Posted: October 3rd, 2022

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

Task: Assessing, Diagnosing, and Treating Musculoskeletal and Neurologic Problems
Think about the instance of Sue from the case examine in Chapter 13 of your textbook:
Sue is a 68-year-old healthy woman with no important medical historical past. She is within the workplace right now with grievance of intractable nausea and vomiting for the previous 5 weeks with an 11-pound weight reduction. On assessment of programs she additionally has famous a boring, persistent headache, issue with focus, and a few blurred imaginative and prescient.
(Kennedy-Malone et al., 2019, p. 359)

Picture Credit score: [Blend Images/Ariel Skelley]/[Blend Images]/Getty Pictures
Sue additionally has a notable household historical past of diabetes and coronary heart assault. How would you, as a complicated follow nurse, assess, diagnose, and deal with Sue? What particular issues associated to the older grownup inhabitants would you might want to take into account? Hold these ideas in thoughts as you look at this week’s case examine.
Reference:
Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. G. (2019). Superior follow nursing within the care of older adults (2nd ed., p. 359). F. A. Davis.
To arrange:
• Assessment the case examine supplied by your Teacher.
• Replicate on the affected person’s signs and elements of problems that could be current.
• Think about the way you may assess, carry out diagnostic exams, and suggest drugs to deal with sufferers presenting with the signs within the case.
• Entry the Targeted SOAP Note Template on this week’s Assets.
The Task:
Full the Targeted SOAP Note Template supplied for the affected person within the case examine. Remember to handle 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 record of prescription and over-the-counter medication the affected person is at the moment taking. Examine this record 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 note from the bodily Assessment? What had been the lab, imaging, or useful assessments outcomes?
• Assessment: Present a minimal of three differential diagnoses. Record them from prime precedence to least precedence. Examine the diagnostic standards for every, and clarify what guidelines every differential in or out. Clarify you important pondering course of that led you to the first prognosis you chose. Embody pertinent positives and pertinent negatives for the particular affected person case.
• Plan: Present a detailed remedy plan for the affected person that addresses every prognosis, as relevant. Embody documentation of diagnostic research that shall be obtained, referrals to different health-care suppliers, therapeutic interventions, schooling, 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, taking into account affected person elements, previous medical historical past (PMH), and different threat elements. Lastly, embrace a reflection assertion on the case that describes insights or classes realized.
• Present at the very least three evidence-based peer-reviewed journal articles or evidenced-based tips, which relate to this case to help your diagnostics and differentials diagnoses. Be certain they’re present (not more than 5 years previous) and help the remedy plan in following present requirements of care. Observe APA seventh version formatting.
By Day 7
Submit your Task.

Targeted SOAP Note

Affected person Info:
M, 66, M, Hispanic
S (subjective)
CC (chief grievance): Historical past of uncontrolled hypertension.
HPI (historical past of current sickness): Mario is a 66-year-old Hispanic male who presents to the emergency room at his native hospital with acute aphasia, proper facial droop, and right-sided weak spot. The sudden onset of signs occurred on the publish workplace the place he works half time. Certainly one of his co-workers known as 911. On the way in which to the hospital, the superior squad workforce evaluated Mario’s neurologic deficits and glucose ranges. The squad workforce then notified the receiving hospital of a doable stroke affected person. Lucinda, his spouse, tells the nurse practitioner that Mario has a historical past of uncontrolled hypertension (and he was usually non-compliant together with his anti-hypertensive drugs). His current prognosis of diabetes additionally was famous, in addition to the oral hypoglycemic brokers he was taking.
Present Medicines:
Tenormin (atenolol) 25-50 mg/day PO to deal with hypertension
Sulfonylureas 2.5/250 mg twice day by day with meals to deal with diabetes
Allergic reactions: No recognized meals and drug allergic reactions.
PMHx: Hypertension and diabetes.

Soc and Substance Hx: Mario leads a sedentary way of life that had contributed to his extra weight. Mario is a smoker, often smoking about a pack and a half every day. He takes alcohol often.
Fam Hx: Mario’s dad and mom handed away from myocardial infarctions once they had been of their late 60s. His kids are healthy with out important medical historical past. His two sisters undergo from hypertension whereas his solely brother is diabetic.
Surgical Hx: Splenectomy at 38 years.
Psychological Hx: Mario has a historical past of melancholy after his retirement one yr in the past. He was handled efficiently. He has no historical past of suicidal ideation or self-harm tendencies.
Violence Hx: Mario lives peacefully with the neighbors with no incidences of sexual or bodily violence.
Reproductive Hx: Mario has two daughters. He is sexually lively together with his spouse. No historical past of sexual dysfunction. He practices vaginal intercourse with out historical past of oral intercourse.
ROS (assessment of signs):
GENERAL: No unintentional fever, chills, fatigue, or physique weight modifications.
HEENT:
• Eyes: Problem in seeing. He makes use of eye glasses as a consequence of a historical past of shortsightedness.
• Ears, Nostril, Throat: No listening to issue, runny nostril, or sore throat.
SKIN: No pores and skin lesions or rashes.
CARDIOVASCULAR: The affected person has a historical past of chest pains and stress.
RESPIRATORY: Contracted Covid-19 final yr June. Since his discharged he has no incidence of shortness of breath or cough.
GASTROINTESTINAL: No historical past of diarrhea, vomiting, or nausea. Has regular bowel motion and no ache.
GENITOURINARY: No historical past of burning on urination.
NEUROLOGICAL: The affected person feels dizzy, lack of stability, and experiences numbness and gentle headache. No change in bowel motion. He has a drooping face and slurred speech.
MUSCULOSKELETAL: No ache or malfunction of the muscular tissues or joint.
HEMATOLOGIC: No historical past of bleeding or anemia.
LYMPHATICS: Splenectomy at 38 years.
PSYCHIATRIC: The affected person has a historical past of melancholy after retirement.
ENDOCRINOLOGIC: No historical past of sweating since recovering from Covid-19.
REPRODUCTIVE: He is sexually lively however previous the child-bearing age.
ALLERGIES: No recognized meals or chilly allergic reactions.
O (goal)
Bodily examination:
Very important indicators: 97.eight F, 124/89 mmHg, 18, 72/100, 5’5” inches, 255 kilos, BMI 42.43
Basic: A&O *three NAD. Dressed appropriately for the clinic appointment.
HEENT: Diffuse involvement of his scalp and plaque. Facial drop.
Chest/Lungs: Chest ache and dyspnea.
Coronary heart/Peripheral Vascular: Leg weak spot and numbness, and chilly toes.
Stomach: No organomegaly or rebound.
Genital/Rectal: Deferred.
Musculoskeletal: Symmetric muscle improvement however complains of weak spot.
Neurological: headache, nausea, and seizures.
Pores and skin: No hemorrhage.
Assessment
Irregular coronary heart rhythm
Elevated Systolic values

Chest ache
Nausea

Diagnostic Assessments:
CT scan to test for mind injury or bleeding.
MRI to diagnose stroke and test for damages within the mind or tissues.
ECG to find out coronary heart illness triggering stroke reminiscent of Atrial Fibrillation or MI.
CBC and coagulation profile to evaluate for thrombocytopenia earlier than recommending antithrombotic remedy.
Diagnostic Outcomes
CT scan reveals a prognosis of stroke. No bleeding or ischemia.
A (Assessment)
Differential diagnoses:
Stroke
Stroke or cerebrovascular accident or CVA entails a lack of blood provide in a single a part of the mind inflicting huge injury (Campbell et al., 2019). It is a medical emergency that is characterised by issue in strolling, slurred speech, numbness, and dizziness (Campbell et al., 2019). Therapy reminiscent of clot buster is efficient in lowering mind injury.
Mind Tumor
Mind tumor entails the expansion of irregular cells within the mind. A number of the threat elements embrace genetic mutations or publicity to radiation (Seetha & Raja, 2018). A mind tumor can lower quick the availability of blood within the mind. People could slowly develop signs associated to speech over months reminiscent of slurred speech.
Hypertensive Encephalopathy
The situation happens as a consequence of mind dysfunction as a consequence of comparatively hypertension (Miller et al., 2018). A number of the signs could embrace headache, vomiting, confusion, and hassle balancing.
Traumatic Mind Damage (Epidural/Subdural Hemorrhage)
The situation entails a sudden damage that causes injury to the mind (Campbell et al., 2019). It happens when the cranium is underneath influence from a blunt object or as a consequence of a fall.
P (plan)
The affected person and the spouse needs to be educated about stroke, the danger elements, diagnostic exams, and applicable remedy. The dialogue with the spouse ought to embrace the symptom and the danger elements (Morin et al., 2021). As an example, mind tumor or influence on the cranium. Different threat elements embrace hypertension, diabetes, smoking, and a sedentary way of life.
It is really useful that the affected person ought to change way of life and begin exercising and lowering the burden. The affected person needs to be thoughtful of the weight loss plan by lowering the quantity of salt and fat within the meals.
The affected person would require remedy to scale back the extent of mind injury. A clot buster is important to scale back the injury. A referral to a bodily therapist, occupational therapist, and speech therapist is important to revive the functioning of the physique components (Morin et al., 2021). Failure of therapeutic interventions can undermine the mobility of a affected person.
Reflection
The case examine reveals that non-adherence to hypertension remedy can enhance the danger of stroke. Educating sufferers about adherence is important for restoration. Practitioners ought to comply with up to make sure applicable adherence. Speedy response is important to scale back the extent of the injury.
The affected person is liable to stroke as a consequence of contributing elements reminiscent of hypertension, diabetes, smoking, and a sedentary way of life. The affected person ought to assessment the approach to life to advertise restoration and scale back 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 Critiques Illness Primers, 5(1), 1-22.
Miller, J. B., Suchdev, Okay., Jayaprakash, N., Hrabec, D., Sood, A., Sharma, S., & Levy, P. D. (2018). New developments in hypertensive encephalopathy. Present hypertension experiences, 20(2), 1-7.
Morin, D., Rémillard, S., Salerno, A., & Michel, P. (2021). Stroke affected person schooling: scientific proof, sensible software. Therapeutische Umschau. Revue Therapeutique, 78(6), 249-258.
Seetha, J., & Raja, S. S. (2018). Mind tumor classification utilizing convolutional neural networks. Biomedical & Pharmacology Journal, 11(three), 1457.

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