Refilled Prescriptions This Visit:**
0
**Types of New/Refilled Prescriptions This Visit:**
**Adherence Issues with Medications:**
Other Questions About This Case
**Patient choice of language:**
English
**Patient is unable verbalize / speak:**
**Patient is verbal and cooperative:**
**Patient does not speak English:**
**Patient comatose / unresponsive:**
**Patient is ambulatory:**
**Maintains NP-patient relationship :**
**Participates in NP role :**
**Manages health care deliverysystems:**
**Proves culturally competent care:**
**Incorporates NP role into care:**
**Indirect :**
**Clinical Notes**
Sex: FeMale
DOB: 11/11/1928
Age: 94 Yrs
CHIEF COMPLAINT:PHYSICAL W.L
HISTORY OF PRESENT ILLNESS:Pleasant 94 year old female presents with daughter for a followup appointment and medication refill. Patient has no complaints or concerns for today's visit. States she lives alone, but near family (daughters). Patient states she walks daily using cane and right hip is feeling strong following hip surgery that took place one year ago. Denies recent illness and states her appetite is very good. She states she is compliant with her medications, Norvasc and ASA, and they are working well for her. Patient states she notices bilateral peripheral edema at the end of the day, but she elevates legs and sees improvement. She uses a walker and cane for ambulation.
MEDICAL HISTORY:Common: Essential Hypertension
SOCIAL HISTORY:
· Alcohol: Denies alcohol use
· Illicit Drugs: Caffeine usage 1 cup /day
· Smoking: Does not actively smoke tobacco and has never smoked
· Marital Status: She is widowed
· Working Status: She is currently unemployed
ACTIVE MEDICATIONS: Medication Reviewed/
**Reconciled**
Amlodipine Besylate 10mg Tablets Take 1 Tablet By Mouth Every Day
Aspirin 81MG Tablet Chewable 1 Po Q D
Norvasc 10MG Tablet 1 Po Q D
**ALLERGIES:**
· No Known Drug Allergies.
· No Known Food Allergies.
· No Known Environmental Allergies.
**VITALS:**
Weight: 107 lbs / 48.53 kg
Height: 5.4 ft BMI: 18.4BSA: 1.5
BP: 140/70
Pulse Rate: 86
BPMResp. Rate: 16 RPM
Temp: 97.5 F
Pain Scale: 0
ROS:Refer to HPI. The patient was also asked about all other systems. All other systems were reviewed and are negative
**PHYSICAL EXAM:**
Gen: Pt. is alert, oriented to place, person and time, NAD
HEENT: Normocephalic, extraocular movements intact, pupils equal and reactive to light, normal moist mucosa of nose and throat.
Chest: CTAB, no wheezes, rales and rhonchi
CVS: RRR, s1/s2
Abd: positive for BS, soft, NT/ND
Ext: no pedal edema, cyanosis/clubbing.
Neuro: II-XII cranial nerves intact, moving all four extremities, FROM, sensory/ motor intact
**ASSESSMENT**
1. Z76.0-Encounter For Issue Of Repeat Prescription
2. Z00.0 encounter for normal physical exam
3. Body mass index (BMI) 19 or less, adult(Z68.1)
Differentials- 3. Normal or high BMI, 1. prescription reaction or need to increase dose (both BP meds BP stable), 2. murmur, enlarged thyroid, adventitious breath sounds (negative assessment none of these finding found) pt declined screenings.
**PLAN:**
Z76.0-Encounter For Issue Of Repeat Prescription
Erx to designated pharmacy.
3. I10-Essential (primary) Hypertension
· Continue medication
· Keep track of the BP readings.
· Cut down coffee intake
· continue the low salt diet and exercise on a daily basis.
· Pt. advised to avoid stress.
· call us if the SBP is more than 150.
PRESCRIPTION ORDERS:Amlodipine Besylate 10MGTAKE 1 TABLET BY MOUTH EVERY DAY1 Refills # 90(Ninety),Norvasc 10MG1 po Q d1 Refills # 90(Ninety)
Body Mass Index: 18.4- eat plenty of healthy foods to maintian caloric intake
Weight: 107
Height: 64Fall Risk Screening 65 Years And Older:How many times in the past year did you fall: 0 or one fall
Confirm Patient has walker/cane or other ambulatory assistance: No
How often does it happen to you that you think you are about to fall, but manage to grab something and then don’t fall: Never or rarely have near falls
Follow up can include visit with PCP, Specialist or Physical Therapy.: Yes
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