Focused SOAP Note<\/p>\n
Student\u2019s Name
\nInstitutional Affiliation
\nCourse
\nProfessor\u2019s Name
\nDate<\/p>\n
Patient Information:
\nJ, 71, F, Race
\nS (subjective)
\nCC (chief complaint): Fatigue, thinning hair, and dry skin.
\nHPI (history of present illness): Ms. Juggenmeir is a 71-year-old Female who comes into your office with concerns of fatigue and dry skin. She is a retired Banker. She is alert awake oriented to time, place, situation, ambulatory, and lives by herself. She does report increased fatigue no matter how much sleep she gets. She is also concerned that she may need to come off one of her meds because her hair is thinning. She had labs done and was informed they would review results at this visit. Other pertinent diagnoses include Hypertension, Hyperlipidemia, and Vitamin D deficiency. She admits to not taking her vitamin D daily as prescribed.
\nCurrent Medications:
\nWomen\u2019s One A Day-Multivitamin daily
\nChlorthalidone 25mg daily
\nFish Oil 1 tablet daily
\nAmlodipine 5mg p.o. daily
\nLosartan 100mg p.o. daily
\nAtorvastatin 40mg p.o. at bedtime daily
\nAspirin 81mg p.o. daily
\nErgocalciferol 50,000 units PO once a month
\nAllergies: I.V. Contrast, ACE Inhibitors reactions.
\nPMHx: Hypertension, Hyperlipidemia, Vitamin D deficiency.<\/p>\n
Soc and Substance Hx: Retired banker who lives by herself.
\nFam Hx: No significant family history.
\nSurgical Hx: Prior surgical procedures.
\nMental Hx: No past diagnosis of mental illness.
\nViolence Hx: No history of violence.
\nReproductive Hx: No significant reproductive history.
\nROS (review of symptoms):
\nGENERAL: No unintended weight loss, gain or fatigue.
\nHEENT:
\n\u2022\tEyesNo visual loss or sclera.
\n\u2022\tEars, Nose, Throat: No hearing loss, running nose or sore throat.
\nSKIN: No lesions or itching.
\nCARDIOVASCULAR: No chest pains or discomfort.
\nRESPIRATORY: No shortness of breath of sputum.
\nGASTROINTESTINAL: No nausea, diarrhea, vomiting or blood in the stool.
\nGENITOURINARY: No burning sensation on urination.
\nNEUROLOGICAL: No history numbness, headache, stroke, or malfunctioning nerves.
\nMUSCULOSKELETAL: No back or muscle pain.
\nHEMATOLOGIC: No bleeding or bruising.
\nLYMPHATICS: No history of splenectomy.
\nPSYCHIATRIC: No history of mental illness or anxiety.
\nENDOCRINOLOGIC: No sweating or reports of polyuria or polydipsia.
\nREPRODUCTIVE: No recent pregnancy or menstrual cycle. Last menstrual period is unknown.
\nALLERGIES: No history of rhinitis or eczema.
\nO (objective)
\nPhysical exam:
\nVital signs: BP 137\/82, HR 89, RR 20, Temp 98.1
\nDiagnostic tests:
\nCXR- Last CXR showed no cardiopulmonary findings. WNL
\nTSH\/Free T4, T3- as noted below in lab results.
\nBasic Metabolic Panel and CBC as shown below.
\nVitamin D Level- as noted below in lab results.
\nDiagnostic results:
\nTest Result Reference Range
\nGLUCOSE 85 65-99
\nSODIUM 134 135-146
\nPOTASSIUM 4.2 3.5-5.3
\nCHLORIDE 104 98-110
\nCARBON DIOXIDE 29 19-30
\nCALCIUM 9.0 8.6- 10.3 BUN 20 7-25
\nCREATININE 1.01 0.70-1.25
\nGLOMERULAR FILTRATION RATE (eGFR) 76 >or=60 mL\/min\/1.73m2
\nTSH 23 0.4-4.0 FREE T4 0.05 0.9-2.4 mcg\/dl T3 3.0 2.0-4.4 ng\/dl
\nVitamin D 1,25 OH 14 36-144
\nWBC 7.3 3.4- 10.8 RBC 4.31 135-146
\nHEMOGLOBIN 14 13-17.2
\nHEMATOCRIT 42% 36-50 MCV 90 80-100
\nMCHC 34 32-36
\nPLATELET 272 150-400
\nMs. Juggenmeir is a 71 y\/o female who is alert awake oriented to time, place, situation. She makes no unusual motor movements and demonstrates no tics. She denies any visual or auditory hallucinations. She denies any suicidal thoughts or ideations. She denies any falls or pain.
\nA (assessment)
\nDifferential diagnoses:
\nAlopecia
\nAlopecia is an autoimmune condition that causes the hair to start thinning. The amount of hair loss is different in different people (Strazzulla et al., 2018: 2024 – Write My Essay For Me | Essay Writing Service For Your Papers Online). The condition may be hereditary, hormonal disturbance, or childbirth illness. The hair can grow back with the help of immune-suppressing medication (Strazzulla et al., 2018: 2024 – Write My Essay For Me | Essay Writing Service For Your Papers Online).
\nHyponatremia
\nHyponatremia is a condition that occurs when the sodium levels in the body are too low. Low sodium levels cause the body cells to start swelling (George et al., 2018: 2024 – Write My Essay For Me | Essay Writing Service For Your Papers Online). The common causes of the condition include heart failure, diarrhea, diuretic use, renal disease, or liver disease. The disease is life-threatening and appropriate action is needed to counter the symptoms (George et al., 2018: 2024 – Write My Essay For Me | Essay Writing Service For Your Papers Online).
\nAutoimmune Thyroiditis
\nThe condition occurs when the immune system attacks the thyroid gland leading to swelling. The swelling affects the ability to produce hormones as required (Koehler et al., 2019: 2024 – Online Assignment Homework Writing Help Service By Expert Research Writers). The symptoms include fatigue, pale and dry skin, unexplained weight gain, memory lapses, increased sensitivity to cold, and constipation (Koehler et al., 2019: 2024 – Online Assignment Homework Writing Help Service By Expert Research Writers). Patients should get immediate care to avoid deterioration and worse health complications.
\nP (plan)
\nThe patient will require additional diagnostic tests to examine the immune system. A referral to a physician for the FT3 test and T4 test is necessary to examine the severity of the condition (Kennedy-Malone et al., 2019: 2024 – Online Assignment Homework Writing Help Service By Expert Research Writers). For instance, a rheumatologist effectively examines conditions relating to autoimmune attacks.
\nThe patient will require immunotherapy drugs such as immunosuppressant drugs. It is important to take care of the patient to ensure their health is not exposed to infections due to suppressed immunity. A physician should educate the patient about the illness and the appropriate interventions (Koehler et al., 2019: 2024 – Online Assignment Homework Writing Help Service By Expert Research Writers). The patient should be under the watch of a physician in the ward and be discharged after a week when the immune attack subsides. The patient should take medication and return to the clinic after two weeks. The autoimmune conditions require appropriate intervention. The patient should continue taking the current medication.
\nThe patient should receive information that vitamin D deficiency is one of the major causes of hair thinning (Koehler et al., 2019: 2024 – Online Assignment Homework Writing Help Service By Expert Research Writers). Vitamin D is essential in stimulating hair follicles. The deficiency causes alopecia which leads to hair thinning in various patches.
\nThe treatment plan should include vitamin D supplements. The supplements will restore the hair and strengthen the bones. It is essential to suspend Chlorthalidone since the condition reduces water and salt in the body. The drug could be a contributing factor to conditions such as hyponatremia.
\nPatient education should include providing information on the risk factors such as salt intake (Munshi et al., 2019: 2024 – Online Assignment Homework Writing Help Service By Expert Research Writers). The patient should take less than 2,300 milligrams (mg) daily. Eat healthy foods such as whole grains, fruits, and fish are important. Taking food with potassium is crucial in lowering blood pressure. The patient should maintain an optimal body weight height ratio. Excess weight can cause diabetes or high blood pressure (American Diabetes Association, 2020). The patient should exercise regularly to lower the risk of obesity, stress, and high blood pressure.
\nReflection
\nI learned that the condition requires appropriate interventions since it can be life-threatening. I learned that patients with various autoimmune disorders should get an appropriate checkup to avoid deterioration of the condition.
\nHealth promotion should include eating a healthy diet, reducing salt intake, and exercising regularly. The patient should suspend Chlorthalidone medication since it can contribute to one of the conditions.
\nProvision of care should respect the cultural background, age, and religious beliefs. The patient requires adequate care and checkup since the age may pose various health risks.<\/p>\n
References
\nAmerican Diabetes Association. (2020). Glycemic targets: Standards of medical care in diabetes\u20142020. Diabetes Care, 43(Suppl. 1), S66\u2013S76. https:\/\/doi.org\/10.2337\/dc20-S006
\nGeorge, J. C., Zafar, W., Bucaloiu, I. D., & Chang, A. R. (2018: 2024 – Write My Essay For Me | Essay Writing Service For Your Papers Online). Risk factors and outcomes of rapid correction of severe hyponatremia. Clinical Journal of the American Society of Nephrology, 13(7), 984-992.
\nKennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019: 2024 – Online Assignment Homework Writing Help Service By Expert Research Writers). Endocrine, metabolic, and nutritional disorders. In Advanced practice nursing in the care of older adults (2nd ed., pp. 361\u2013406). F. A. Davis.
\nKoehler, V. F., Filmann, N., & Mann, W. A. (2019: 2024 – Online Assignment Homework Writing Help Service By Expert Research Writers). Vitamin D status and thyroid autoantibodies in autoimmune thyroiditis. Hormone and Metabolic Research, 51(12), 792-797.
\nMunshi, M., Nathan, D. M., Schmader, K. E., Mulder, J. E., & Givens, J. (2019: 2024 – Online Assignment Homework Writing Help Service By Expert Research Writers). Treatment of type 2 diabetes mellitus in the older patient. UpToDate. Retrieved June 8, 2020, from https:\/\/www.uptodate.com\/contents\/treatment-of-type-2-diabetes-mellitus-in-the-older-patient
\nStrazzulla, L. C., Wang, E. H. C., Avila, L., Sicco, K. L., Brinster, N., Christiano, A. M., & Shapiro, J. (2018: 2024 – Write My Essay For Me | Essay Writing Service For Your Papers Online). Alopecia areata: disease characteristics, clinical evaluation, and new perspectives on pathogenesis. Journal of the American Academy of Dermatology, 78(1), 1-12.
\n—
\nNRNP_6540_Week9_Assignment_Rubric
\n\u2022\tGrid View
\n\u2022\tList View
\nExcellent\tGood\tFair\tPoor
\nCreate documentation in the Focused SOAP Note Template about the patient in the case study to which you were assigned.<\/p>\n
In the Subjective section, provide:<\/p>\n
\u2022 Chief complaint<\/p>\n
\u2022 History of present illness (HPI)<\/p>\n
\u2022 Current medications, checked against Beers Criteria<\/p>\n
\u2022 Allergies<\/p>\n
\u2022 Patient medical history (PMHx)<\/p>\n
\u2022 Review of systems\t9 (9%) – 10 (10%)
\nThe response throughly and accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A thorough cross-check of medications against the Beers Criteria has been completed and appropriate alternative drugs recommended if applicable.\t8 (8%) – 8 (8%)
\nThe response accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A cross-check of medications against the Beers Criteria has been completed and appropriate alternative drugs recommended if applicable.\t7 (7%) – 7 (7%)
\nThe response describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis, but is somewhat vague or contains minor innacuracies. A cross-check of medications against the Beers Criteria has been completed but alternatives may be missing.\t0 (0%) – 6 (6%)
\nThe response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A cross-check of medications against the Beers Criteria has not been completed. Or, subjective documentation is missing.<\/p>\n","protected":false},"excerpt":{"rendered":"
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