Case Study For Focused Soap Note Discussion

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Case Study For Focused Soap Note Discussion

OBJECTIVE

VITAL SIGNS: BP: 167/88mmHg sitting R arm P: 74 bpm RR: 16b/min T: 98.1o F temporal artery SpO2: 94% at RA, Pain scale;7/10

Ht: 5 feet 1-inch Wt: 199.4 lbs with clothing on, BMI: 37.7

PHYSICAL EXAM:

General Survey: Patient is well-developed, healthy-appearing, and obese. Patient strains to ambulate with some facial distress. She is well-groomed and neat Case Study For Focused Soap Note Discussion.

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Head: Normocephalic and atraumatic.

Eyes: The conjunctiva and lids are on-injected and with no pallor or discharge. The cornea is grossly intact, no hemorrhage or exudates. Has non-icteric sclera, clear lens, and grossly intact peripheral vision. Pupils: PERRLA.

ENMT: Ears; bilaterally clear EACs, no lesions, hearing loss, and with clear TMs. Nose; clear nasal passages, symmetrical septum present, no sinus tenderness, nasal membranes not inflamed. Lips, teeth, and gums; normal dentition, no gingivitis, ulceration, or foul smell. Moist mucous membranes with normal tonsillar tissue size.

Neck: No masses, midline-positioned trachea, supple. Lymph nodes; axillary LAD, supraclavicular LAD, inguinal LAD, and cervical LAD. Non-tender normally-sized thyroid.

Respiratory: On examination, no dyspnea or respiratory effort. Percussion; no flatness, dullness, or hyper resonance. Auscultation; no crackles, wheezing, rales, or rhonchi. Normal vesicular breath sounds heard.

Cardiovascular: Apical impulse is normal, no murmurs, S1 and S2 heart sound heard, no gallops. No hyperdistention of the neck veins.

Musculoskeletal: Normal motor strength and tone. No muscular and bone tenderness, contractures, abnormalities, or malalignment. Exhibits limited ROM and strained ambulation. Extremities; no varicose veins, edema, palpable cord, or cyanosis.

Skin: Inspection and palpation; no ulcers, lesions, induration, abnormal nevi, jaundice, or nodule. Good turgor.

Back: Normal curvature as well as thoracolumbar appearance.

Neurologic: Station and gait are normal. Grossly intact cranial nerves, sensation, and monofilament test. DTRs 2+ bilaterally throughout. Coordination and cerebellum; finger-to-nose intact and resting tremor; a pill-rolling tremor noted in her left hand.

Psychiatric: Good insight and judgment. Normal affect and mood. The patient is alert and active. Oriented to place, time, and person. Both recent and remote memories are normal Case Study For Focused Soap Note Discussion.

ASSESSMENT

Differential Diagnoses:

  1. Bilateral knees osteoarthritis
  2. Age-related osteoporosis
  3. Postherpetic neuralgia

FINAL DX: Bilateral knees osteoarthritis

Its clinical manifestations can include pain, stiffness, and decreased range of motion in the affected joints. Some diagnostic tests that may be conducted to rule out the other diagnoses may include a physical examination, nerve conduction studies, electromyography, and imaging tests such as MRI or CT (Przybylski et al., 2021). Blanco experiences joint pain, muscle weakness, and difficulty walking. The postherpetic neuralgia may be considered an underlying condition as she was affected by shingles on her right upper back (Lee, 2021). However, it is not as painful and debilitating as her bilateral knee pain. Age-related osteoporosis is also ruled out since Maria does not present or have a history of pathological fractures (Lee, 2021)Case Study For Focused Soap Note Discussion.

PLAN

Therapeutic interventions for postherpetic neuralgia (PHN) and bilateral knee osteoarthritis (OA) include both pharmacological and non-pharmacological measures (Nishizawa et al., 2021). Pharmacological interventions for PHN typically involve using antidepressants, anticonvulsants, corticosteroids, and local anesthetics. Prescribe Medrol 4mg OD orally, topically apply 2mg of 1% diclofenac gel to the affected area 4 times a day, and capsaicin 0.025% topical cream for application to the affected area TDS (Iijima et al., 2018). The patient is to continue with the other currently prescribed medications. Non-pharmacological interventions for PHN and OA typically involve physical therapy, massage, exercise, and heat therapy. Physical exercise therapy is most effective in reducing pain and enhancing body/joint functionality.

When it comes to health education and disease prevention, there are a few key things to keep in mind for elderly individuals like Maria, who suffer from postherpetic neuralgia and bilateral knee osteoarthritis. Firstly, it is important to maintain a healthy lifestyle through regular exercise and a balanced diet to prevent further deterioration of their health (Przybylski et al., 2021). Secondly, it is important to seek medical attention if symptoms such as pain or tingling worsen, as treating the condition early can help to minimize ongoing damage and improve the overall prognosis)Case Study For Focused Soap Note Discussion.

-Finally, health promotion interventions can play a vital role in helping individuals like Maria stay as healthy and active as possible. Providing information on the various treatments and therapies available, as well as encouraging her to get involved in mainstream society, can go a long way in improving her quality of life (Iijima et al., 2018). Achieving a normal BMI would be crucial in reducing the overall pressure on her knees, among other positive health benefits.

Referral- no referral was initiated.

F/U plan – Instructed Blanco to check up with a rheumatologist and not to hesitate to return to the office in case of unmanageable side effects or adverse drug reactions.

Reflection

Regarding the presenting patient’s chief complaint, I recommend similar physical examinations and diagnostic tests to elicit and rule out the differential diagnoses. Knee osteoarthritis presents with acute knee joint pain, notably when moving. As such, prescribing diclofenac gel and other pain relievers is in line with the guidelines for bilateral knee osteoarthritis management. I agree with the preceptor’s treatment plan to allow the patient to continue taking her current medication for the other underlying health complications Case Study For Focused Soap Note Discussion.

References

Iijima, H., Aoyama, T., Fukutani, N., Isho, T., Yamamoto, Y., Hiraoka, M., … & Matsuda, S. (2018). Psychological health is associated with knee pain and physical function in patients with knee osteoarthritis: an exploratory cross-sectional study. BMC psychology, 6(1), 1-10. https://link.springer.com/article/10.1186/s40359-018-0234-3

Lee, S. M. (2021). Diagnosis and Differential Diagnosis. In A Strategic Approach to Knee Arthritis Treatment (pp. 111-121). Springer, Singapore. https://link.springer.com/chapter/10.1007/978-981-16-4217-3_7

Nishizawa, K., Harato, K., Morishige, Y., Kobayashi, S., Niki, Y., & Nagura, T. (2021). Correlation between weight-bearing asymmetry and bone mineral density in patients with bilateral knee osteoarthritis. Journal of Orthopaedic Surgery and Research, 16(1), 1-5. https://josr-online.biomedcentral.com/articles/10.1186/s13018-021-02252-5

Przybylski, P., Skoczyński, M., Tarkowski, P., Tarczyńska, M., Gawęda, K., & Drop, A. (2021). Bilateral double-layered patella in a patient with advanced knee osteoarthritis. Folia Morphologica, 80(3), 735-738. https://journals.viamedica.pl/folia_morphologica/article/view/68846

Episodic/Focus Note Template.

O.

Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format (i.e., General: Head: EENT: etc.)Case Study For Focused Soap Note Discussion.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

A.

Differential Diagnoses (list a minimum of three differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient and any planned follow up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. Also included in this section is the reflection. The student should reflect on this case and discuss whether or not they agree with their preceptor’s treatment of the patient and why or why not. What did they learn from this case? What would they do differently?

Also include in your reflection, a discussion related to health promotion and disease prevention taking into consideration patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background).

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References

You are required to include at least three evidence-based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting Case Study For Focused Soap Note Discussion.

THIS CASE IS A REAL PATIENT, PLEASE READ THE PATIENT HISTORY CAREFULLY PATIENT CAME IN FOR “BILATERAL KNEE PAIN”
FOR ANY DIAGNOSTIC TEST PROVIDE EVIDENCE BASED WITH CITATION, THERAPEUTIC INTERVENTION, EDUCATION, MEDICATION MUST BE WRITTEN IN PRESCRIPTION FORMAT, PROVIDE HEALTH PROMOTION AND DISEASE PREVENTION, FOLLOW UP
READ THE TEMPLATE AND ANSWER EACH QUESTION APPROPRIATELY. PLEASE DO A GOOD JOB BECAUSE i HAVE NO TIME FOR REVISION.
i’M GOING TO UPLOAD THE TEMPLATE AND RUBRIC EVERYTHING IS THERE
THANK YOU