Targeted SOAP Observe
Scholar’s Identify
Institutional Affiliation
Course
Professor’s Identify
Date
Affected person Info:
J, 71, F, Race
S (subjective)
CC (chief criticism): Fatigue, thinning hair, and dry skin.
HPI (historical past of current sickness): Ms. Juggenmeir is a 71-year-old Feminine who comes into your workplace with considerations of fatigue and dry skin. She is a retired Banker. She is alert awake oriented to time, place, scenario, ambulatory, and lives by herself. She does report elevated fatigue irrespective of how a lot sleep she will get. She can be involved that she may have to return off one in all her meds as a result of her hair is thinning. She had labs accomplished and was knowledgeable they might Assessment outcomes at this go to. Different pertinent diagnoses embody Hypertension, Hyperlipidemia, and Vitamin D deficiency. She admits to not taking her vitamin D every day as prescribed.
Present Medicines:
Girls’s One A Day-Multivitamin every day
Chlorthalidone 25mg every day
Fish Oil 1 pill every day
Amlodipine 5mg p.o. every day
Losartan 100mg p.o. every day
Atorvastatin 40mg p.o. at bedtime every day
Aspirin 81mg p.o. every day
Ergocalciferol 50,000 models PO as soon as a month
Allergy symptoms: I.V. Distinction, ACE Inhibitors reactions.
PMHx: Hypertension, Hyperlipidemia, Vitamin D deficiency.
Soc and Substance Hx: Retired banker who lives by herself.
Fam Hx: No vital household historical past.
Surgical Hx: Prior surgical procedures.
Psychological Hx: No previous prognosis of psychological sickness.
Violence Hx: No historical past of violence.
Reproductive Hx: No vital reproductive historical past.
ROS (Assessment of signs):
GENERAL: No unintended weight reduction, acquire or fatigue.
HEENT:
• EyesNo visible loss or sclera.
• Ears, Nostril, Throat: No listening to loss, operating nostril or sore throat.
SKIN: No lesions or itching.
CARDIOVASCULAR: No chest pains or discomfort.
RESPIRATORY: No shortness of breath of sputum.
GASTROINTESTINAL: No nausea, diarrhea, vomiting or blood within the stool.
GENITOURINARY: No burning sensation on urination.
NEUROLOGICAL: No historical past numbness, headache, stroke, or malfunctioning nerves.
MUSCULOSKELETAL: No again or muscle ache.
HEMATOLOGIC: No bleeding or bruising.
LYMPHATICS: No historical past of splenectomy.
PSYCHIATRIC: No historical past of psychological sickness or nervousness.
ENDOCRINOLOGIC: No sweating or stories of polyuria or polydipsia.
REPRODUCTIVE: No current being pregnant or menstrual cycle. Final menstrual interval is unknown.
ALLERGIES: No historical past of rhinitis or eczema.
O (goal)
Bodily examination:
Very important indicators: BP 137/82, HR 89, RR 20, Temp 98.1
Diagnostic checks:
CXR- Final CXR confirmed no cardiopulmonary findings. WNL
TSH/Free T4, T3- as famous under in lab outcomes.
Fundamental Metabolic Panel and CBC as proven under.
Vitamin D Stage- as famous under in lab outcomes.
Diagnostic outcomes:
Take a look at End result Reference Vary
GLUCOSE 85 65-99
SODIUM 134 135-146
POTASSIUM Four.2 three.5-5.three
CHLORIDE 104 98-110
CARBON DIOXIDE 29 19-30
CALCIUM 9.Zero eight.6- 10.three BUN 20 7-25
CREATININE 1.01 Zero.70-1.25
GLOMERULAR FILTRATION RATE (eGFR) 76 >or=60 mL/min/1.73m2
TSH 23 Zero.Four-Four.Zero FREE T4 Zero.05 Zero.9-2.Four mcg/dl T3 three.Zero 2.Zero-Four.Four ng/dl
Vitamin D 1,25 OH 14 36-144
WBC 7.three three.Four- 10.eight RBC Four.31 135-146
HEMOGLOBIN 14 13-17.2
HEMATOCRIT 42% 36-50 MCV 90 80-100
MCHC 34 32-36
PLATELET 272 150-400
Ms. Juggenmeir is a 71 y/o feminine who’s alert awake oriented to time, place, scenario. She makes no uncommon motor actions and demonstrates no tics. She denies any visible or auditory hallucinations. She denies any suicidal ideas or ideations. She denies any falls or ache.
A (Assessment)
Differential diagnoses:
Alopecia
Alopecia is an autoimmune situation that causes the hair to begin thinning. The quantity of hair loss is totally different in several individuals (Strazzulla et al., 2018). The situation could also be hereditary, hormonal disturbance, or childbirth sickness. The hair can develop again with the Helpance of immune-suppressing treatment (Strazzulla et al., 2018).
Hyponatremia
Hyponatremia is a situation that happens when the sodium ranges within the physique are too low. Low sodium ranges trigger the physique cells to begin swelling (George et al., 2018). The frequent causes of the situation embody coronary heart failure, diarrhea, diuretic use, renal illness, or liver illness. The illness is life-threatening and applicable motion is required to counter the signs (George et al., 2018).
Autoimmune Thyroiditis
The situation happens when the immune system assaults the thyroid gland resulting in swelling. The swelling impacts the flexibility to provide hormones as required (Koehler et al., 2019). The signs embody fatigue, pale and dry skin, unexplained weight acquire, reminiscence lapses, elevated sensitivity to chilly, and constipation (Koehler et al., 2019). Sufferers ought to get instant care to keep away from deterioration and worse well being issues.
P (plan)
The affected person would require extra diagnostic checks to look at the immune system. A referral to a doctor for the FT3 check and T4 check is critical to look at the severity of the situation (Kennedy-Malone et al., 2019). As an example, a rheumatologist successfully examines situations regarding autoimmune assaults.
The affected person would require immunotherapy medicine comparable to immunosuppressant medicine. It is very important care for the affected person to make sure their well being will not be uncovered to infections as a result of suppressed immunity. A doctor ought to educate the affected person concerning the sickness and the suitable interventions (Koehler et al., 2019). The affected person must be below the watch of a doctor within the ward and be discharged after per week when the immune assault subsides. The affected person ought to take treatment and return to the clinic after two weeks. The autoimmune situations require applicable intervention. The affected person ought to proceed taking the present treatment.
The affected person ought to obtain info that vitamin D deficiency is among the main causes of hair thinning (Koehler et al., 2019). Vitamin D is important in stimulating hair follicles. The deficiency causes alopecia which results in hair thinning in numerous patches.
The therapy plan ought to embody vitamin D dietary supplements. The dietary supplements will restore the hair and strengthen the bones. It’s important to droop Chlorthalidone for the reason that situation reduces water and salt within the physique. The drug could possibly be a contributing issue to situations comparable to hyponatremia.
Affected person schooling ought to embody offering info on the chance components comparable to salt consumption (Munshi et al., 2019). The affected person ought to take lower than 2,300 milligrams (mg) every day. Eat wholesome meals comparable to complete grains, fruits, and fish are necessary. Taking meals with potassium is essential in reducing blood strain. The affected person ought to keep an optimum physique weight peak ratio. Extra weight could cause diabetes or hypertension (American Diabetes Affiliation, 2020). The affected person ought to train often to decrease the chance of weight problems, stress, and hypertension.
Reflection
I discovered that the situation requires applicable interventions since it may be life-threatening. I discovered that sufferers with numerous autoimmune issues ought to get an applicable checkup to keep away from deterioration of the situation.
Well being promotion ought to embody consuming a nutritious diet, lowering salt consumption, and exercising often. The affected person ought to droop Chlorthalidone treatment since it will possibly contribute to one of many situations.
Provision of care ought to respect the cultural background, age, and non secular beliefs. The affected person requires satisfactory care and checkup for the reason that age could pose numerous well being dangers.
References
American Diabetes Affiliation. (2020). Glycemic targets: Requirements of medical care in diabetes—2020. Diabetes Care, 43(Suppl. 1), S66–S76. https://doi.org/10.2337/dc20-S006
George, J. C., Zafar, W., Bucaloiu, I. D., & Chang, A. R. (2018). Danger components and outcomes of speedy correction of extreme hyponatremia. Medical Journal of the American Society of Nephrology, 13(7), 984-992.
Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Endocrine, metabolic, and dietary issues. In Superior follow nursing within the care of older adults (2nd ed., pp. 361–406). F. A. Davis.
Koehler, V. F., Filmann, N., & Mann, W. A. (2019). Vitamin D standing and thyroid autoantibodies in autoimmune thyroiditis. Hormone and Metabolic Analysis, 51(12), 792-797.
Munshi, M., Nathan, D. M., Schmader, Okay. E., Mulder, J. E., & Givens, J. (2019). Remedy of kind 2 diabetes mellitus within the older affected person. UpToDate. Retrieved June eight, 2020, from https://www.uptodate.com/contents/treatment-of-type-2-diabetes-mellitus-in-the-older-patient
Strazzulla, L. C., Wang, E. H. C., Avila, L., Sicco, Okay. L., Brinster, N., Christiano, A. M., & Shapiro, J. (2018). Alopecia areata: illness traits, medical analysis, and new views on pathogenesis. Journal of the American Academy of Dermatology, 78(1), 1-12.
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NRNP_6540_Week9_Assignment_Rubric
• Grid View
• Listing View
Glorious Good Honest Poor
Create documentation within the Targeted SOAP Observe Template concerning the affected person within the case research to which you have been assigned.
Within the Subjective part, present:
• Chief criticism
• Historical past of current sickness (HPI)
• Present medicines, checked towards Beers Standards
• Allergy symptoms
• Affected person medical historical past (PMHx)
• Overview of programs 9 (9%) – 10 (10%)
The response throughly and precisely describes the affected person’s subjective criticism, historical past of current sickness, present medicines, allergy symptoms, medical historical past, and Assessment of all programs that will inform a differential prognosis. A radical cross-check of medicines towards the Beers Standards has been accomplished and applicable various medicine really helpful if relevant. eight (eight%) – eight (eight%)
The response precisely describes the affected person’s subjective criticism, historical past of current sickness, present medicines, allergy symptoms, medical historical past, and Assessment of all programs that will inform a differential prognosis. A cross-check of medicines towards the Beers Standards has been accomplished and applicable various medicine really helpful if relevant. 7 (7%) – 7 (7%)
The response describes the affected person’s subjective criticism, historical past of current sickness, present medicines, allergy symptoms, medical historical past, and Assessment of all programs that will inform a differential prognosis, however is considerably obscure or incorporates minor innacuracies. A cross-check of medicines towards the Beers Standards has been accomplished however options could also be lacking. Zero (Zero%) – 6 (6%)
The response supplies an incomplete or inaccurate description of the affected person’s subjective criticism, historical past of current sickness, present medicines, allergy symptoms, medical historical past, and Assessment of all programs that will inform a differential prognosis. A cross-check of medicines towards the Beers Standards has not been accomplished. Or, subjective documentation is lacking.
