Assignment 1: Practicum Week 7 SOAP Note
Select a geriatric patient that you examined during the last 4 weeks. The patient you select should be currently taking at least five prescription and/or over-the-counter drugs. With this patient in mind, address the following in a SOAP Note:
Subjective: What was the patients subjective complaint? What details did the patient provide regarding his or her personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the Beers Criteria and consider alternative drugs if appropriate.
Objective: What observations did you make during the physical assessment? What functional assessments were used?
Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from top priority to least priority.
Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management including alternative therapies? What is your care plan for the patient? How would you offer caregiver support?
Reflection notes: What would you do differently in a similar patient evaluation? How might you improve your assessment, diagnosis, and/or plan through interprofessional collaboration?
PLEASE USE THIS PATIENR CENARIO
HIEF COMPLAINT:
Visual changes.
HISTORY OF PRESENT ILLNESS:
This is a very pleasant 75-year-old Caucasian male with a past medical history significant for hypertension, atherosclerosis of the aorta, dyslipidemia, and Parkinson\’s disease. He reports that he awoke from a nap this afternoon around 3:30 or 4 and could not read the time on his digital clock. He said he could see the numbers and knew that they were numbers but could not read them. He also was unable to read words, although he was aware that he was looking at words. He says that he was supposed to drive to Annapolis but did not even try to drive because of the fact that he could not read anything, and he knew something was wrong. He said that he tried to make his cell phone work and could not figure out how to make it work and was also unable to get his computer to work. His daughter, Hilary, went to check on him and found that coffee had been spilled everywhere, and that he was talking and walking more slowly than usual. When I examined the patient, I showed him four numbers in a row, he was only able to see the two right numbers with either eye but was not able to see the two left numbers. However, when I told him that there were two numbers on the left he was able to force himself to look and was able to tell me what the numbers were. It was only one when I told him that there were four numbers rather than two that he was able to register that they were present and tell me what they were. He says that he has not had a headache, nausea, or vomiting, and he reports that he currently does not feel weak in any specific area, and there is no numbness anywhere; however, he did note some chest pressure, which was not radiating.
REVIEW OF SYSTEMS:
Other than as stated in the HPI, 10-point review of systems is negative.
(PLEASE WRITE OUT SYSTEM REVIEW IN DETAILS EVEN IF ITS NEGATIVE)
ALLERGIES:
PENICILLIN AND SELEGILINE HYDROCHLORIDE.
HOME MEDICATIONS:
1. Lovastatin 40 mg p.o. at bedtime.
2. Omeprazole 20 mg p.o. twice a day.
3. Finasteride 5 mg p.o. at bedtime.
4. Lamotrigine 200 mg p.o. q.a.m. and 100 mg p.o. q.p.m.
5. Losartan 25 mg p.o. twice a day.
6. Carbidopa/levodopa 25/100 mg at 8:00 a.m., noon, 4 p.m., and 8 p.m.
7. Terazosin 4 mg p.o. at bedtime.
PAST MEDICAL HISTORY:
Hypertension, atherosclerosis of aorta, GERD, diverticulosis of the colon, hemorrhoids, dyslipidemia, narcolepsy, Parkinson\’s disease, BPH, obstructive sleep apnea, depression, and sensorineural hearing loss.
PAST SURGICAL HISTORY:
Right inguinal hernia repair.
FAMILY HISTORY:
He denies any significant family medical history, and his mother lived to be 98.
SOCIAL HISTORY:
He denies history of tobacco, alcohol, or drug use.
PHYSICAL EXAMINATION:
VITAL SIGNS: Weight 74.6 kg, temperature 98, pulse 56, respiratory rate 18, blood pressure 168/80, and pulse ox 96% on room air.
GENERAL: Alert and oriented to person, place, time, and events in no acute distress.
HEENT: PERRLA, EOMI. Normal conjunctivae. Head normocephalic and atraumatic. Face symmetrical. No abrasions, ecchymoses, or lacerations. Throat: No erythema, no exudates. Mouth mucosal lining pink and moist without lesions. Tongue normal.
NECK: Supple and nontender. No thyromegaly. No masses and no carotid bruits.
RESPIRATORY: Lungs are clear to auscultation bilaterally.
CARDIOVASCULAR: Borderline bradycardic, regular rhythm, no murmurs, and no gallops.
GASTROINTESTINAL: Bowel sounds present. ABDOMEN: Soft, nontender, and nondistended. No masses palpated. No organomegaly.
GENITOURINARY: Kidneys bilateral, no tenderness.
LYMPH NODES: No lymphadenopathy in the cervical or axillary regions.
MUSCULOSKELETAL: 2/4 pulses all 4 extremities. No edema all 4 extremities.
INTEGUMENTARY: No rashes and no lesions.
NEUROLOGIC: Alert and oriented x4. Cranial nerves 2 through 12 grossly intact. The patient was able to draw a clock with noted some difficulty drawing the left side of the clock, so he did get all the numbers correct. He also was noted to have impairment in his ability to be aware of the left side of his visual field; however, with prompting to look at specific things, he was able to recognize it, which is an improvement per the patient compared to earlier in the day. 5/5 muscle strength in all 4 extremities. No sensation problems noted. The patient is noted to have tremors which are at baseline for the patient due to Parkinson\’s in his upper extremities. The patient is also right handed.
PSYCHIATRIC: Alert, appropriate, calm, and cooperative. No evidence of impaired judgment or impaired cognition.
RESULTS REVIEW:
CT of the head shows on initial read a 7-cm hypodensity in the right parietal, temporal, and occipital regions. Sodium 141, potassium 4.1, chloride 106, CO2 of 24, BUN 21, creatinine 0.9, and glucose 88. Total protein 6.5. CK 143, troponin 0.00. Alkaline phosphatase 59, ALT 5, AST 18, total bilirubin 0.6, direct bilirubin 0.2, and albumin 3.8. WBC 6.2, hemoglobin 13.8, hematocrit 40.8, and platelets 186. An EKG showed sinus rhythm with a rate of 83 and a QTc of 410.
IMPRESSION AND PLAN:
1. New right temporal cerebrovascular accident. We will consult Neurology and order an MRI/MRA of the head and neck. We will order a bubble study echocardiogram. We will start the patient on aspirin 325 mg p.o. daily. We will allow the patient\’s blood pressure to remain elevated up to 220/110. We will continue to trend the patient\’s cardiac enzymes every 6 hours for a total of 3. We will check a lipid panel. Continue atorvastatin 10 mg p.o. at bedtime. We will order PT and OT.
2. Hypertension. As stated above, we will allow the patient\’s blood pressure to remain elevated overnight, and we will hold Losartan.
3. Hyperlipidemia. We will check lipid panel stated above and continue atorvastatin and aspirin 325 mg p.o. daily.
4. Parkinson\’s disease. Continue the patient\’s home medications of Lamictal and levodopa/carbidopa at home doses.
5. Gastroesophageal reflux disease. Pantoprazole 40 mg p.o. twice a day.
6. Benign prostatic hypertrophy. Continue finasteride 5 mg p.o. at bedtime and doxazosin 4 mg p.o. at bedtime.
7. Deep venous thrombosis prophylaxis. Heparin 5000 units subcutaneous q.8 h.
11. Healthcare maintenance. The patient received a flu vaccine on 09/21/2015, Prevnar 13 on 03/24/2015 and pneumococcal vaccine on 05/12/2006.
CODE STATUS:
The patient is a full code. He is admitted to Med/Surg as an inpatient as he will require 2 or more midnights hospitalization for an acute stroke.
his is a new inpatient consult visit for me on Eugene A Sprehn, a 75 yr old male for evaluation of stroke, sent by Dr. Levin.
Deficits – pt awoke from a nap yest afternoon with a complaint that he could not read things properly
Also seemed more confused and could not make sense of the things he was seeing
No clear hemiparesis, loss of consciousness, seiz, etc
Later on developed a headache
Came to CDU where he was found to have a left sided HH and his CT showed evid of a right sided hemispheric lesion
I was called about him by Dr Campbell and we arranged for him to be admitted
He denies stroke
He has a hx of bipolar disease, depression worse since wife died
He also has a hx of parkinsons
On sinemet thru Dr Dutka for this
Has a right sided rest tremor and overall bradykinesia
Normally very functional and independent though
No tobacco
Has hx of htn
No cad but he has had some chest wall pain of late on the left
Workup:
MRI – done here at HCH showing stroke right mca territory posterior portion
mra neck clear
mra head here questions basilar tip aneurysm
CT – pos at GB showing ischemic stroke same territory as above
Echo – pending
Carotid Ultrasound – n/a
Angiogram – n/a
Holter – neg tele so far
Prior strokes or TIAs – no
Prior preventive treatments – not on asa because of a prior hx of GI bleed.
Risk factors:
1. hypertension – y
2. diabetes – n
3. smoking – n
4. cholesterol – n
5. sleep apnea – n
6. coronary disease – n
7. atrial fibrillation – n
8. valvular heart disease – n
9. sickle cell disease – n
10. clotting disorders – n
11. migraine – n
12. peripheral vascular disease – n
13. hormonal therapy – n
14. neck manipulations – n
PMHx: Patient Active Problem List:
PARKINSONS DISEASE
Date Noted: 03/24/2015
ATHEROSCLEROSIS OF AORTA
Date Noted: 03/24/2015
BILAT PSEUDO
Date Noted: 07/15/2009
HEMORRHOID
Date Noted: 07/21/2008
DEPRESSION, UNSPECIFIED
Date Noted: 07/08/2008
SENSORINEURAL HEARING LOSS.
Date Noted: 06/01/2006
GERD (GASTROESOPHAGEAL REFLUX DISEASE)
Date Noted: 05/12/2006
BPH (BENIGN PROSTATIC HYPERTROPHY)
Date Noted: 05/12/2006
his is a new inpatient consult visit for me on Eugene A Sprehn, a 75 yr old male for evaluation of stroke, sent by Dr. Levin.
Deficits – pt awoke from a nap yest afternoon with a complaint that he could not read things properly
Also seemed more confused and could not make sense of the things he was seeing
No clear hemiparesis, loss of consciousness, seiz, etc
Later on developed a headache
Came to CDU where he was found to have a left sided HH and his CT showed evid of a right sided hemispheric lesion
I was called about him by Dr Campbell and we arranged for him to be admitted
He denies stroke
He has a hx of bipolar disease, depression worse since wife died
He also has a hx of parkinsons
On sinemet thru Dr Dutka for this
Has a right sided rest tremor and overall bradykinesia
Normally very functional and independent though
No tobacco
Has hx of htn
No cad but he has had some chest wall pain of late on the left
Workup:
MRI – done here at HCH showing stroke right mca territory posterior portion
mra neck clear
mra head here questions basilar tip aneurysm
CT – pos at GB showing ischemic stroke same territory as above
Echo – pending
Carotid Ultrasound – n/a
Angiogram – n/a
Holter – neg tele so far
Prior strokes or TIAs – no
Prior preventive treatments – not on asa because of a prior hx of GI bleed.
Risk factors:
1. hypertension – y
2. diabetes – n
3. smoking – n
4. cholesterol – n
5. sleep apnea – n
6. coronary disease – n
7. atrial fibrillation – n
8. valvular heart disease – n
9. sickle cell disease – n
10. clotting disorders – n
11. migraine – n
12. peripheral vascular disease – n
13. hormonal therapy – n
14. neck manipulations – n
PMHx: Patient Active Problem List:
PARKINSONS DISEASE
Date Noted: 03/24/2015
ATHEROSCLEROSIS OF AORTA
Date Noted: 03/24/2015
BILAT PSEUDOPHAKIA
Date Noted: 01/08/2015
LEFT POSTERIOR VITREOUS DETACHMENT
Date Noted: 01/08/2015
HTN (HYPERTENSION)
Date Noted: 12/09/2014
SCREENING FOR COLON CANCER
