Health Promotion And Disease Prevention Essay Discussion Paper

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Health Promotion And Disease Prevention Essay Discussion Paper

Episodic/Focus Note Template

Patient Information:

Initials, Age, Sex, Race

CC (chief complaint) a BRIEF statement identifying why the patient is here in the patient’s own words (e.g., “headache,” NOT “bad headache for 3 days”).

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example:

Location: head Health Promotion And Disease Prevention Essay Discussion Paper

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

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Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs intolerance).

PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (i.e., previous and current use), any other pertinent data. Always add some health promo question here (e.g., whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system).

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat. Health Promotion And Disease Prevention Essay Discussion Paper

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES: No history of asthma, hives, eczema, or rhinitis.

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.).

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

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).

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 7^th edition formatting. Health Promotion And Disease Prevention Essay Discussion Paper

GIT-Focused SOAP Note

Patient Initials: H.A.

Age: 67 years

Gender: Male

Race: Caucasian

SUBJECTIVE

CC (Chief Complaint): Abdominal pain.

History of Present Illness (HPI): H.A. is a 67-year-old male who presents to the clinic with abdominal pain. He reports that he has been experiencing right and left lower quadrant pain for a duration that he can’t recall. He describes the pain as sharp, intermittent, and sudden. H.A. highlights that the pain worsens during quick movements such as twisting, does not radiate, and is relieved spontaneously. He rates the pain level as ten out of ten.

Current Medications:

Lisinopril 5mg OD for essemtial hypertemsion.

Glipizide 5mg OD for diabetes.

Metoprolol tartarate 25mg BD for hypertension.

Atorvastatin 10mg O.D. Nocte for hyperlipidemia.

Allergies: No known drug allergy. No known food allergy.

Past Medical History (PMH): H.A. has a history of colon cancer (9/14/2021), hyperlipidemia (6/16/2022), lung cancer (9/14/2021), bilateral cataracts (9/14/2021), diabetes (9/28/2021), obesity (9/14/2021), deep venous thrombosis (9/14/2021), hypertension (9/14/2021), benign prostate hyperplasia (9/14/2021), gastro-esophageal reflux disease (9/14/2021) and liver cancer (9/14/2021). H.A.’s immunization status is up to date. He received the Moderna vaccine for covid 19 on 9/17/2021.

Social History: H.A. is divorced with two children. He is retired and lives with his son. He has been a former tobacco smoker for 25 years and has never taken alcohol. He uses caffeine once in a while but does not like it. He has a pet dog who lives with him. He is heterosexual but is currently sexually inactive. He cannot fully care for himself; therefore, his son employs a caretaker to help H.A. perform his daily activities. The caretaker ensures H.A. exercises daily by taking walks around the neighborhood. H.A. has a Medicare insurance cover which he finds to be efficient.

Family History: H.A.’s children are alive and healthy. H.A.’s father died of malignant neoplastic disease while his mother was alive and suffering from malignant neoplastic disease, type 2 diabetes mellitus, hypertension, and hypercholesterolemia. H.A. is the last born of two children. His brother has prostate cancer.

ROS:

General: Denies chills, fever, headache, day sweats, fatigue, daytime sleepiness, weight loss, or weight gain.

HEENT/Neck: Denies difficulty swallowing and rhinorrhea. Denies double vision, itchy eyes, painful eyes, blurred vision, and visual loss. Denies changes in hearing, ear fullness, ear noises, ear discharge, and ear infection. Denies dry mouth, difficulty swallowing, oral lesions, gum bleeding, or nasal congestion.

Skin: Denies rashes and itching.

Cardiovascular: Denies chest pain, chest discomfort, or chest pressure. Denies dyspnea, leg edema, palpitations, arrhythmias, or orthopnea.

Respiratory: Denies cough, wheezing, choking when swallowing, chest pains, shortness of breath, holding breath during sleep, difficulty breathing, or sputum production.

Gastrointestinal: Reports abdominal pain. Denies vomiting, diarrhea, heartburn, nausea, choking during sleep, indigestion, loss of appetite, acid reflux, constipation, or difficulty swallowing.

Genitourinary: Denies painful urination, vaginal discharge, urinary incontinence, dribbling, decreased stream, frequent urination, and blood in the urine.

Neurological: Denies memory loss, headache, changes in memory, loss of consciousness, seizures, confusion, difficulty balancing, numbness, tingling sensation, spells of blindness, or dizziness.

Musculoskeletal: Denies muscle pain, back pain, stiffness, or joint pain.

Hematologic: Denies easy bruising, exposure to HIV, swollen glands, anemia, and bleeding problems.

Lymphatic: Denies enlarged lymph nodes or splenectomy.

Psychiatric: Denies history of anxiety, depression, stress, loss of interest, or insomnia.

Endocrinology: Denies sweating, cold intolerance, polyuria, heat intolerance, or polydipsia.

Allergies: Denies hives, rhinitis, eczema, or asthma. Health Promotion And Disease Prevention Essay Discussion Paper

OBJECTIVE

Physical Exam:

Vital signs: BP 148/84 mmHg, HR-102 bpm, SPO2- 96% on room air, Temp 98.3, RR-18bpm, Height- 160.02cm, Weight- 93kgs, BMI 36.3.

General: The patient is comfortable, cooperative, hygienic, and well dressed. He is obese.

Psychiatric: He is aware of context and oriented to time and place. His recent and remote memory is normal. He is alert and in a normal mood.

HEENT: Clear oronasophaynx, PERRLA, normocephalic and atraumatic head, no visual acuity issues.

Neck: Neck has a full range of motion in all directions, normal symmetry, normal length, and no palpable lymph nodes.

Respiratory: On palpation, no tenderness or palpable mass. On auscultation, normal breath sounds without wheezing or audible breath sounds. No chest deformities.

Heart/Peripheral Vascular: On palpation, normal heart size and normal heart location. On auscultation, normal heart rate, normal rhythm, and no murmurs. Normal extremities.

Abdomen: Normal and present bowel sounds. Murphy’s assessment reveals the absence of pain in the right upper quadrant (Mealie et al., 2021). A Psoas test indicates a positive result for lower abdominal pain. On palpation, ventral hernia. Visible epigastric pulsation. Abdominal scarring left lower quadrant and right lower quadrant. On visual inspection, asymmetrical.

Musculoskeletal: Symmetric muscle development. Muscle power of 5/5 on extremities. No deformities or swelling on joints.

Neurological: All cranial nerves and deep tendon reflexes are intact.

Genital/Rectal: This exam was not conducted.

Lymphatic: No swollen lymph nodes.

Skin: His skin tone is appropriate to his ethnicity.

Diagnostic results:

C.T. scan: A CT scan is recommended to ascertain the diagnosis of ventral hernia and assess the exact position. The patient is obese; therefore, his physique might make it difficult to perform a conclusive physical examination.

Pulmonary function tests: This test is recommended because H.A. has a history of smoking tobacco for 25 years and a history of lung cancer.

Complete blood count: A CBC is recommended to check leukocytosis with the left shift.

Urinalysis: Urinalysis is recommended to rule out genitourinary factors leading to groin pain. Health Promotion And Disease Prevention Essay Discussion Paper

Ultrasonography: This imaging is recommended to detect ascetic fluid and free peritoneal blood. Results showed the absence of free peritoneal blood and ascetic fluid.

Lactate level test: This test is recommended to assess perfusion and strangulation. Elevated lactate levels signify hypoperfusion.

Endoscopy: This test is recommended to rule out ulceration in the intestinal walls or blockade.

ASSESSMENT

Differential Diagnoses

Abdominal ventral hernia: Patients diagnosed with a ventral hernia usually complain of abdominal pain, fullness, or swelling (Smith & Parmely, 2022). H.A. complained of abdominal pain. A strangulated or incarcerated hernia can cause asymmetry, as seen in H.A.’s abdominal visual assessment, which reveals asymmetry. Obesity is a primary risk factor for abdominal hernia. H.A. has a BMI of 36.3, which signifies that he is obese. H.A. also has a history of hernia, which tend to relapse in some patients.

Abdominal aortic aneurysm: Patients diagnosed with abdominal aortic aneurysm usually complain of severe abdominal pain and the presence of a palpable mass. Men above 65 years old, hypertensives, and smokers are at a high risk of suffering from abdominal aortic aneurysms (Shaw et al., 2022). This is a differential diagnosis since H.A. is male, 67 years old, has a history of smoking, and is a known hypertensive.

Ascites: This condition is described by fluid accumulation in the abdominal cavity. Liver disease is a primary underlying factor of ascites (Chiejina et al., 2022). H.A. has a history of liver cancer which makes ascites a differential diagnosis. Patients diagnosed with ascites usually have a palpable mass and sometimes experience severe pain.

PLAN

Additional tests: I would have performed a stain of nodal tissue. Although the patient is not coughing, he has smoked for 25 years and is highly susceptible to T.B. or COPD.

Therapeutic interventions: The primary diagnosis is a ventral abdominal hernia. The patient is scheduled for a laparoscopic ventral hernia repair. Intravenous ceftriaxone and general anesthesia were administered before the procedure. The patient was discharged on amoxicillin. H.A. was prescribed oral tramadol for pain management.

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PRIME HOSPITAL

2020 MAIN STREET

Name: H.A. Sex: Male

Age: 67 Date: 29/7/2022

Amoxicillin 500mg TDS × 7/7

Tramadol 50mg B.D. × 1/12 (Dispense 60 tablets of 50mg tramadol tablets for pain management postoperative care)

Doctor’s signature: DR. T.T

Dispensed by: Health Promotion And Disease Prevention Essay Discussion Paper

Referral: A surgeon is consulted to determine if the hernia can be reduced, if there are comorbid risks for sedation, and assess of strangulated or incarcerated hernia. Looking at the patient’s history, there was a need to refer to an oncologist and gastroenterologist for further evaluation. The oncologist should rule out the presence of a malignancy. The patient is directed to a nutritionist to advise on the benefits and ways of losing weight through a healthy diet.

Follow-up: The follow-up is scheduled for three weeks after repair to observe the patient’s progress. The patient is advised to report to the hospital in case of severe pain, signs of wound infection, or any other concern.

Reflection: I learned that preoperative planning is crucial to determining the need for general anesthesia. The patient’s rights were respected, and he was informed o the benefits and risks of the surgical procedure. The patient was allowed to consent to his surgery. I agree with the patient’s management except for the duration of the prescribed tramadol. I would have prescribed the tramadol for three weeks since the patient is scheduled for a review in three weeks.

Health promotion and disease prevention: H.A. and his caretaker are advised to do strenuous activities that can increase intraabdominal pressure. They are advised against the patient lifting anything above 4.5kg in the first week after repair. The patient and his caregiver are trained on wound care, hygiene, and how to prevent wound contamination. They are advised to ensure the patient is compliant with his other medications. Health Promotion And Disease Prevention Essay Discussion Paper

References

Chiejina M, Kudaravalli P, Samant H. Ascites. [Updated 2022 May 8]. In: StatPearls [Internet]. Treasure Island (F.L.): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470482/

Mealie CA, Ali R, Manthey DE. Abdominal Exam. [Updated 2021 Oct 15]. In: StatPearls [Internet]. Treasure Island (F.L.): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459220/

Shaw PM, Loree J, Gibbons RC. Abdominal Aortic Aneurysm. [Updated 2022 May 8]. In: StatPearls [Internet]. Treasure Island (F.L.): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470237/

Smith J, Parmely JD. Ventral Hernia. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (F.L.): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499927/