Posted: March 30th, 2022

Sue is a 68-year-old healthy woman soap note

Assignment: Assessing, Diagnosing, and Treating Musculoskeletal and Neurologic Disorders
Consider the example of Sue from the case study in Chapter 13 of your textbook:
Sue is a 68-year-old healthy woman with no significant medical history. She is in the office today with complaint of intractable nausea and vomiting for the past 5 weeks with an 11-pound weight loss. On review of systems she also has noted a dull, persistent headache, difficulty with concentration, and some blurred vision.
(Kennedy-Malone et al., 2019, p. 359)

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Sue also has a notable family history of diabetes and heart attack. How would you, as an advanced practice nurse, assess, diagnose, and treat Sue? What specific considerations related to the older adult population would you need to consider? Keep these thoughts in mind as you examine this week’s case study.
Reference:
Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. G. (2019). Advanced practice nursing in the care of older adults (2nd ed., p. 359). F. A. Davis.
To prepare:
• Review the case study provided by your Instructor.
• Reflect on the patient’s symptoms and aspects of disorders that may be present.
• Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the case.
• Access the Focused SOAP Note Template in this week’s Resources.
The Assignment:
Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:
• Subjective: What was the patient’s 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®, and consider alternative drugs if appropriate. Provide a review of systems.
• Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results?
• 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.
• 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.
• 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.
By Day 7
Submit your Assignment.

Focused SOAP Note

Patient Information:
M, 66, M, Hispanic
S (subjective)
CC (chief complaint): History of uncontrolled hypertension.
HPI (history of present illness): 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’s neurologic deficits and glucose levels. The squad team then notified the receiving hospital of a possible stroke patient. Lucinda, his wife, 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.
Current Medications:
Tenormin (atenolol) 25-50 mg/day PO to treat hypertension
Sulfonylureas 2.5/250 mg twice daily with meals to treat diabetes
Allergies: No known food and drug allergies.
PMHx: Hypertension and diabetes.

Soc and Substance Hx: Mario leads a sedentary lifestyle that had contributed to his excess weight. Mario is a smoker, usually smoking about a pack and a half each day. He takes alcohol occasionally.
Fam Hx: Mario’s parents passed away from myocardial infarctions when they were in their late 60s. His children are healthy without significant medical history. His two sisters suffer from hypertension while his only brother is diabetic.
Surgical Hx: Splenectomy at 38 years.
Mental Hx: Mario has a history of depression after his retirement one year ago. He was treated successfully. He has no history of suicidal ideation or self-harm tendencies.
Violence Hx: Mario lives peacefully with the neighbors with no incidences of sexual or physical violence.
Reproductive Hx: Mario has two daughters. He is sexually active with his wife. No history of sexual dysfunction. He practices vaginal sex without history of oral sex.
ROS (review of symptoms):
GENERAL: No unintentional fever, chills, fatigue, or body weight changes.
HEENT:
• Eyes: Difficulty in seeing. He uses eye glasses due to a history of shortsightedness.
• Ears, Nose, Throat: No hearing difficulty, runny nose, or sore throat.
SKIN: No skin lesions or rashes.
CARDIOVASCULAR: The patient has a history of chest pains and pressure.
RESPIRATORY: Contracted Covid-19 last year June. Since his discharged he has no incidence of shortness of breath or cough.
GASTROINTESTINAL: No history of diarrhea, vomiting, or nausea. Has normal bowel movement and no pain.
GENITOURINARY: No history of burning on urination.
NEUROLOGICAL: The patient feels dizzy, loss of balance, and experiences numbness and mild headache. No change in bowel movement. He has a drooping face and slurred speech.
MUSCULOSKELETAL: No pain or malfunction of the muscles or joint.
HEMATOLOGIC: No history of bleeding or anemia.
LYMPHATICS: Splenectomy at 38 years.
PSYCHIATRIC: The patient has a history of depression after retirement.
ENDOCRINOLOGIC: No history of sweating since recovering from Covid-19.
REPRODUCTIVE: He is sexually active but past the child-bearing age.
ALLERGIES: No known food or cold allergies.
O (objective)
Physical exam:
Vital signs: 97.8 F, 124/89 mmHg, 18, 72/100, 5’5” inches, 255 pounds, BMI 42.43
General: A&O *3 NAD. Dressed appropriately for the clinic appointment.
HEENT: Diffuse involvement of his scalp and plaque. Facial drop.
Chest/Lungs: Chest pain and dyspnea.
Heart/Peripheral Vascular: Leg weakness and numbness, and cold feet.
Abdomen: No organomegaly or rebound.
Genital/Rectal: Deferred.
Musculoskeletal: Symmetric muscle development but complains of weakness.
Neurological: headache, nausea, and seizures.
Skin: No hemorrhage.
Assessment
Irregular heart rhythm
Elevated Systolic values

Chest pain
Nausea

Diagnostic Tests:
CT scan to check for brain damage or bleeding.
MRI to diagnose stroke and check for damages in the brain or tissues.
ECG to determine heart disease triggering stroke such as Atrial Fibrillation or MI.
CBC and coagulation profile to assess for thrombocytopenia before recommending antithrombotic therapy.
Diagnostic Results
CT scan shows a diagnosis of stroke. No bleeding or ischemia.
A (assessment)
Differential diagnoses:
Stroke
Stroke or cerebrovascular accident or CVA involves a loss of blood supply in one part of the brain causing massive damage (Campbell et al., 2019). It is a medical emergency that is characterized by difficulty in walking, slurred speech, numbness, and dizziness (Campbell et al., 2019). Treatment such as clot buster is effective in reducing brain damage.
Brain Tumor
Brain tumor involves the growth of abnormal cells in the brain. Some of the risk factors include genetic mutations or exposure to radiation (Seetha & Raja, 2018). A brain tumor can cut short the supply of blood in the brain. Individuals may slowly develop symptoms related to speech over months such as slurred speech.
Hypertensive Encephalopathy
The condition occurs due to brain dysfunction due to relatively high blood pressure (Miller et al., 2018). Some of the symptoms may include headache, vomiting, confusion, and trouble balancing.
Traumatic Brain Injury (Epidural/Subdural Hemorrhage)
The condition involves a sudden injury that causes damage to the brain (Campbell et al., 2019). It occurs when the skull is under impact from a blunt object or due to a fall.
P (plan)
The patient and the wife should be educated about stroke, the risk factors, diagnostic tests, and appropriate treatment. The discussion with the wife should include the symptom and the risk factors (Morin et al., 2021). For instance, brain tumor or impact on the skull. Other risk factors include hypertension, diabetes, smoking, and a sedentary lifestyle.
It is recommended that the patient should change lifestyle and start exercising and reducing the weight. The patient should be considerate of the diet by reducing the amount of salt and fats in the food.
The patient will require medication to reduce the extent of brain damage. A clot buster is essential to reduce the damage. A referral to a physical therapist, occupational therapist, and speech therapist is essential to restore the functioning of the body parts (Morin et al., 2021). Failure of therapeutic interventions can undermine the mobility of a patient.
Reflection
The case study shows that non-adherence to hypertension medication can increase the risk of stroke. Educating patients about adherence is essential for recovery. Practitioners should follow up to ensure appropriate adherence. Immediate response is essential to reduce the extent of the damage.
The patient is at risk of stroke due to contributing factors such as hypertension, diabetes, smoking, and a sedentary lifestyle. The patient should review the lifestyle to promote recovery and reduce reoccurrence.

References
Campbell, B. C., De Silva, D. A., Macleod, M. R., Coutts, S. B., Schwamm, L. H., Davis, S. M., & Donnan, G. A. (2019). Ischaemic stroke. Nature Reviews Disease Primers, 5(1), 1-22.
Miller, J. B., Suchdev, K., Jayaprakash, N., Hrabec, D., Sood, A., Sharma, S., & Levy, P. D. (2018). New developments in hypertensive encephalopathy. Current hypertension reports, 20(2), 1-7.
Morin, D., Rémillard, S., Salerno, A., & Michel, P. (2021). Stroke patient education: scientific evidence, practical application. Therapeutische Umschau. Revue Therapeutique, 78(6), 249-258.
Seetha, J., & Raja, S. S. (2018). Brain tumor classification using convolutional neural networks. Biomedical & Pharmacology Journal, 11(3), 1457.

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