For this assignment, you are to complete a clinical case – narrated PowerPoint report that will follow the SOAP note example provided below. The case report will be based on the clinical case scenario list below.
You are to approach this clinical scenario as if it is a real patient in the clinical setting.
Instructions:
Step 1 – Read the assigned clinical scenario and using your clinical reasoning skills, decide on the diagnoses. This step informs your next steps.
Step 2 – Document the given information in the case scenario under the appropriate sections, headings, and subheadings of the SOAP note.
Step 3 – Document all the classic symptoms typically associated with the diagnoses in Step 1. This information may NOT be given in the scenario; you are to obtain this information from your textbooks. Include APA citations.
Example of Steps 1 – 3:
You decided on Angina after reading the clinical case scenario (Step 1)
Review of Symptoms (list of classic symptoms):
CV: sweating, squeezing, pressure, heaviness, tightening, burning across the chest starting behind the breastbone
GI: indigestion, heartburn, nausea, cramping
Pain: pain to the neck, jaw, arms, shoulders, throat, back, and teeth
Resp: shortness of breath
Musculo: weakness
Step 4 – Document the abnormal physical exam findings typically associated with the acute and chronic diagnoses decided on in Step 1. Again, this information may NOT be given. Cull this information from the textbooks. Include APA citations.
Example of Step 4:
You determined the patient has Angina in Step 1
Physical Examination (list of classic exam findings):
CV: RRR, murmur grade 1/4
Resp: diminished breath sounds left lower lobe
Step 5 – Document the diagnoses in the appropriate sections, including the ICD-10 codes, from Step 1. Include three differential diagnoses. Define each diagnosis and support each differential diagnosis with pertinent positives and negatives and what makes these choices plausible. This information may come from your textbooks. Remember to cite using APA.
Step 6 – Develop a treatment plan for the diagnoses. Only use National Clinical Guidelines to develop your treatment plans. This information will not come from your textbooks. Use your research skills to locate appropriate guidelines. The treatment plan must address the following:
a) Medications (include the dosage in mg/kg, frequency, route, and the number of days)
b) Laboratory tests ordered (include why ordered and what the results of the test may indicate)
c) Diagnostic tests ordered (include why ordered and what the results of the test may indicate)
d) Vaccines administered this visit & vaccine administration forms given,
e) Non-pharmacological treatments
f) Patient/Family education including preventive care
g) Anticipatory guidance for the visit (be sure to include exactly what you discussed during the visit; review Bright Futures website for this section)
h) Follow-up appointment with a detailed plan of f/u
CLINICAL CASE SCENARIOA 7-month-old male child arrives at your clinic for a well-child examination. His family recently emigrated to the United States from West Africa. His medical history is positive for abdominal pain and his family history is positive for maternal hypertension and paternal hyperlipidemia. The father smokes a pack a day and smokes in the home. The child’s sole source of nutrition is goat’s milk. He appears to be healthy on examination and his point-of-care complete blood count shows large red blood cells. Today, his vitals are as follows: weight 18.3 lbs, height 27.2 inches, BP 80/56, HR 100, RR 26, and Temperature is 98.6 F.
Diagnosis – Megaloblastic Anemia
As you develop your narrated PowerPoint, be sure to address the criteria discussed in the video above and the instructions listed below:
FOLLOW THE TEMPLATE BELOW for the Clinical Case Report – SOAP PowerPoint Assignment:
DO NOT INCLUDE THESE INSTRUCTIONS IN THE POWERPOINT. POINTS WILL BE DEDUCTED. REFER TO THE EXAMPLE CASE REPORT FOR GUIDANCE.
SUBJECTIVE (S): Describes what the patient reports about their condition.
For INITIAL visits gather the info below from the clinical scenario and the textbook. DO NOT COPY AND PASTE THE SCENARIO; EXTRACT THE RELEVANT INFORMATION.
Historian (required; unless the patient is 16 y/o and older): document name and relationship of guardian
Patient’s Initials + CC (Identification and Chief Complaint): E.g. 6-year-old female here for evaluation of a palmar rash
HPI (History of Present Illness): Remember OLD CAARTS (onset, location, duration, character, aggravating/alleviating factors, radiation, temporal association, severity) written in paragraph form
PMH (Past Medical History): List any past or present medical conditions, surgeries, or other medical interventions the patient has had. Specify what year they took place
MEDs: List prescription medications the patient is taking. Include dosage and frequency if known. Inquire and document any over-the-counter, herbal, or traditional remedies.
Allergies: List any allergies the patient has and indicate the reaction. e.g. Medications (tetracycline-> shortness of breath), foods, tape, iodine->rash
FH (Family History): List relevant health history of immediate family: grandparents, parents, siblings, or children. e.g. Inquire about any cardiovascular disease, HTN, DM, cancer, or any lung, liver, renal disease, etc…
SHx (Social history): document parent’s work (current), educational level, living situation (renting, homeless, owner), substance use/abuse (alcohol, tobacco, marijuana, illicit drugs), firearms in-home, relationship status (married, single, divorced, widowed), number of children in the home (in SF or abroad), how recently pt immigrated to the US and from what country of origin (if applicable), the gender of sexual partners, # of partners in last 6 mo, vaginal/anal/oral, protected/unprotected.
Patient Profile: Activities of Daily Living (age-appropriate): (include feeding, sleeping, bathing, dressing, chores, etc.), Changes in daycare/school/after-school care, Sports/physical activity, and Developmental History: (provide a history of development over the child’s lifespan. If a child is 1y/o or younger, provide birth history also)
HRB (Health-related behaviors):
ROS (Review of Systems): Asking about problems by organ system systematically from head-to-toe. Included classic associated symptoms (this includes pertinent negatives and positives).
OBJECTIVE: Physical findings you observe or find on the exam.
1. Age, gender, general appearance
2. Vitals – HR, BP, RR, Temp, BMI, Height & Percentile; Weight & Percentile, Include the Growth Chart
3. Physical Exam: note pertinent positives and negatives (refer to the textbook for classic findings related to present complaint and the diagnosis you believe the patient has)
4. Lab Section – what results do you have?
5. Studies/Radiology/Pap Results Section – what results do you have?
RISK FACTORS: List risk factors for the acute and chronic conditions
ASSESSMENT: What do you think is going on based on the clinical case scenario? This is based on the case. You are to list the acute diagnosis and three differential diagnoses, in order of what is likely, possible, and unlikely (include supporting information that helped you to arrive at these differentials). You must include the ICD-10 codes, the definition for the acute and differential diagnoses, and the pertinent positives and negatives of each diagnosis.
You are to also list any chronic conditions with the ICD-10 codes.
NATIONAL CLINICAL GUIDELINES: List the guidelines you will use to guide your treatment and management plan
TREATMENT & MANAGEMENT PLAN: Number problems (E.g. 1. HTN, 2. DM, 3. Knee sprain), use bullet points, and include A – F below for each diagnosis and G – H after you’ve addressed all conditions.
Example:
1. HTN
a) Vaccines administered this visit & vaccine administration forms given,
b) Medication-include dosage amounts and mg/kg for drug and number of days,
c) Laboratory tests ordered
d) Diagnostic tests ordered
e) Non-pharmaceutical treatments
f) Patient/Family education including preventive care
2. HLD
a) Vaccines administered this visit & vaccine administration forms given,
b) Medication-include dosage amounts and mg/kg for drug and number of days,
c) Laboratory tests ordered
d) Diagnostic tests ordered
e) Non-pharmaceutical treatments
f) Patient/Family education including preventive care
Also discussed:
g) Anticipatory guidance for next well-child visit (be sure to include exactly what you discussed during the visit; review Bright Futures website for this section)
Return to the clinic:
h) Follow-up appointment with a detailed plan for f/u and any referrals
Gout Jane Doe
NSG 6435
Faculty
Chief Complaint
M.C. is a 55 year old Caucasian male presenting with complaints of pain, with redness and
swelling in his right great toe.
HPI
Historian: (include this information for patients <16 y/o and older patients PRN)
Patient is an obese male who reports pain, redness and swelling in right great toe(location) which started 3 days ago(Onset) and has progressively gotten worse(duration). He describes the pain as a burning constant(character) pain irritated with any touch or friction(aggravating). He tried over the counter ibuprofen(alleviating) and states it did mildly help the with the pain. The pain does radiate to the entire foot(radiation) and he cannot bear weight. He rates the pain as a 10/10 on the pain scale(severity). He mentions that he does have daily ethanol ingestion and was recently started on chlorthalidone for hypertension (HTN), which he feels contributed to the flare(temporal).
Medical History
• Kidney stones in 2012
• HTN
• Obesity
• No Surgeries
Medication Lists
• Ibuprofen – 800mg- tid
• Chlorthalidone 25mg- daily
• No Known Allergies
Family Medical History Summary
Father- Died at 72yrs old- hypertension, heart disease, and renal failure.
Mother- Died at age 65 of breast Cancer.
Sister- Age 55- Alive and well – HTN
Paternal Grandfather- Unknown
Paternal Grandmother – Died at age 82yr- Heart Disease
Maternal Grandmother- Dies at 87yr- Stroke- HTN and Diabetes
Paternal Grandfather- Died at 62 yrs in a car accident
Social History
C.M – Is divorced and lives alone. He was married for 20 years and has 1 male child age 28yr. He works full-time as a manager of a local Tires Plus. He rents an apartment in the local town in which he works. He is in a monagomous relationship with a female partner for past 2 years.
C.M. does not smoke. He drinks 2-3 alcoholic drinks per day. He reports sleeping 5-6 hours daily, and exercises twice weekly. He drinks 2-3 caffeinated beverages per day and eats at a fast food restaurant 4-5 days a week. He does eat beef daily.
He does report a history of methamphetamine abuse from ages 20-22. He was admitted to a drug rehabilitation program and has been drug free for 30 years.
Patient Profile
Activities of Daily Living (age appropriate): independent
Safety Practices: 2 firearms in home secured in a gun closet
Changes in daycare/school/after-school care: (address if appropriate)
Developmental History: (provide a history of development over the child’s lifespan. If
child is 1y/o or younger, provide birth history also)
Review of Systems
• CONSTITUTIONAL: No night sweats. No fatigue, malaise, lethargy. No fever or chills.
• HEENT: Eyes: No visual changes. No eye pain. No eye discharge. ENT: No runny nose. No epistaxis, No sinus pain. No sore throat. No odynophagia. No ear pain. No congestion.
• BREASTS: No breast pain, soreness, lumps, or discharge.
• RESPIRATORY: No cough. No wheeze. No hemoptysis. No shortness of breath.
• CARDIOVASCULAR: No chest pains. No palpitations.
• GASTROINTESTINAL: No abdominal pain. No nausea or vomiting. No diarrhea or constipation. No hematemesis. No hematochezia. No melena. BM- daily
• GENITOURINARY: No urgency. No frequency. No dysuria. No hematuria. No obstructive symptoms. No discharge. No pain. No significant abnormal bleeding.
Review of Systems
MUSCULOSKELETAL: musculoskeletal pain in right foot and toe and joint swelling in right great toe for past 3 days. No prior history of gout, No arthritis. No surgery in foot or ankle or leg. Difficulty bearing weight on right foot. “Warmth, pain, swelling, and extreme tenderness in a joint, usually a big toe joint (Podagra) Red or purplish skin around the affected joint (in-text citation from textbook).”
NEUROLOGICAL: No confusion or weakness. No headache or neck pain. No syncope or seizure.
PSYCHIATRIC: He gets occasionally confused.
SKIN: No rashes. No lesions. No wounds.
ENDOCRINE: No unexplained weight loss. No polydipsia. No polyuria. No polyphagia.
HEMATOLOGIC: No anemia. No purpura. No petechiae. No prolonged or excessive bleeding.
ALLERGIC AND IMMUNOLOGIC: No pruritus. No swelling.
Physical Examination
• Vital signs – Temp 99.1, Pulse 100, respiration -24, BP-151/95.
• Swelling and erythema in right great toe. “Nodules
• Pain and tenderness to right toe and right foot with palpation
• 2+ edema to right foot
Physical Examination
• “Warmth, redness, swelling, and decreased range of motion of the affected joint or joints. The initial episode is usually monoarticular in men. The first metatarsophalangeal (MTP) joint is the initial one involved in approximately half the patients. Acute synovitis of the first MTP joint of the big toe is referred to as podagra. Other joints involved (in decreasing order of frequency) are insteps, heels, knees, wrists, fingers, and elbows. In his classic description of the onset of an acute flare (in-text citation).”
Labs/Diagnostic Exam Results
CBC – white blood count elevated at 12,000.
His pertinent laboratory values reveal a mild leukocytosis and increased erythrocyte sedimentation rate.
Serum uric acid (SUA) level is 11.6 mg/dL. His SCr and BUN are elevated.
A synovial fluid aspirate of the affected toe joint contains white blood cells and monosodium urate crystals, confirming the diagnosis of gout.
• Comprehensive Chemistry – LFT’S- elevated- AST- 48, ALT- 38 GFR-<90,
• Renal Ultrasound –mild hydronephrosis of the left kidney noted. No renal abscess noted. No calculi or scarring noted.
Risk Factors for Gout
• Male
• Diet – limit foods with high –purine content
• Alcohol
• Obesity
• Renal Failure- High Blood Pressure
• Medications- Chlorthalidone
Diagnosis and Differential Diagnosis
• Acute Diagnosis – Gout M10.9
Differential Diagnosis
1. Pseudogout M11.20
2. Cellulitis L03.90
3. Rheumatoid Arthritis M06.9
• Chronic Diagnosis
1. Hypertension 401.9
2. Obesity E66.9
Diagnosis and Differential Diagnosis
Acute Diagnosis – Gout M10.90
Include the Definition of Gout
Include Pertinent Positives &
Negatives
Diff Dx – Pseudogout M11.20
Include the Definition of Pseudogout
Include Pertinent Positives &
Negatives
Diagnosis and Differential Diagnosis
Diff Dx – Cellutitis L03.90
Include the Definition of Gout
Include Pertinent Positives &
Negatives
Diff Dx – Rheumatoid Arthritis M06.90
Include Definition of Pseudogout
Include Pertinent Positives &
Negatives
National Clinical Guidelines
Hainer, B., Matheson, E., & Wilkes, R. (2014, December 15). Diagnosis, Treatment, and Prevention of Gout. Retrieved September 03, 2020, from https://www.aafp.org/afp/2014/1215/p831.html
Armstrong, C. (2014, October 01). JNC8 Guidelines for the Management of Hypertension in Adults. Retrieved September 03, 2020, from https://www.aafp.org/afp/2014/1001/p503.html
Treatment of Gout
Gout
• a) Medication-include dosage amounts and mg/kg for drug and number of days, b) Laboratory tests ordered
c) Diagnostic tests ordered
d) Vaccines administered this visit & vaccine administration forms given,
e) Non-pharmaceutical treatments
f) Patient/Family education including preventive care
(Hainer, Matheson, & Wilkes, 2014)
F)Teaching/Health Promotion
• Educate patient and family that frequent post-treatment surveillance for recurrent infection until 4–6 weeks postpartum is recommended. Monthly
urinalysis for culture and sensitivity for 3 months, use of Macrobid as
suppressive therapy, and initiating prevention strategies will reduce the risk
of acute pyelonephritis recurrence.
• Educate patients on strategies for preventing acute gout flares including adequate fluid intake, avoidance of high –purine foods(e.g., beef, seafood,
coffee, tea, colas, alcohol) medications as directed to reduce uric acid concentrations.
Treatment of HTN
HTN
• a) Medication-include dosage amounts and mg/kg for drug and number of days, b) Laboratory tests ordered
c) Diagnostic tests ordered
d) Vaccines administered this visit & vaccine administration forms given,
e) Non-pharmaceutical treatments
f) Patient/Family education including preventive care
(Armstrong, 2014)
Follow-up
g) Anticipatory guidance for visit (be sure to include exactly what you discussed during visit; review
Bright Futures website for this section), and
h) Follow-up appointment with detailed plan of f/u
References continued
Hainer, B., Matheson, E., & Wilkes, R. (2014, December 15). Diagnosis, Treatment, and
Prevention of Gout. Retrieved September 03, 2020, from
https://www.aafp.org/afp/2014/1215/p831.html
McCance, K. & Huether, S. (2014). Pathophysiology: the biologic for disease in adults and children, (7th
ed), St. Louis: MO; Elsevier/Mosby.
MeeOnn, C. & Amir-Ansari, B. (2012). Disease profile: pyelonephritis. Journal of Renal Nursing,
4(3), 128-130.
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