(M1021) Primary Diagnosis Code:
\nE11.9
\n03
\n(M1021) Primary Diagnosis
\nType 2 diabetes mellitus without
\ncomplications
\nSeverity:
\n(M1023) Other Diagnosis Code:
\nI10
\n03
\n(M1023) Other Diagnosis
\nEssential (primary) hypertension
\nSeverity:
\n(M1023) Other Diagnosis Code:
\nE87.1
\n02
\n(M1023) Other Diagnosis
\nHypo-osmolality and hyponatremia
\nSeverity:
\n(M1023) Other Diagnosis Code:
\nN39.0
\n02
\n(M1023) Other Diagnosis
\nUrinary tract infection, site not specified
\nSeverity:
\n(M1023) Other Diagnosis Code:
\nR11.2
\n02
\n(M1023) Other Diagnosis
\nNausea with vomiting, unspecified
\nSeverity:
\n(M1023) Other Diagnosis Code:
\nF32.A
\n02
\n(M1023) Other Diagnosis
\nDepression, unspecified
\nSeverity:
\n(M1023) Other Diagnosis Code:
\nM54.59
\n02
\n(M1023) Other Diagnosis
\nOther low back pain
\nSeverity:
\n(M1023) Other Diagnosis Code:
\nE78.5
\n02
\n(M1023) Other Diagnosis
\nHyperlipidemia, unspecified
\nSeverity:
\n(M1023) Other Diagnosis Code:
\nG90.09
\n02
\n(M1023) Other Diagnosis
\nOther idiopathic peripheral autonomic
\nneuropathy<\/p>\n
1 – Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)
\n\u2713
\n\u2713
\n2 – Diabetes Mellitus (DM)
\n3 – None of the above<\/p>\n
Patient is a 82 years old hispanic
\nfemale presented due to health\/medical condition being unstable
\nand genarlized weakness, and recent discharge from hospital after a acute episode of UTI. Patient
\nrequires partial Help with transfer.
\nPatient with multiple DX: DM II,
\nHTN, Depression, chronic low back pain, and other comorbidities.
\nPatient for Admission to HHCS based upon medical necessity and homebound status and based on the
\nassessment of the patient’s rehabilitation potential, that D\/T multiple and complex medical condition that could deteriorate at anytime, the condition of the patient will
\nimprove with continued skilled SN teachings\/Management\/monitoring for optimal outcomes \/ goal attainment, and or the services are necessary to the establishment of a
\nsafe and effective maintenance program, and to prevent and exacerbation. Live with daughter. Referral to home care Apex SN , HHA, PT services for strengthen . UTI cleared at this time<\/p>\n
1.\tLISINOPRIL 20 MG ORAL TABLET
\n1 tab twice a day By mouth (PO) New cardiovascular agents
\n2.\t 12\/19\/2022 GABAPENTIN 300 MG ORAL CAPSULE
\n2 cap twice a day By mouth (PO) New anticonvulsants
\n3.\t 12\/19\/2022 SODIUM CHLORIDE 1 mg
\n1 tab day QHS By mouth (PO) New nutritional products
\n4.\t 12\/19\/2022 PREDNISONE4MG ORAL TABLET
\n1 tab x 5 days By mouth (PO) New glucocorticoids
\n5.\t 12\/19\/2022 CARVEDILOL 25 MG ORAL TABLET
\n1 tab twice a day By mouth (PO) New cardiovascular agents
\n6.\t 12\/19\/2022 METFORMIN 500 MG ORAL TABLET
\n2 tab twice a day By mouth (PO) New antidiabetic agents
\n7.\t 12\/19\/2022 HYDROXYZINE HYDROCHLORIDE 25 MG ORAL TABLET
\n1 tab as need By mouth (PO) New central nervous system agents
\n8.\t 12\/19\/2022 SIMVASTATIN 40 MG ORAL TABLET
\n1 tab day By mouth (PO) New antihyperlipidemic agents
\n9.\t 12\/19\/2022 novolog 70\/30 flex pen
\n30 units AM subcutaneous (SQ) New insulin
\n10.\t 12\/19\/2022 novolog 70\/30 flex pen
\n20 units PM subcutaneous (SQ) New insulin
\n11.\t 11\/17\/2022 Tylenol 8HRS ARTHRITIS 650MG
\n1-2TABS EVERY 6HRS AS NEEDED FOR PAIN By mouth (PO)
\nHeart Rate: Greater Than(>) 90 Less Than (<) 60
\nTemp: Greater Than (>) 100 Less Than (<) 95 Respirations: Greater Than (>) 24 Less Than (<) 12 Pain Level: Greater Than (>) 7 O2
\nSaturation: Less Than (<) 95 Systolic BP: Greater Than (>) 160 Less Than (<) 60
\nDiastolic BP: Greater Than (>) 90 Less Than (<) 60 Blood Sugar, Fasting: Greater Than (>) 200 Less Than (<) 60 Blood Sugar, Random:
\nGreater Than (>) 300 Less Than (<) 60<\/p>\n
—
\nIn Week 3, you completed a focused SOAP note. This week, you will complete a comprehensive SOAP note. Both types of SOAP note provide a cognitive framework for diagnostic reasoning and treatment planning.<\/p>\n
To prepare:<\/p>\n
Review the Comprehensive SOAP Note Template.
\nSelect a patient who you saw at your practicum site during the last 5 weeks. With this patient in mind, consider the following:
\nSubjective: What details did the patient provide regarding the personal and medical history?
\nObjective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities and psychosocial issues.
\nAssessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their CPT and ICD-10 codes for the diagnosis. What was your primary diagnosis and why?
\nPlan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
\nReflection notes: What was your \u201caha\u201d moment? What would you do differently in a similar patient Assessment?
\n—
\nBased on the provided information, the patient is an 82 year old Hispanic (the best nursing writing service, a studybay for your papers) female with type 2 diabetes mellitus (DM II), hypertension (HTN), depression, chronic low back pain, and other comorbidities. The patient has recently had an acute episode of a urinary tract infection (UTI) and is experiencing genarlized weakness and instability in their health. They require partial Helpance with transfers and are being admitted to home health care services (HHCS) due to their medical necessity and homebound status. The patient’s condition is expected to improve with continued skilled nursing (SN) teachings, management, and monitoring for optimal outcomes and goal attainment, and the services are necessary to establish a safe and effective maintenance program and prevent exacerbation of their medical conditions. The patient lives with their daughter and will be receiving home care services including skilled nursing, home health aide (HHA), and physical therapy (PT) to help with strengthening. The patient is currently prescribed several medications including lisinopril, gabapentin, sodium chloride, prednisone, carvedilol, metformin, hydroxyzine hydrochloride, simvastatin, and insulin. They are also taking over-the-counter medications including acetaminophen and ibuprofen.<\/p>\n","protected":false},"excerpt":{"rendered":"
(M1021) Primary Diagnosis Code: E11.9 03 (M1021) Primary Diagnosis Type 2 diabetes mellitus without complications Severity: (M1023) Other Diagnosis Code: I10 03 (M1023) Other Diagnosis Essential (primary) hypertension Severity: (M1023) Other Diagnosis Code: E87.1 02 (M1023) Other Diagnosis Hypo-osmolality and hyponatremia Severity: (M1023) Other Diagnosis Code: N39.0 02 (M1023) Other Diagnosis Urinary tract infection, site […]<\/p>\n","protected":false},"author":4,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[10083,1797,1799],"tags":[10082],"class_list":["post-117883","post","type-post","status-publish","format-standard","hentry","category-comprehensive-soap-note","category-soap-note","category-soap-note-assignment-writing-help","tag-patient-is-a-82-years-old-hispanic"],"_links":{"self":[{"href":"https:\/\/www.colapapers.com\/assessments\/wp-json\/wp\/v2\/posts\/117883","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.colapapers.com\/assessments\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.colapapers.com\/assessments\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/assessments\/wp-json\/wp\/v2\/users\/4"}],"replies":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/assessments\/wp-json\/wp\/v2\/comments?post=117883"}],"version-history":[{"count":0,"href":"https:\/\/www.colapapers.com\/assessments\/wp-json\/wp\/v2\/posts\/117883\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.colapapers.com\/assessments\/wp-json\/wp\/v2\/media?parent=117883"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.colapapers.com\/assessments\/wp-json\/wp\/v2\/categories?post=117883"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.colapapers.com\/assessments\/wp-json\/wp\/v2\/tags?post=117883"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}