Mario is a 66-year-old Hispanic male<\/p>\n
The Assignment:
\nComplete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:
\n\u2022 Subjective: What was the patient\u2019s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria\u00ae, and consider alternative drugs if appropriate. Provide a review of systems.
\n\u2022 Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results?
\n\u2022 Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential in or out. Explain you critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
\n\u2022 Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.
\n\u2022 Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. Follow APA 7th edition formatting. Plan: Give the patient a detailed treatment plan that takes into account each diagnosis, as needed. Include information about the diagnostic tests that will be done, referrals to other health care providers, therapeutic interventions, education, the patient\u2019s disposition, support for the caregiver, and any follow-up visits that are planned. Provide a discussion about improving the patient\u2019s health and preventing disease, taking into account the patient\u2019s factors, past medical history (PMH), and other risk factors. Lastly, include a statement about what you learned or what you thought about the case.
\n\u2022 Give at least three peer-reviewed journal articles or evidence-based guidelines that relate to this case and support your diagnostics and differential diagnoses. Make sure they are up-to-date (no older than 5 years) and help the treatment plan meet current standards of care. Use the format of the APA 7th edition.<\/p>\n
Case Study
\nHPI: Mario is a 66-year-old Hispanic male who presents to the emergency room at his local hospital with acute aphasia, right facial droop, and right-sided weakness. The sudden onset of symptoms occurred at the post office where he works part time. One of his co-workers called 911. On the way to the hospital, the advanced squad team evaluated Mario\u2019s neurologic deficits and glucose levels. The squad team then notified the receiving hospital of a possible stroke patient.
\nUpon Mario\u2019s arrival to the hospital, the ER nurse practitioner proceeds to gather the patient\u2019s medical history from his wife, Lucinda, who accompanied him in the ambulance. She tells the nurse practitioner that Mario has a history of uncontrolled hypertension (and he was often non-compliant with his anti-hypertensive medications). His recent diagnosis of diabetes also was noted, as well as the oral hypoglycemic agents he was taking.
\nThe wife states both of Mario\u2019s parents passed away from myocardial infarctions when they were in their late 60s.
\nSmoking history: Mario is a smoker, usually smoking about a pack and a half each day.
\nExercise history: Mario\u2019s leads a sedentary lifestyle that had contributed to his excess weight.
\nAt 5\u20195\u201d inches, Mario weighs 255 pounds. BMI of: ____
\nWhat other family history, social history, and vital signs will you obtain from the wife and the patient?
\nWhat diagnostic tests will you order for Mario to determine what type of stroke he is having? List at least four diagnostic tests you would order and explain the rationale of each test.
\nThe CT scan indicated a diagnosis of stroke. However, the lab tests and CT scan performed on Mario indicated there was no hemorrhage or early signs of ischemia. What education can you provide the family about the results of a CT scan for diagnosis of brain stroke?
\nYou tell Mario\u2019s wife that it is crucial to recognize the signs of an impending stroke. Describe at least four symptoms and signs of stroke you will educate the patient and family to look for.
\nYou also discuss the RISK factors for stroke with Mario\u2019s family. Lucinda realizes that Mario meets the criteria for all of them. List at least four risk factors for having a stroke:
\nList at least three differential diagnoses for the symptoms listed above:
\nWhat referrals will you make for Mario after his stroke? List at least three.
\nFocused SOAP Note Template<\/p>\n
Patient Information:
\nInitials, Age, Sex, Race
\nS (subjective)
\nCC (chief complaint): a BRIEF statement identifying why the patient is here, stated in the patient\u2019s own words (for instance \u201cheadache,\u201d NOT \u201cbad headache for 3 days\u201d).
\nHPI (history of present illness): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was \u201cheadache\u201d, the LOCATES for the HPI might look like the following example:
\n\u2022 Location: Head
\n\u2022 Onset: 3 days ago
\n\u2022 Character: Pounding, pressure around the eyes and temples
\n\u2022 Associated signs and symptoms: Nausea, vomiting, photophobia, phonophobia
\n\u2022 Timing: After being on the computer all day at work
\n\u2022 Exacerbating\/relieving factors: Light bothers eyes; Aleve makes it tolerable but not completely better
\n\u2022 Severity: 7\/10 pain scale
\nCurrent Medications: Include dosage, frequency, length of time used, and reason for use; also include over the counter (OTC) or homeopathic products.
\nAllergies: Include medication, food, and environmental allergies separately, including a description of what the allergy is (i.e., angioedema, anaphylaxis, etc.). This will help determine a true reaction versus intolerance.
\nPMHx: Include immunization status (note date of last tetanus for all adults), past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed.<\/p>\n
Soc and Substance Hx: Include occupation and major hobbies, family status, tobacco and alcohol use (previous and current use), and any other pertinent data. Always add some health promo question here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text\/cell phone use while driving, and support system.
\nFam Hx: Illnesses with possible genetic predisposition, contagious, or chronic illnesses. Reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
\nSurgical Hx: Prior surgical procedures.
\nMental Hx: Diagnosis and treatment. Current concerns (anxiety and\/or depression). History of self-harm practices and\/or suicidal or homicidal ideation.
\nViolence Hx: Concern or issues about safety (personal, home, community, sexual (current and historical).
\nReproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing\/lactating (yes or no), contraceptive use (method used), types of intercourse (oral, anal, vaginal, other, any sexual concerns).
\nROS (review of symptoms): Cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows:
\n\u2022 General:
\n\u2022 Head:
\n\u2022 EENT (eyes, ears, nose, and throat):
\n\u2022 Etc.:
\nNote: You should list these in bullet format, and document the systems in order from head to toe.
\nExample of Complete ROS:
\nGENERAL: No weight loss, fever, chills, weakness, or fatigue.
\nHEENT:
\n\u2022 Eyes: No visual loss, blurred vision, double vision or yellow sclerae.
\n\u2022 Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
\nSKIN: No rash or itching.
\nCARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
\nRESPIRATORY: No shortness of breath, cough or sputum.
\nGASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
\nGENITOURINARY: Burning on urination. Last menstrual period (LMP), MM\/DD\/YYYY.
\nNEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
\nMUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
\nHEMATOLOGIC: No anemia, bleeding or bruising.
\nLYMPHATICS: No enlarged nodes. No history of splenectomy.
\nPSYCHIATRIC: No history of depression or anxiety.
\nENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
\nREPRODUCTIVE: Not pregnant and no recent pregnancy. No reports of vaginal or penile discharge. Not sexually active.
\nALLERGIES: No history of asthma, hives, eczema or rhinitis.
\nO (objective)
\nPhysical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use \u201cWNL\u201d or \u201cnormal.\u201d You must describe what you see. Always document in head to toe format (i.e., General: Head: EENT: etc.).
\nDiagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).
\nA (assessment)
\nDifferential diagnoses: List a minimum of three differential diagnoses. Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.
\nP (plan)
\nIncludes documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, and any planned follow up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.
\nAlso included in this section is the reflection. Reflect on this case, and discuss what you learned, including any \u201caha\u201d moments or connections you made.
\nAlso include in your reflection, a discussion related to health promotion and disease prevention taking into consideration patient factors (such as, age, ethnic group, etc.), PMH, and other risk factors (e.g., socio-economic, cultural background, etc.).
\nReferences
\nYou are required to include at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting. —<\/p>\n
_____________________________________________________
\nPatient Information:<\/p>\n
Initials: M.M.
\nAge: 66
\nSex: Male
\nRace: Hispanic
\nS (Subjective)<\/p>\n
CC (Chief Complaint): Acute aphasia, right facial droop, and right-sided weakness.
\nHPI (History of Present Illness):
\nPatient is a 66-year-old Hispanic male.
\nOnset of symptoms occurred suddenly at his workplace (post office).
\nCo-worker called 911.
\nAdvanced squad team assessed neurologic deficits and glucose levels during transport.
\nPatient’s History:
\nHistory of uncontrolled hypertension and non-compliance with antihypertensive medications.
\nRecent diagnosis of diabetes and oral hypoglycemic agent use.
\nSocial and Substance History:
\nSmoking history: 1.5 packs\/day.
\nSedentary lifestyle contributing to excess weight (BMI: ____).
\nFamily History:
\nParents both deceased due to myocardial infarctions in their late 60s.
\nVital Signs: To be obtained from the patient and wife.
\nObjective<\/p>\n
Physical Exam:
\nNeurologic assessment findings.
\nCardiovascular and respiratory assessments as needed.
\nDiagnostic Results:
\nCT scan indicates stroke diagnosis.
\nLab tests show no hemorrhage or early ischemia.
\nAssessment<\/p>\n
Differential Diagnoses:
\nIschemic Stroke
\nDiagnostic criteria: Neurologic deficits, sudden onset.
\nSupporting evidence: CT scan.
\nHemorrhagic Stroke
\nDiagnostic criteria: Neurologic deficits, sudden onset, positive CT scan.
\nTransient Ischemic Attack (TIA)
\nDiagnostic criteria: Brief episode of neurologic dysfunction.
\nFacial Nerve Palsy
\nDiagnostic criteria: Isolated right facial droop.
\nPrimary Diagnosis: Ischemic Stroke, based on sudden onset neurologic deficits and positive CT scan.
\nPlan:
\nDiagnostic studies: MRI, EKG, carotid ultrasound.
\nReferrals: Neurologist, physical therapy, speech therapy.
\nTherapeutic interventions: IV thrombolysis, anticoagulants.
\nEducation: Stroke awareness for patient and family.
\nDisposition: Admission to stroke unit.
\nFollow-up visits: Neurology follow-up in one week.
\nHealth Promotion and Disease Prevention:
\nSmoking cessation.
\nBlood pressure and glucose control.
\nWeight reduction and exercise.
\nReflection:
\nImportance of recognizing stroke signs.
\nSignificance of risk factors.
\nContinual learning in stroke management.
\nReferences<\/p>\n
Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., … & American Heart Association Stroke Council. (2019). 2018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals from the American Heart Association\/American Stroke Association. Stroke, 49(3), e46-e110.<\/p>\n
Jauch, E. C., Saver, J. L., Adams, H. P., Bruno, A., Connors, J. J., Demaerschalk, B. M., … & Vagal, A. (2013). Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association\/American Stroke Association. Stroke, 44(3), 870-947.<\/p>\n
Kernan, W. N., Ovbiagele, B., Black, H. R., Bravata, D. M., Chimowitz, M. I., Ezekowitz, M. D., … & Wentworth, D. (2014). Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association\/American Stroke Association. Stroke, 45(7), 2160-2236.<\/p>\n
Meschia, J. F., Bushnell, C., Boden-Albala, B., Braun, L. T., Bravata, D. M., Chaturvedi, S., … & American Heart Association Stroke Council. (2014). Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association\/American Stroke Association. Stroke, 45(12), 3754-3832.<\/p>\n","protected":false},"excerpt":{"rendered":"
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