Focused SOAP Note Assignment Sample

Assignment: Assessing, Diagnosing, and Treating Endocrine, Metabolic, and Dietary Problems
Like many problems affecting different programs, these associated to endocrine, metabolic, and dietary considerations have particular issues for geriatric populations. Correct historical past taking of signs related to these problems is crucial for finishing an Assessment of the older grownup, since onset of signs (for instance, with some endocrine problems) might seem extra subtly than these in youthful sufferers. It can be tough to find out onset and severity of sickness in older adults.

Bear in mind particular issues for older adults as you full your case Assessment and SOAP be aware on endocrine, metabolic, and dietary problems.

Picture Credit score: [Mark Hatfield]/[iStock / Getty Images Plus]/Getty Photos

To organize:

Evaluate the case research supplied by your Teacher.
Replicate on the affected person’s signs and points of problems that could be current.
Contemplate the way you may assess, carry out diagnostic exams, and suggest medicines to deal with sufferers presenting with the signs within the case.
Entry the Focused SOAP Note Template on this week’s Sources.
The Assignment:

Full the Focused SOAP Note Template supplied for the affected person within the case research. You’ll want to tackle the next:

Subjective: What was the affected person’s subjective grievance? What particulars did the affected person present relating to their historical past of current sickness and private and medical historical past? Embody a listing of prescription and over-the-counter medication the affected person is at present taking. Examine this checklist to the American Geriatrics Society Beers Standards®, and take into account various medication if applicable. Present a assessment of programs.
Goal: What observations did you be aware from the bodily Assessment? What had been the lab, imaging, or purposeful assessments outcomes?
Assessment: Present a minimal of three differential diagnoses. Listing them from high precedence to least precedence. Examine the diagnostic standards for every, and clarify what guidelines every differential in or out. Clarify you important considering course of that led you to the first prognosis you chose. Embody pertinent positives and pertinent negatives for the precise affected person case.
Plan: Present an in depth remedy plan for the affected person that addresses every prognosis, as relevant. Embody documentation of diagnostic research that will probably be obtained, referrals to different health-care suppliers, therapeutic interventions, training, disposition of the affected person, caregiver help, and any deliberate follow-up visits. Present a dialogue of well being promotion and illness prevention for the affected person, making an allowance for affected person components, previous medical historical past (PMH), and different threat components. Lastly, embrace a mirrored image assertion on the case that describes insights or classes realized.
Present not less than three evidence-based peer-reviewed journal articles or evidenced-based pointers, which relate to this case to help your diagnostics and differentials diagnoses. Make certain they’re present (not more than 5 years outdated) and help the remedy plan in following present requirements of care. Observe APA seventh version formatting.

The 2 to select from
WEEK 9 CASES: CHOOSE ONE to your SOAP be aware.

Week 9 Case 1: Low Blood Sugar

HPI: Ms. Lewis is a 63-year-old feminine who comes into your workplace with considerations of low blood sugar within the morning, fasting. She experiences seeing blood sugar as little as 50 fasting within the mornings for the previous few weeks. She has a identified historical past of Diabetes, Hypertension, Hyperlipidemia, and Continual Osteoarthritis. She additionally experiences elevated blood pressures. Her blood strain at presentation is 165/90.

RESOURCE FOR THIS WEEK: Evaluate endocrine-related Proof Primarily based Observe Pointers.

Ms. Lewis is a 63 y/o feminine who’s alert awake oriented to time, place, scenario. She makes no uncommon motor actions and demonstrates no tics. She denies any visible or auditory hallucinations. She denies any suicidal ideas or ideations. She denies any falls, denies any ache.

(All different Evaluate of System and Bodily Examination findings are detrimental aside from said. Please doc detrimental findings as you’ll with an actual affected person as a substitute of writing ‘regular’ or ‘detrimental’)

Very important Indicators: BP 165/90, HR 89, RR 20, Temp 98.1 Weight:____BMI:___

PMH: Hypertension, Hyperlipidemia, Diabetes, Continual Osteoarthritis

Allergy symptoms: Penicillin, lisinopril: checklist reactions

Drugs:

Girls’s One A Day-Multivitamin each day

Chlorthalidone 25mg each day

Fish Oil 1 pill each day

Amlodipine 5mg p.o. each day

Atorvastatin 40mg p.o. at bedtime each day

Novolog 10 items with meals TID

Aspirin 81mg p.o. each day

Lantus 25 items Subcutaneous nightly

Ergocalciferol 50,000 items PO as soon as a month

Social Historical past: as said in Case Examine.

ROS: as said in Case research

Diagnostics/Assessments finished:

CXR- Final CXR confirmed no cardiopulmonary findings. Inside regular limits.
Fundamental Metabolic Panel and CBC as proven beneath.
Vitamin D Stage- as famous beneath in lab outcomes.
TEST

RESULT

REFERENCE RANGE

GLUCOSE

85

65-99

SODIUM

134

135-146

POTASSIUM

Four.2

three.5-5.three

CHLORIDE

104

98-110

CARBON DIOXIDE

29

19-30

CALCIUM

9.Zero

eight.6- 10.three

BUN

20

7-25

CREATININE

1.01

Zero.70-1.25

GLOMERULAR FILTRATION RATE (eGFR)

76

>or=60 mL/min/1.73m2

TEST

RESULT

REFERENCE RANGE

Vitamin D 1,25 OH

58

36-144

TEST

RESULT

REFERENCE RANGE

WBC

7.three

three.Four- 10.eight

RBC

Four.31

135-146

HEMOGLOBIN

14

13-17.2

HEMATOCRIT

42%

36-50

MCV

90

80-100

MCHC

34

32-36

PLATELET

272

150-400

(All different Evaluate of System and Bodily Examination findings are detrimental aside from said. Please describe what your detrimental ROS and PE findings can be somewhat than writing ‘detrimental” or “regular”)

CASE 2:

HPI: Ms. Juggenmeir is a 71-year-old Feminine who comes into your workplace with considerations of fatigue and dry pores and skin. She is a retired Banker. She is alert awake oriented to time, place, scenario, ambulatory, and lives by herself. She does report elevated fatigue regardless of how a lot sleep she will get. She can be involved that she might have to return off one in every of her meds as a result of her hair is thinning. She had labs finished and was knowledgeable they might assessment outcomes at this go to. Different pertinent diagnoses embrace Hypertension, Hyperlipidemia, and Vitamin D deficiency. She admits to not taking her vitamin D each day as prescribed.

RESOURCE FOR THIS WEEK: Evaluate Endocrine-related Proof Primarily based Observe Pointers.

Ms. Juggenmeir is a 71 y/o feminine who’s alert awake oriented to time, place, scenario. She makes no uncommon motor actions and demonstrates no tics. She denies any visible or auditory hallucinations. She denies any suicidal ideas or ideations. She denies any falls or ache.

(All different Evaluate of System and Bodily Examination findings are detrimental aside from said. Please doc detrimental findings as you’ll with an actual affected person as a substitute of writing ‘regular’ or ‘detrimental’)

Very important Indicators: BP 137/82, HR 89, RR 20, Temp 98.1 Weight:____BMI:___

PMH: Hypertension, Hyperlipidemia, Vitamin D deficiency

Allergy symptoms: I.V. Distinction, ACE Inhibitors – checklist reactions to every

Drugs:

Girls’s One A Day-Multivitamin each day

Chlorthalidone 25mg each day

Fish Oil 1 pill each day

Amlodipine 5mg p.o. each day

Losartan 100mg p.o. each day

Atorvastatin 40mg p.o. at bedtime each day

Aspirin 81mg p.o. each day

Ergocalciferol 50,000 items PO as soon as a month

Social Historical past: as said in Case Examine.

ROS: as said in Case research

Diagnostics/Assessments finished:

CXR- Final CXR confirmed no cardiopulmonary findings. WNL
TSH/Free T4, T3- as famous beneath in lab outcomes.
Fundamental Metabolic Panel and CBC as proven beneath.
Vitamin D Stage- as famous beneath in lab outcomes.
TEST

RESULT

REFERENCE RANGE

GLUCOSE

85

65-99

SODIUM

134

135-146

POTASSIUM

Four.2

three.5-5.three

CHLORIDE

104

98-110

CARBON DIOXIDE

29

19-30

CALCIUM

9.Zero

eight.6- 10.three

BUN

20

7-25

CREATININE

1.01

Zero.70-1.25

GLOMERULAR FILTRATION RATE (eGFR)

76

>or=60 mL/min/1.73m2

TEST

RESULT

REFERENCE RANGE

TSH

23

Zero.Four-Four.Zero

FREE T4

Zero.05

Zero.9-2.Four mcg/dl

T3

three.Zero

2.Zero-Four.Four ng/dl

Vitamin D 1,25 OH

14

36-144

TEST

RESULT

REFERENCE RANGE

WBC

7.three

three.Four- 10.eight

RBC

Four.31

135-146

HEMOGLOBIN

14

13-17.2

HEMATOCRIT

42%

36-50

MCV

90

80-100

MCHC

34

32-36

PLATELET

272

150-400

Sources that must be used

Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Endocrine, metabolic, and dietary problems. In Superior observe nursing within the care of older adults (2nd ed., pp. 361–406). F. A. Davis.

American Diabetes Affiliation. (2020). Glycemic targets: Requirements of medical care in diabetes—2020. Diabetes Care, 43(Suppl. 1), S66–S76. https://doi.org/10.2337/dc20-S006

Munshi, M., Nathan, D. M., Schmader, Okay. E., Mulder, J. E., & Givens, J. (2019). Remedy of sort 2 diabetes mellitus within the older affected person. UpToDate. Retrieved June eight, 2020, from https://www.uptodate.com/contents/treatment-of-type-2-diabetes-mellitus-in-the-older-patient

NIH Nationwide Institute on Growing old. (2017). Fundamentals of Alzheimer’s illness and dementia: What’s Alzheimer’s illness? [Multimedia file]. https://www.nia.nih.gov/well being/what-alzheimers-disease

Doc: Focused SOAP Note Template (Phrase Doc)

Required Media (click on to broaden/scale back)

Really helpful Media (click on to broaden/scale back)
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Sample reply: Focused SOAP Note

Affected person Data:
J, 71, F, Race
S (subjective)
CC (chief grievance): Fatigue, thinning hair, and dry pores and skin.
HPI (historical past of current sickness): Ms. Juggenmeir is a 71-year-old Feminine who comes into your workplace with considerations of fatigue and dry pores and skin. She is a retired Banker. She is alert awake oriented to time, place, scenario, ambulatory, and lives by herself. She does report elevated fatigue regardless of how a lot sleep she will get. She can be involved that she might have to return off one in every of her meds as a result of her hair is thinning. She had labs finished and was knowledgeable they might assessment outcomes at this go to. Different pertinent diagnoses embrace Hypertension, Hyperlipidemia, and Vitamin D deficiency. She admits to not taking her vitamin D each day as prescribed.
Present Drugs:
Girls’s One A Day-Multivitamin each day
Chlorthalidone 25mg each day
Fish Oil 1 pill each day
Amlodipine 5mg p.o. each day
Losartan 100mg p.o. each day
Atorvastatin 40mg p.o. at bedtime each day
Aspirin 81mg p.o. each day
Ergocalciferol 50,000 items PO as soon as a month
Allergy symptoms: I.V. Distinction, ACE Inhibitors reactions.
PMHx: Hypertension, Hyperlipidemia, Vitamin D deficiency.

Soc and Substance Hx: Retired banker who lives by herself.
Fam Hx: No important household historical past.
Surgical Hx: Prior surgical procedures.
Psychological Hx: No previous prognosis of psychological sickness.
Violence Hx: No historical past of violence.
Reproductive Hx: No important reproductive historical past.
ROS (assessment of signs):
GENERAL: No unintended weight reduction, acquire or fatigue.
HEENT:
• EyesNo visible loss or sclera.
• Ears, Nostril, Throat: No listening to loss, operating nostril or sore throat.
SKIN: No lesions or itching.
CARDIOVASCULAR: No chest pains or discomfort.
RESPIRATORY: No shortness of breath of sputum.
GASTROINTESTINAL: No nausea, diarrhea, vomiting or blood within the stool.
GENITOURINARY: No burning sensation on urination.
NEUROLOGICAL: No historical past numbness, headache, stroke, or malfunctioning nerves.
MUSCULOSKELETAL: No again or muscle ache.
HEMATOLOGIC: No bleeding or bruising.
LYMPHATICS: No historical past of splenectomy.
PSYCHIATRIC: No historical past of psychological sickness or anxiousness.
ENDOCRINOLOGIC: No sweating or experiences of polyuria or polydipsia.
REPRODUCTIVE: No latest being pregnant or menstrual cycle. Final menstrual interval is unknown.
ALLERGIES: No historical past of rhinitis or eczema.
O (goal)
Bodily examination:
Very important indicators: BP 137/82, HR 89, RR 20, Temp 98.1
Diagnostic exams:
CXR- Final CXR confirmed no cardiopulmonary findings. WNL
TSH/Free T4, T3- as famous beneath in lab outcomes.
Fundamental Metabolic Panel and CBC as proven beneath.
Vitamin D Stage- as famous beneath in lab outcomes.
Diagnostic outcomes:
Check Consequence Reference Vary
GLUCOSE 85 65-99
SODIUM 134 135-146
POTASSIUM Four.2 three.5-5.three
CHLORIDE 104 98-110
CARBON DIOXIDE 29 19-30
CALCIUM 9.Zero eight.6- 10.three BUN 20 7-25
CREATININE 1.01 Zero.70-1.25
GLOMERULAR FILTRATION RATE (eGFR) 76 >or=60 mL/min/1.73m2
TSH 23 Zero.Four-Four.Zero FREE T4 Zero.05 Zero.9-2.Four mcg/dl T3 three.Zero 2.Zero-Four.Four ng/dl
Vitamin D 1,25 OH 14 36-144
WBC 7.three three.Four- 10.eight RBC Four.31 135-146
HEMOGLOBIN 14 13-17.2
HEMATOCRIT 42% 36-50 MCV 90 80-100
MCHC 34 32-36
PLATELET 272 150-400
Ms. Juggenmeir is a 71 y/o feminine who’s alert awake oriented to time, place, scenario. She makes no uncommon motor actions and demonstrates no tics. She denies any visible or auditory hallucinations. She denies any suicidal ideas or ideations. She denies any falls or ache.
A (Assessment)
Differential diagnoses:
Alopecia
Alopecia is an autoimmune situation that causes the hair to begin thinning. The quantity of hair loss is completely different in numerous folks (Strazzulla et al., 2018). The situation could also be hereditary, hormonal disturbance, or childbirth sickness. The hair can develop again with the Helpance of immune-suppressing treatment (Strazzulla et al., 2018).
Hyponatremia
Hyponatremia is a situation that happens when the sodium ranges within the physique are too low. Low sodium ranges trigger the physique cells to begin swelling (George et al., 2018). The widespread causes of the situation embrace coronary heart failure, diarrhea, diuretic use, renal illness, or liver illness. The illness is life-threatening and applicable motion is required to counter the signs (George et al., 2018).
Autoimmune Thyroiditis
The situation happens when the immune system assaults the thyroid gland resulting in swelling. The swelling impacts the power to supply hormones as required (Koehler et al., 2019). The signs embrace fatigue, pale and dry pores and skin, unexplained weight acquire, reminiscence lapses, elevated sensitivity to chilly, and constipation (Koehler et al., 2019). Sufferers ought to get rapid care to keep away from deterioration and worse well being problems.
P (plan)
The affected person would require extra diagnostic exams to look at the immune system. A referral to a doctor for the FT3 check and T4 check is important to look at the severity of the situation (Kennedy-Malone et al., 2019). As an illustration, a rheumatologist successfully examines circumstances regarding autoimmune assaults.
The affected person would require immunotherapy medication akin to immunosuppressant medication. It is very important maintain the affected person to make sure their well being isn’t uncovered to infections attributable to suppressed immunity. A doctor ought to educate the affected person concerning the sickness and the suitable interventions (Koehler et al., 2019). The affected person needs to be below the watch of a doctor within the ward and be discharged after every week when the immune assault subsides. The affected person ought to take treatment and return to the clinic after two weeks. The autoimmune circumstances require applicable intervention. The affected person ought to proceed taking the present treatment.
The affected person ought to obtain data that vitamin D deficiency is likely one of the main causes of hair thinning (Koehler et al., 2019). Vitamin D is crucial in stimulating hair follicles. The deficiency causes alopecia which results in hair thinning in varied patches.
The remedy plan ought to embrace vitamin D dietary supplements. The dietary supplements will restore the hair and strengthen the bones. It’s important to droop Chlorthalidone because the situation reduces water and salt within the physique. The drug might be a contributing issue to circumstances akin to hyponatremia.
Affected person training ought to embrace offering data on the chance components akin to salt consumption (Munshi et al., 2019). The affected person ought to take lower than 2,300 milligrams (mg) each day. Eat wholesome meals akin to entire grains, fruits, and fish are essential. Taking meals with potassium is essential in reducing blood strain. The affected person ought to preserve an optimum physique weight peak ratio. Extra weight may cause diabetes or hypertension (American Diabetes Affiliation, 2020). The affected person ought to train recurrently to decrease the chance of weight problems, stress, and hypertension.
Reflection
I realized that the situation requires applicable interventions since it may be life-threatening. I realized that sufferers with varied autoimmune problems ought to get an applicable checkup to keep away from deterioration of the situation.
Well being promotion ought to embrace consuming a nutritious diet, lowering salt consumption, and exercising recurrently. The affected person ought to droop Chlorthalidone treatment since it may contribute to one of many circumstances.
Provision of care ought to respect the cultural background, age, and spiritual beliefs. The affected person requires ample care and checkup because the age might pose varied well being dangers.

References
American Diabetes Affiliation. (2020). Glycemic targets: Requirements of medical care in diabetes—2020. Diabetes Care, 43(Suppl. 1), S66–S76. https://doi.org/10.2337/dc20-S006
George, J. C., Zafar, W., Bucaloiu, I. D., & Chang, A. R. (2018). Danger components and outcomes of speedy correction of extreme hyponatremia. Scientific Journal of the American Society of Nephrology, 13(7), 984-992.
Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Endocrine, metabolic, and dietary problems. In Superior observe nursing within the care of older adults (2nd ed., pp. 361–406). F. A. Davis.
Koehler, V. F., Filmann, N., & Mann, W. A. (2019). Vitamin D standing and thyroid autoantibodies in autoimmune thyroiditis. Hormone and Metabolic Analysis, 51(12), 792-797.
Munshi, M., Nathan, D. M., Schmader, Okay. E., Mulder, J. E., & Givens, J. (2019). Remedy of sort 2 diabetes mellitus within the older affected person. UpToDate. Retrieved June eight, 2020, from https://www.uptodate.com/contents/treatment-of-type-2-diabetes-mellitus-in-the-older-patient
Strazzulla, L. C., Wang, E. H. C., Avila, L., Sicco, Okay. L., Brinster, N., Christiano, A. M., & Shapiro, J. (2018). Alopecia areata: illness traits, medical analysis, and new views on pathogenesis. Journal of the American Academy of Dermatology, 78(1), 1-12.