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Soap Note 2 Chronic Conditions Discussion Assignment

Soap Note 2 Chronic Conditions Discussion AssignmentSoap Note 2 Chronic Conditions Discussion AssignmentPick any Chronic Disease from Weeks 6-10 (See Syllabus) Diseases and Disorders of the  Gastrointestinal System • Gastritis • Gastroesophageal Reflux Disease • Hemorrhoids • Hepatic Encephalopathy • Hepatitis • Irritable Bowel Syndrome (IBS) • Pancreatic Cancer • Pancreatitis • Peptic Ulcer Disease (ZollingerEllison Syndrome) • Salmonella Infection   Addison Disease • Cushing Syndrome •  Graves’ Disease • Hyper-, Hypoparathyroidism • Hyper-,Hypothyroidism • Myasthenia Gravis • Syndrome ofInappropriate Antidiuretic  Hormone SecretionMust use the sample template for your soap note, keep this template for when you start clinicFollow the MRU Soap Note Rubric as a guideUse APA format and must include minimum of 2 Scholarly Citations. USE THE TEMPLATE AND EXAMPLE I ATTACHEDSoap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)Soap Note 2 Chronic Conditions Discussion AssignmentORDER A PLAGIARISM-FREE PAPER HERETurn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement.The use of tempates is ok with regards of Turn it in, but the Patient History, CC, HPI, The Assessment and Plan should be of your own work and individualized to your made up patient.  #Grading Rubric Student______________________________________This sheet is to help you understand what we are looking for, and what our margin remarks might be about on your write ups of patients. Since at all of the white-ups that you hand in are uniform, this represents what MUST be included in every write-up.Soap Note 2 Chronic Conditions Discussion Assignment 1) Identifying Data (___5pts): The opening list of the note. It contains age, sex, race, marital status, etc. The patient complaint should be given in quotes. If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number. 2) Subjective Data (___30pts.): This is the historical part of the note. It contains the following: a) Symptom analysis/HPI(Location, quality , quantity or severity, timing, setting, factors that make it better or worse, and associate manifestations.(10pts).b) Review of systems of associated systems, reporting all pertinent positives and negatives (10pts).c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem (10pts). If more than one chief complaint, each should be written u in this manner. 3) Objective Data(__25pt.): Vital signs need to be present. Height and Weight should be included where appropriate. a) Appropriate systems are examined, listed in the note and consistent with those identified in 2b.(10pts).b) Pertinent positives and negatives must be documented for each relevant system.c) Any abnormalities must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe things. (5pts). 4) Assessment (___10pts.): Diagnoses should be clearly listed and worded appropriately.Soap Note 2 Chronic Conditions Discussion Assignment 5) Plan (___15pts.): Be sure to include any teaching, health maintenance and counseling along with the pharmacological and non-pharmacological measures. If you have more than one diagnosis, it is helpful to have this section divided into separate numbered sections. 6) Subjective/ Objective, Assessment and Management and Consistent (___10pts.): Does the note support the appropriate differential diagnosis process? Is there evidence that you know what systems and what symptoms go with which complaints? The assessment/diagnoses should be consistent with the subjective section and then the assessment and plan. The management should be consistent with the assessment/ diagnoses identified. 7) Clarity of the Write-up(___5pts.): Is it literate, organized and complete? Comments: Total Score: ____________ Instructor: __________________________________   Soap Note 2 Chronic Conditions Discussion Assignment  Guidelines for Focused SOAP Notes· Label each section of the SOAP note (each body part and system).· Do not use unnecessary words or complete sentences.· Use Standard AbbreviationsS: SUBJECTIVE DATA (information the patient/caregiver tells you).Chief Complaint (CC): a statement describing the patient’s symptoms, problems, condition, diagnosis, physician-recommended return(s) for this patient visit. The patient’s own words should be in quotes.Soap Note 2 Chronic Conditions Discussion AssignmentHistory of present illness (HPI): a chronological description of the development of the patient’s chief complaint from the first symptom or from the previous encounter to the present. Include the eight variables (Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Treatment, Severity-OLDCARTS), or an update on health status since the last patient encounter.Past Medical History (PMH): Update current medications, allergies, prior illnesses and injuries, operations and hospitalizations allergies, age-appropriate immunization status.Family History (FH): Update significant medical information about the patient’s family (parents, siblings, and children). Include specific diseases related to problems identified in CC, HPI or ROS.Soap Note 2 Chronic Conditions Discussion AssignmentSocial History(SH): An age-appropriate review of significant activities that may include information such as marital status, living arrangements, occupation, history of use of drugs, alcohol or tobacco, extent of education and sexual history.Review of Systems (ROS). There are 14 systems for review. List positive findings and pertinent negatives in systems directly related to the systems identified in the CC and symptoms which have occurred since last visit; (1) constitutional symptoms (e.g., fever, weight loss), (2) eyes, (3) ears, nose, mouth and throat, (4) cardiovascular, (5) respiratory, (6) gastrointestinal, (7) genitourinary, (8) musculoskeletal, (9-}.integument (skin and/or breast), (10) neurological, (11) psychiatric, (12) endocrine, (13) hematological/lymphatic, {14) allergic/immunologic. The ROS should mirror the PE findings section.Soap Note 2 Chronic Conditions Discussion Assignment0: OBJECTIVE DATA (information you observe, assessment findings, lab results).Sufficient physical exam should be performed to evaluate areas suggested by the history and patient’s progress since last visit. Document specific abnormal and relevant negative findings. Abnormal or unexpected findings should be described. You should include only the information which was provided in the case study, do not include additional data.Record observations for the following systems if applicable to this patient encounter (there are 12 possible systems for examination): Constitutional (e.g. vita! signs, general appearance), Eyes, ENT/mouth, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin, Neurological, Psychiatric, Hematological/lymphatic/immunologic/lab testing. The focused PE should only include systems for which you have been given data.NOTE: Cardiovascular and Respiratory systems should be assessed on every patient regardless of the chief complaint.Testing Results: Results of any diagnostic or lab testing ordered during that patient visit.A: ASSESSMENT: (this is your diagnosis (es) with the appropriate ICD 10 code)List and number the possible diagnoses (problems) you have identified. These diagnoses are the conclusions you have drawn from the subjective and objective data.Soap Note 2 Chronic Conditions Discussion AssignmentRemember: Your subjective and objective data should support your diagnoses and your therapeutic plan.Do not write that a diagnosis is to be “ruled out” rather state the working definitions of each differential or primary diagnosis (es).Soap Note 2 Chronic Conditions Discussion AssignmentFor each diagnoses provide a cited rationale for choosing this diagnosis. This rationale includes a one sentence cited definition of the diagnosis (es) the pathophysiology, the common signs and symptoms, the patients presenting signs and symptoms and the focused PE findings and tests results that support the dx. Include the interpretation of all lab data given in the case study and explain how those results support your chosen diagnosis.P: PLAN (this is your treatment plan specific to this patient). Each step of your plan must include an EBP citation.1. Medications write out the prescription including dispensing information and provide EBP to support ordering each medication. Be sure to include both prescription and OTC medications.2. Additional diagnostic tests include EBP citations to support ordering additional tests3. Education this is part of the chart and should be brief, this is not a patient education sheet and needs to have a reference.4. Referrals include citations to support a referral5. Follow up. Patient follow-up should be specified with time or circumstances of return. You must provide a reference for your decision on when to follow up.(Student Name)Miami Regional UniversityDate of Encounter:Preceptor/Clinical Site:Clinical Instructor: Dr. David Trabanco DNP, APRN, AGNP-C, FNP-CSoap Note 2 Chronic Conditions Discussion AssignmentSoap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension) PATIENT INFORMATIONName: Mr. DTAge: 68-year-oldGender at Birth: MaleGender Identity: MaleSource: PatientAllergies: PCN, IodineCurrent Medications:· Atorvastatin tab 20 mg, 1-tab PO at bedtime· ASA 81mg po daily· Multi-Vitamin Centrum SilverPMH: HypercholesterolemiaImmunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.Soap Note 2 Chronic Conditions Discussion AssignmentPreventive Care: Coloscopy 5 years ago (Negative)Surgical History: Appendectomy 47 years ago.Family History: Father- died 81 does not report informationMother-alive, 88 years old, Diabetes Mellitus, HTNDaughter-alive, 34 years old, healthySocial History: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.Sexual Orientation: StraightNutrition History: Diets off and on, Does not each seafoodSubjective Data:Chief Complaint: “headaches” that started two weeks agoSymptom analysis/HPI:The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month. Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting. Review of Systems (ROS)CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures.HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.RESPIRATORY: Patient denies shortness of breath, cough or hemoptysis.CARDIOVASCULAR: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnaldyspnea.Soap Note 2 Chronic Conditions Discussion AssignmentGASTROINTESTINAL: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting ordiarrhea.GENITOURINARY: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound.SKIN: No change of coloration such as cyanosis or jaundice, no rashes or pruritus. Objective Data:VITAL SIGNS: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 2/10. GENERAL APPREARANCE: The patient is alert and oriented x 3. No acute distress noted. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5.HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without lesions,. Lids non-remarkable and appropriate for race.Soap Note 2 Chronic Conditions Discussion AssignmentNeck: supple without cervical lymphadenopathy, no jugular vein distention, no thyroid swelling or masses.CARDIOVASCULAR: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary refill < 2 sec.RESPIRATORY: No dyspnea or use of accessory muscles observed. No egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on auscultation.Soap Note 2 Chronic Conditions Discussion AssignmentGASTROINTESTINAL: No mass or hernia observed. Upon auscultation, bowel sounds present in all four quadrants, no bruits over renal and aorta arteries. Abdomen soft non-tender, no guarding, no rebound no distention or organomegaly noted on palpationMUSKULOSKELETAL: No pain to palpation. Active and passive ROM within normal limits, no stiffness.INTEGUMENTARY: intact, no lesions or rashes, no cyanosis or jaundice. ASSESSMENT:Main DiagnosisEssential (Primary) Hypertension (ICD10 I10): Given the symptoms and high blood pressure (156/92 mmhg), classified as stage 2. Once the organic cause of hypertension has been ruled out, such as renal, adrenal or thyroid, this diagnosis is confirmed (Codina Leik, 2015). Diagnosis is based on the clinical evaluation through history, physical examination, and routine laboratory tests to assess risk factors, reveal identifiable causes and detect target-organ damage, including evidence of cardiovascular disease (Domino et al,. 2017).Soap Note 2 Chronic Conditions Discussion AssignmentDifferential diagnosis:· Renal artery stenosis (ICD10 I70.1)· Chronic kidney disease (ICD10 I12.9)· Hyperthyroidism (ICD10 E05.90)PLAN: Labs and Diagnostic Test to be ordered:· CMP· Complete blood count (CBC)· Lipid profile· Thyroid-stimulating hormone (TSH)· Urinalysis with Micro· Electrocardiogram (EKG 12 lead) Pharmacological treatment:· Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily.· Lisinopril 10mg PO Daily Non-Pharmacologic treatment:· Weight loss· Healthy diet (DASH dietary pattern): Diet rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced content of saturated and trans l fat· Reduced intake of dietary sodium: <1,500 mg/d is optimal goal but at least 1,000 mg/d reduction in most adults· Enhanced intake of dietary potassium· Regular physical activity (Aerobic): 90–150 min/wk· Tobacco cessation· Measures to release stress and effective coping mechanisms.Soap Note 2 Chronic Conditions Discussion AssignmentEducation· Provide with nutrition/dietary information.· Daily blood pressure monitoring log at home twice a day for 7 days, keep a record, bring the record on the next visit with her PCP· Instruction about medication intake compliance.· Education of possible complications such as stroke, heart attack, and other problems.· Patient was educated on course of hypertension, as well as warning signs and symptoms, which could indicate the need to attend the E.R/U.C. Answered all pt. questions/concerns. Pt verbalizes understanding to allFollow-ups/Referrals· Follow up appointment 1 weeks for managing blood pressure and to evaluate current hypotensive therapy.· No referrals needed at this time.  ReferencesCodina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).ISBN 978-0-8261-3424-0Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Clinical Consult 2017(25th ed.). Print (The 5-Minute Consult Series).(Student Name)Miami Regional UniversityDate of Encounter:Preceptor/Clinical Site:Clinical Instructor: Grivel J. Hera Gomez APRN, FNP-CSoap Note 2 Chronic Conditions Discussion AssignmentSoap Note # ____ Main Diagnosis ______________ PATIENT INFORMATIONName:Age:Gender at Birth:Gender Identity:Source:Allergies:Current Medications:·PMH:Immunizations:Preventive Care:Surgical History:Family History:Social History:Sexual Orientation:Nutrition History: Subjective Data:Chief Complaint:Symptom analysis/HPI:The patient is … Review of Systems (ROS)CONSTITUTIONAL:NEUROLOGIC:HEENT:RESPIRATORY:CARDIOVASCULAR:GASTROINTESTINAL:GENITOURINARY:MUSCULOSKELETAL:SKIN: Objective Data:VITAL SIGNS:Soap Note 2 Chronic Conditions Discussion AssignmentGENERAL APPREARANCE:NEUROLOGIC:HEENT:CARDIOVASCULAR:RESPIRATORY:GASTROINTESTINAL:MUSKULOSKELETAL:INTEGUMENTARY: ASSESSMENT:Main Diagnosis(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 6th or 7th Edition.Differential diagnosis (minimum 3)–––PLAN:Labs and Diagnostic Test to be ordered (if applicable)· –· –Pharmacological treatment:–Non-Pharmacologic treatment:Education (provide the most relevant ones tailored to your patient) Follow-ups/ReferralsReferences (in APA Style)ExamplesCodina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).ISBN 978-0-8261-3424-0Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010(25th ed.). Print (The 5-Minute Consult Series). Soap Note 2 Chronic Conditions Discussion Assignment

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