In 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 evaluation?<\/p>\n
(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 assist 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
\n—
\nSubjective: The patient is a 82 year old Hispanic female who presented to the clinic with generalized weakness and an unstable health condition. She recently had an acute episode of a urinary tract infection and was discharged from the hospital. The patient requires partial assistance with transfers and lives with her daughter.
\nObjective: During the physical assessment, the patient was alert and oriented with clear speech. She had dry mucous membranes and a regular pulse and respiratory rate. The patient had stable vital signs and no distress. She had a history of Type 2 diabetes mellitus, hypertension, depression, chronic low back pain, and other comorbidities. The patient’s lower extremities had poor perfusion and she had multiple wounds on her feet. The patient also had a history of peripheral vascular disease or peripheral arterial disease.
\nAssessment: Based on the patient’s presentation and medical history, the following are the differential diagnoses, listed from highest priority to lowest priority:
\nPeripheral vascular disease or peripheral arterial disease (CPT code: 93922, ICD-10 code: I70.2)
\nDiabetes mellitus (CPT code: 250.00, ICD-10 code: E11.9)
\nNone of the above (CPT code: N\/A, ICD-10 code: N\/A)
\nThe primary diagnosis is Peripheral vascular disease or peripheral arterial disease due to the patient’s history of poor perfusion in her lower extremities and the presence of wounds on her feet.
\nPlan: The plan for diagnostics for the primary diagnosis includes referral for a vascular study and wound care management. The plan for treatment and management includes pharmacologic and non-pharmacologic interventions, such as aspirin and wound care dressings, as well as referral for physical therapy and home health care services to improve the patient’s strength and mobility. The patient will also receive education on how to manage her diabetes and hypertension, as well as follow-up with her primary care physician.
\nReflection notes: My “aha” moment during this patient evaluation was when I realized the potential impact of the patient’s comorbidities on her overall health and well-being. In a similar situation, I would be sure to thoroughly assess and address all of the patient’s medical conditions in order to provide the most comprehensive care possible.<\/p>\n","protected":false},"excerpt":{"rendered":"
In 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. To prepare: Review the Comprehensive SOAP Note Template. Select a patient who you saw at your practicum site during the last 5 […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[405,271],"tags":[418,149],"class_list":["post-881","post","type-post","status-publish","format-standard","hentry","category-soap-note-assignment-help","category-nursing-assignment-help","tag-comprehensive-soap-note","tag-nursing-essay-writers"],"_links":{"self":[{"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/posts\/881","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/comments?post=881"}],"version-history":[{"count":0,"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/posts\/881\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/media?parent=881"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/categories?post=881"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/tags?post=881"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}