Posted: January 7th, 2023

Patient is a 82 years old hispanic

(M1021) Primary Diagnosis Code:
E11.9
03
(M1021) Primary Diagnosis
Type 2 diabetes mellitus without
complications
Severity:
(M1023) Other Diagnosis Code:
I10
03
(M1023) Other Diagnosis
Essential (primary) hypertension
Severity:
(M1023) Other Diagnosis Code:
E87.1
02
(M1023) Other Diagnosis
Hypo-osmolality and hyponatremia
Severity:
(M1023) Other Diagnosis Code:
N39.0
02
(M1023) Other Diagnosis
Urinary tract infection, site not specified
Severity:
(M1023) Other Diagnosis Code:
R11.2
02
(M1023) Other Diagnosis
Nausea with vomiting, unspecified
Severity:
(M1023) Other Diagnosis Code:
F32.A
02
(M1023) Other Diagnosis
Depression, unspecified
Severity:
(M1023) Other Diagnosis Code:
M54.59
02
(M1023) Other Diagnosis
Other low back pain
Severity:
(M1023) Other Diagnosis Code:
E78.5
02
(M1023) Other Diagnosis
Hyperlipidemia, unspecified
Severity:
(M1023) Other Diagnosis Code:
G90.09
02
(M1023) Other Diagnosis
Other idiopathic peripheral autonomic
neuropathy

1 – Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)
✓
✓
2 – Diabetes Mellitus (DM)
3 – None of the above

Patient is a 82 years old hispanic
female presented due to health/medical condition being unstable
and genarlized weakness, and recent discharge from hospital after a acute episode of UTI. Patient
requires partial Help with transfer.
Patient with multiple DX: DM II,
HTN, Depression, chronic low back pain, and other comorbidities.
Patient for Admission to HHCS based upon medical necessity and homebound status and based on the
assessment 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
improve with continued skilled SN teachings/Management/monitoring for optimal outcomes / goal attainment, and or the services are necessary to the establishment of a
safe 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

1. LISINOPRIL 20 MG ORAL TABLET
1 tab twice a day By mouth (PO) New cardiovascular agents
2. 12/19/2022 GABAPENTIN 300 MG ORAL CAPSULE
2 cap twice a day By mouth (PO) New anticonvulsants
3. 12/19/2022 SODIUM CHLORIDE 1 mg
1 tab day QHS By mouth (PO) New nutritional products
4. 12/19/2022 PREDNISONE4MG ORAL TABLET
1 tab x 5 days By mouth (PO) New glucocorticoids
5. 12/19/2022 CARVEDILOL 25 MG ORAL TABLET
1 tab twice a day By mouth (PO) New cardiovascular agents
6. 12/19/2022 METFORMIN 500 MG ORAL TABLET
2 tab twice a day By mouth (PO) New antidiabetic agents
7. 12/19/2022 HYDROXYZINE HYDROCHLORIDE 25 MG ORAL TABLET
1 tab as need By mouth (PO) New central nervous system agents
8. 12/19/2022 SIMVASTATIN 40 MG ORAL TABLET
1 tab day By mouth (PO) New antihyperlipidemic agents
9. 12/19/2022 novolog 70/30 flex pen
30 units AM subcutaneous (SQ) New insulin
10. 12/19/2022 novolog 70/30 flex pen
20 units PM subcutaneous (SQ) New insulin
11. 11/17/2022 Tylenol 8HRS ARTHRITIS 650MG
1-2TABS EVERY 6HRS AS NEEDED FOR PAIN By mouth (PO)
Heart Rate: Greater Than(>) 90 Less Than (<) 60
Temp: Greater Than (>) 100 Less Than (<) 95 Respirations: Greater Than (>) 24 Less Than (<) 12 Pain Level: Greater Than (>) 7 O2
Saturation: Less Than (<) 95 Systolic BP: Greater Than (>) 160 Less Than (<) 60
Diastolic BP: Greater Than (>) 90 Less Than (<) 60 Blood Sugar, Fasting: Greater Than (>) 200 Less Than (<) 60 Blood Sugar, Random:
Greater Than (>) 300 Less Than (<) 60

—
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 weeks. With this patient in mind, consider the following:
Subjective: What details did the patient provide regarding the personal and medical history?
Objective: 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.
Assessment: 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?
Plan: 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.
Reflection notes: What was your “aha” moment? What would you do differently in a similar patient Assessment?
—
Based on the provided information, the patient is an 82 year old Hispanic female with type 2 diabetes mellitus (DM II), hypertension (HTN), depression, chronic low back pain, and other comorbidities. The patient has recently had an acute episode of a urinary tract infection (UTI) and is experiencing genarlized weakness and instability in their health. They require partial Helpance with transfers and are being admitted to home health care services (HHCS) due to their medical necessity and homebound status. The patient’s condition is expected to improve with continued skilled nursing (SN) teachings, management, and monitoring for optimal outcomes and goal attainment, and the services are necessary to establish a safe and effective maintenance program and prevent exacerbation of their medical conditions. The patient lives with their daughter and will be receiving home care services including skilled nursing, home health aide (HHA), and physical therapy (PT) to help with strengthening. The patient is currently prescribed several medications including lisinopril, gabapentin, sodium chloride, prednisone, carvedilol, metformin, hydroxyzine hydrochloride, simvastatin, and insulin. They are also taking over-the-counter medications including acetaminophen and ibuprofen.

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