Episodic/Focused SOAP Note Template

Patient Information:

Initials: C.M.,  Age: 70, Sex: Female, Race: White 

S.

CC (chief complaint): The patient presents with the condition of forgetfulness that makes her forget what she had gone to pick in the next room. 

HPI: C.M. is a 70-years old patient presents with case of forgetfulness that has lasted for a period of 1 year. The condition has been worsening with time and lately she indicates that she could go to the next room just to realize that she cannot remember what she went to do. The patient report though indicates that she was still able to carry out her normal choirs like performing driving herself and managing her finances. The patient’s family has noticed the situation. 

Location: head

Onset: 1 year ago

Character: Forgetfulness, short term forgetfulness that makes her forget short term activities. 

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

Timing: This occurs continuously and seems to be worsening with time. 

Severity: 6/10 forgetfulness scale 

Current Medications: The patient has been using Rivastigmine drug for the last three months, 1.5 mg orally twice every day for the initial two weeks, then she continued with 3mg twice every day for the next two weeks and and she is currently using 4.5mg twice each day (Khachaturian, & Radebaugh, (Eds.), 2019). 

Allergies: No recorded allergic reactions to either food or any other substance. 

PMHx: The last tetanus immunization date was recorded to be 5th of January 2020. The patient indicates no known surgical procedure done to them in the last few years. She indicated that she was diagnosed with hypertension when she was 40 and she was able to manage the condition and by the age of 42 she was declared free from hypertension. She reports no mental diagnosis before the specific diagnosis for the prevailing condition. 

Soc Hx: Lifestyle is one of the most crucial contributing factors to the health of a patient (Dubois, et al. 2016). Considering the the patient presented is 70 years old, she has a higher prevalence to chronic health conditions. The development of specific measures that would be more effective in the control of the specific conditions. C.M. reports never smoking but reports that she used to drink between the age of 25 to 40 years old when she was diagnosed of high blood pressure when she stopped drinking. C.M. enjoys adventure and she used to go swimming every day before her husband passed away one and half years ago. She confirms that she found it difficult to live without him. She is a Christian and she seeks solace in the church when she feels lonely. Two of her children live within the city and one of them visits her frequently. She rarely talks with one of the children who lives in another state. 

Fam Hx: The identification of the patient health conditions contributes to better understanding of the possible present health condition (Li, et al. 2019). In the case of C.M. her father died ten years ago because of dementia after several years of suffering from hypertension and diabetes. Her mother died of a road accident when she was 30 years old. All her siblings are still alive. The eldest is 74 years old and has been diagnosed with mild dementia. The other two are younger than her and do not have any health condition. 

ROS: 

GENERAL:  lost 5 pounds in the last five months, effective self-expression, remembers her date of birth, today’s date and month, she drove herself to the facility. Forgets some of the connective words and took time to recall the name of her younger sister’s name until her daughter reminds her. 

HEENT:  Eyes:  Blurred vision for longer regions.  Ears: No hearing loss, Nose; No running nose nor sneezing. Throat: No sore throats and no congestions.  

SKIN:  No visible rash and reported no itching. 

CARDIOVASCULAR: No visible edema on palpation, chest difficulties nor chest pain, chest 

RESPIRATORY:  No sputum, no breathing difficulties and no sound abnormal sound produced during breathing. 

GASTROINTESTINAL: no diarrhea recorded and no vomiting, reported no nausea nor anorexia. No blood stains on the stool and no reported abdominal pain. 

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

NEUROLOGICAL:  difficulty following simple instructions, forgetting the contexts of the immediate previous conversation. No paralysis, no headache and no dizziness nor syncope. 

MUSCULOSKELETAL:  Minor slowed muscle response when standing up from sitting position, Slight stiffness reported on the muscles, No back pain, joint pain 

HEMATOLOGIC:  No anemia, bleeding or bruising.

LYMPHATICS:  No enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  mild depression after losing her husband. 

ENDOCRINOLOGIC:   No polyuria nor polydipsia, No reports of sweating, cold or heat intolerance.

ALLERGIES:  No history of allergic reactions such as asthma. 

O.

Physical exam:

GENERAL: Physically upright and fit when she stands, effective self-expression, fluent speech, no reported pain in any part of the body, 64 kgs, 5’3 ft, effective eye sight for her age, remembers her date of birth, today’s date and month, she drove herself to the facility. Forgets some of the connective words and took time to recall the name of her younger sister’s name until her daughter reminds her. 

HEENT:  Eyes:  Blurred vision for longer distance objects.  

MUSCULOSKELETAL: Minor slowed muscle response when standing up from sitting position, Slight stiffness reported on the muscles, she also does not walk straight when walking across an open room.  

Diagnostic results: The diagnosis for mental conditions may be carried out by testing blood to determine rule out the possible cause of the condition. Blood tests indicate negative for vitamin deficiencies and thyroid disorder condition. 

A.

Differential Diagnoses 

Psychotic disorders: This condition is considered as one of the differential diagnosis considering that the patient indicates forgetfulness.

Anxiety disorder: This condition is also considered due to fact that the patient experiences forgetfulness for common terms and names of people and items. 

Alzheimer’s Disease: The poor vision, the poor gait when waking up and when walking across the open room also contribute to the selection of this condition as one of the possible differential diagnosis (Dubois, et al. 2016).

References

Dubois, B., Padovani, A., Scheltens, P., Rossi, A., & Dell’Agnello, G. (2016). Timely diagnosis for Alzheimer’s disease: a literature review on benefits and challenges. Journal of Alzheimer’s disease, 49(3), 617-631.

Khachaturian, Z. S., & Radebaugh, T. S. (Eds.). (2019). Alzheimer’s disease: cause (s), diagnosis, treatment, and care. CRC Press.

Li, M., Yue, L., Gong, X., Li, J., Ji, H., & Asoke, N. (2019). Hierarchical Feature Extraction for Early Alzheimer’s Disease Diagnosis.

 COLLAPSE

The Inclusion of Nurses in the Systems Development Life Cycle

In the media introduction to this module, it was suggested that you as a nurse have an important role in the Systems Development Life Cycle (SDLC). With a focus on patient care and outcomes, nurses may not always see themselves as contributors to the development of new systems. However, as you may have observed in your own experience, exclusion of nurse contributions when implementing systems can have dire consequences.

In this Discussion, you will consider the role you might play in systems development and the ramifications of not being an active participant in systems development.

To Prepare:

• Review the steps of the Systems Development Life Cycle (SDLC) as presented in the Resources.
• Reflect on your own healthcare organization and consider any steps your healthcare organization goes through when purchasing and implementing a new health information technology system.
• Consider what a nurse might contribute to decisions made at each stage of the SDLC when planning for new health information technology.

By Day 3 of Week 9

Post a description of what you believe to be the consequences of a healthcare organization not involving nurses in each stage of the SDLC when purchasing and implementing a new health information technology system. Provide specific examples of potential issues at each stage of the SDLC and explain how the inclusion of nurses may help address these issues. Then, explain whether you had any input in the selection and planning of new health information technology systems in your nursing practice or healthcare organization and explain potential impacts of being included or not in the decision-making process. Be specific and provide examples.

 

This week we will be discussing the term “workaround.” Perhaps you have been using a healthcare information system and have found that at times it can be very frustrating and time consuming. Perhaps you have been tempted to find a creative “workaround” this issue. However, you quickly realize that this would be non-compliant with your company and just wait…This is a real problem in healthcare. What are your thoughts on these workarounds. Are there risks or benefits to discuss? Does this impact patient safety? In what ways? This should be a great discussion this week! Can’t wait to see you all in the threads!

What is a workaround? Identify a workaround (specific to technology used in a hospital setting) that you have used or perhaps seen someone else use, and analyze why you feel this risk-taking behavior was chosen over behavior that conforms to a safety culture. What are the risks? Are there benefits? Why or why not?
Discuss the current patient safety characteristics used by your current workplace or clinical site. Identify at least three aspects of your workplace or clinical environment that need to be changed with regard to patient safety (including confidentiality), and then suggest strategies for change

Read chapter 23, 33 and 34 of the class textbook and review the attached PowerPoint presentations.  Read content chapter 33 and 34 in Davis Plus Online Website.  Once done answer the following questions;

1.  Discuss the organization and the family role in every one of the heritages mentioned about and how they affect (positively or negatively) the delivery of health care.

2.  Identify sociocultural variables within the Irish, Italian and Puerto Rican heritage and mention some examples.

 A minimum of 3 evidenced-based references must be used (excluding the class textbook).    References must be no older than 5 years.  A minimum of 700 words is required.

Musical Challenge

Instructions:

Try your own experiment by choosing a challenging online article to read, and listen to 4 different types of music while trying to read and comprehend the article. List the challenging passage in APA format, and answer the following questions for every piece of music:

• Make a note of the genre of music, (Vivaldi, death metal, jazz, gospel, hip hop, blues, rap, country).
• Was it easy or difficult to understand the challenging paragraphs?
• Why do you think it was easier to understand what you were reading while listening to some music and not to others?
• What impact do you think having certain music in schools or on the job would have on the people in those environments?

Please be sure to validate your opinions and ideas with citations and references in APA format.