create a grand round presentation using created Soap note w/uploaded Health Hx.

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Dhvaayr77

Health Medical

Description

  1. create a teaching presentation based on a case ( uploaded pt. health history) the discussion is on common abdominal pain, or Gi disease. The patient uploaded has bowel obstruction.
  2. Create a minimum of three high level learning objectives for this presentation. (What do you want the learners to know after they view your presentation?) There are multiple web sources on how to write learning objectives using Bloom's taxonomy online. Click here for an example or conduct your own search.
  3. Your case will start with a complete SOAP note ( uploaded)—then major research and discussion of the disease process are presented.
  4. Your case will also include an extended SOAP note. Used uploaded paper for guidelines on what should be included in the extended SOAP note.
  5. A minimum of five test questions should be created and posted with your presentation.
    1. The test questions will focus on appropriate intellectual activities ranging from simple recall (no more than one question), problem solving, critical thinking, reasoning, and evaluation.
    2. There are multiple Internet sources on how to write test questions
  6. A minimum of five scholarly sources should be used for your presentation. (Course texts can count for one source only; if using data from websites you must go back to the literature source for the information—no secondary sources are allowed.)
  7. As a recap, your Grand Rounds presentation must include:

    1. Three learning objectives that must be clearly written and presented
    2. A complete SOAP on the approved template.
    3. Extended SOAP note
    4. At least five test questions (such as multiple choice and matching) designed to asses the mastery of the learning objectives
    5. A minimum of five scholarly resources, no later than 5yrs. old.

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DONALD W. ROBERTSON DO, PA • 2828 SOUTH MCCALL RD SUITE 21, ENGLEWOOD FL 34224-9517 HARRIS, EDMOND (id #2008, dob: 02/16/1942) Patient Name HARRIS, EDMOND (74yo, M) ID# 2008 02/16/1942 DONALD W. ROBERTSON, DO DOB Provider Insurance Appt. Date/Time 09/22/2016 11:15AM Service Dept. Main Office Med Primary: MEDICARE-FL (MEDICARE) Insurance # : 291369457A Med Secondary: AARP (MEDICARE SUPPLEMENT) Insurance # : 03334882111 Prescription: ARGSDIR - Member is eligible. Chief Complaint Left abdominal pain, unexplained weight loss, cough pt states he has a lump in his lower left abdominal pain. BM is very dense and watery Patient's Care Team Other: DONALD W ROBERTSON DO: 2828 S MCCALL RD STE 21, ENGLEWOOD, FL 34224, Ph (941) 474-8154, Fax (941) 473-3583 NPI: 1164405007 Patient's Pharmacies WAL-MART PHARMACY 1874 (ERX): 2931 SOUTH MCCALL ROAD, ENGLEWOOD FL 34224, Ph (941) 475-8899, Fax (941) 473-8949 Vitals Pain Scale: 3 09/22/2016 12:40 Pulse: 100 bpm 09/22/2016 pm T: 97.8 F° 09/22/2016 12:40 pm Wt: 164 lbs 09/22/2016 12:39 pm BMI: 24.9 09/22/2016 12:39 pm Ht: 5 ft 8 in 09/22/2016 12:39 pm 12:39 pm RR: 22 09/22/2016 12:40 pm BP: 129/87 sitting L wrist 09/22/2016 12:40 pm O2Sat: 98% Room Air at Rest 09/22/2016 12:48 pm Measurements None recorded. Allergies Reviewed Allergies PENICILLINS: - BUT CAN TAKE CEPHALOSPORINS allery to PCN Medications Reviewed Medications Asprin Ec Low Dose 81 mg tablet,delayed release Take 1 tablet(s) every day by oral route. 09/08/16 entered Bactrim DS 800 mg-160 mg tablet Take 1 tablet(s) every 12 hours by oral route. 09/22/16 prescribed carvedilol 25 mg tablet Take 1 tablet(s) twice a day by oral route. 09/15/16 prescribed Ceftin 500 mg tablet Take 1 tablet(s) every 12 hours by oral route. 09/22/16 prescribed cefTRIAXone 1 gram solution for injection Take 1 g by injection route. 09/08/16 administered DONALD W. ROBERTSON DO, PA • 2828 SOUTH MCCALL RD SUITE 21, ENGLEWOOD FL 34224-9517 HARRIS, EDMOND (id #2008, dob: 02/16/1942) clonazePAM 1 mg tablet Take 1 tablet(s) twice a day by oral route. 09/15/16 prescribed clopidogrel 75 mg tablet Take 1 tablet(s) every day by oral route. 09/08/16 entered ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL nebulization soln Inhale 3 mL 4 times a day by nebulization route. 09/22/16 prescribed metroNIDAZOLE 500 mg tablet Take 1 tablet(s) every 8 hours by oral route. 09/22/16 prescribed NIFEdipine ER 30 mg tablet,extended release Take 1 tablet(s) twice a day by oral route. 09/15/16 prescribed ondansetron 4 mg disintegrating tablet Take 1 tablet(s) 4 times a day by oral route. 09/08/16 prescribed pantoprazole 40 mg tablet,delayed release Take 1 tablet(s) every day by oral route. 09/15/16 prescribed promethazine 25 mg tablet Take 1 tablet(s) every 4 hours by oral route. 09/08/16 prescribed raNITIdine 300 mg tablet Take 1 tablet(s) every day by oral route. 09/08/16 entered simvastatin 40 mg tablet Take 1 tablet(s) every day by oral route. 09/15/16 prescribed tamsulosin 0.4 mg capsule Take 1 capsule(s) every day by oral route. 09/15/16 prescribed Zantac 150 mg tablet Take 1 tablet(s) twice a day by oral route. 09/15/16 prescribed klor-cov, m20, magnesium, b12 500 mcq, D3 1000 IU, Co Q 10, Vaccines Reviewed Vaccines Vaccine Type Date Amt. Route Site Lot # Mfr. 1413101 Novartis Pharmaceutical Corporation Influenza influenza, seasonal, injectable 09/24/14 influenza, seasonal, injectable 10/05/13 novel Influenza-H1N1-09, all formulations 01/21/10 Intramuscular Problems Reviewed Problems Acute sinusitis - Onset: 09/19/2016 Generalized anxiety disorder - Onset: 09/15/2016 Chronic hypokalemia - Onset: 09/15/2016 Large bowel obstruction - Onset: 09/15/2016 - 9/16 Mixed hyperlipidemia - Onset: 09/08/2016 Benign prostatic hyperplasia - Onset: 09/08/2016 Gastritis - Onset: 09/08/2016 Essential hypertension - Onset: 09/08/2016 Exp. Date Date on VIS VIS Given Vaccinator DONALD W. ROBERTSON DO, PA • 2828 SOUTH MCCALL RD SUITE 21, ENGLEWOOD FL 34224-9517 HARRIS, EDMOND (id #2008, dob: 02/16/1942) Diverticulitis - Onset: 09/08/2016 - WITH 2 COLON RESECTIONS Coronary arteriosclerosis - Onset: 09/08/2016 - with 5 stents and CABG Family History Reviewed Family History Father - No current problems or disability Mother - No current problems or disability Social History Social History not reviewed (last reviewed 09/15/2016) Smoking Status: Never smoker Surgical History Surgical History not reviewed (last reviewed 09/15/2016) Past Medical History Past Medical History not reviewed (last reviewed 09/15/2016) HPI ED HAS NOT BEEN EATING HIS STOOLS ARE LIKE PUDDING SEE PREVIOUS NOTES HE IS HAVING PAIN IN THE LLQ AGAIN ROS Patient reports sore throat but reports no bleeding gums, no snoring, no dry mouth, no mouth ulcers, and no teeth problems. He reports cough but reports no wheezing, no shortness of breath, no coughing up blood, and no sleep apnea. He reports no abdominal pain, no nausea, no vomiting, no constipation, normal appetite, no diarrhea, not vomiting blood, no dyspepsia, and no GERD; ABDOMINAL PAIN LLQ STOOL IS LIKE PUDDING ANOREXIA. He reports fatigue; VERY. He reports no fever, no night sweats, no significant weight gain, no significant weight loss, and no exercise intolerance. He reports no dry eyes, no vision change, and no irritation. He reports no difficulty hearing and no ear pain. He reports no frequent nosebleeds, no nose problems, and no sinus problems. He reports no chest pain, no arm pain on exertion, no shortness of breath when walking, no shortness of breath when lying down, no palpitations, and no known heart murmur. He reports no incontinence, no difficulty urinating, no hematuria, and no increased frequency. He reports no muscle aches, no muscle weakness, no arthralgias/joint pain, no back pain, and no swelling in the extremities. He reports no abnormal mole, no jaundice, no rashes, and no laceration. He reports no loss of consciousness, no weakness, no numbness, no seizures, no dizziness, no migraines, no headaches, and no tremor. He reports no depression, no sleep disturbances, feeling safe in a relationship, no alcohol abuse, no anxiety, no hallucinations, and no suicidal thoughts. He reports no swollen glands, no bruising, and no excessive bleeding. He reports no runny nose, no sinus pressure, no itching, no hives, and no frequent sneezing. Physical Exam Patient is a 74-year-old male. Chaperone: Chaperone: present. Constitutional: General Appearance: healthy-appearing, well-nourished, and well-developed. Level of Distress: mild distress. Ambulation: ambulating normally. Psychiatric: Insight: good judgement. Mental Status: normal mood and affect and active and alert. Orientation: to time, place, and person. Memory: recent memory normal and remote memory normal. Head: Head: normocephalic and atraumatic. ENMT: Ears: no lesions on external ear, EACs clear, TMs clear, and TM mobility normal. Hearing: no hearing loss and Rinne AC>BC. Nose: no lesions on external nose, septal deviation, sinus tenderness, or nasal discharge and nares patent and nasal passages clear. Lips, Teeth, and Gums: no mouth or lip ulcers or bleeding gums and normal dentition. Oropharynx: no erythema or exudates and moist mucous membranes and tonsils not enlarged; LEFT MAXILLARY SINUS DOES ILLUMINATE PERSISTENT SOUNDS NASAL. Neck: Neck: supple, FROM, trachea midline, and no masses. Lymph Nodes: no cervical LAD, supraclavicular LAD, axillary LAD, or inguinal LAD. Thyroid: no enlargement or nodules and non-tender. Lungs: Respiratory effort: no dyspnea. Percussion: no dullness, flatness, or hyperresonance. Auscultation: no wheezing, rales/crackles, or rhonchi and breath sounds normal and diminished air movement. Cardiovascular: Apical Impulse: not displaced. Heart Auscultation: normal S1 and S2; no murmurs, rubs, or gallops; and RRR. Neck vessels: no carotid bruits. Pulses including femoral / pedal: normal throughout. Abdomen: Bowel Sounds: normal. Inspection and Palpation: no guarding, masses, rebound tenderness, or CVA tenderness and soft, non-distended, and LLQ tenderness; AND MILDLY FIRM. Liver: non-tender and no hepatomegaly. Spleen: nontender and no splenomegaly. Hernia: none palpable. DONALD W. ROBERTSON DO, PA • 2828 SOUTH MCCALL RD SUITE 21, ENGLEWOOD FL 34224-9517 HARRIS, EDMOND (id #2008, dob: 02/16/1942) Musculoskeletal:: Motor Strength and Tone: normal and hypotonicity; WEAK. Joints, Bones, and Muscles: no contractures, malalignment, tenderness, or bony abnormalities and normal movement of all extremities. Extremities: no cyanosis, edema, varicosities, or palpable cord. Neurologic: Gait and Station: normal gait and station. Cranial Nerves: grossly intact. Sensation: grossly intact and monofilament test intact. Reflexes: DTRs 2+ bilaterally throughout. Coordination and Cerebellum: finger-to-nose intact and no tremor. Skin: Inspection and palpation: no rash, lesions, ulcer, induration, nodules, jaundice, or abnormal nevi and good turgor. Nails: normal. Back: Thoracolumbar Appearance: normal curvature. Assessment / Plan 1. Diverticulitis - CHECK HEMOCCULTS AND STOOL FOR C DIFF K57.92: Diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding metronidazole 500 mg tablet - Take 1 tablet(s) every 8 hours by oral route. Qty: 30 tablet(s) Refills: 9 Pharmacy: WAL-MART PHARMACY 1874 Bactrim DS 800 mg-160 mg tablet - Take 1 tablet(s) every 12 hours by oral route. Qty: 20 tablet(s) Refills: 2 Pharmacy: WAL-MART PHARMACY 1874 Patient Instructions stop the cipro and replace with bactrim he could have the complication of diverticulitis and restart the ceftin as he still has the sinusitis discussed bowel program and get a kub today with a call report Discussion Notes CALLED PATIENT THE KUB WAS NEGATIVE I FEEL HE HAS DIVERTICULITIS AT THE AREA OF THE ANASTAMOSIS OR AN ABSCESS WE WILL SPEAK TO THE GASTROENTEROLOGIST AND HE WAS ADVISED TO GO TO THE ER OVER THE WEEKEND INI Return to Office Donald W. Robertson, DO for ESTABLISHED PATIENT 30 at Main Office on 10/27/2016 at 10:30 AM Encounter Sign-Off Encounter signed-off by Donald W. Robertson, DO, 09/22/2016. Encounter performed and documented by Donald W. Robertson, DO Encounter reviewed & signed by Donald W. Robertson, DO on 09/22/2016 at 7:00pm DONALD W. ROBERTSON DO, PA • 2828 SOUTH MCCALL RD SUITE 21, ENGLEWOOD FL 34224-9517 HARRIS, EDMOND (id #2008, dob: 02/16/1942) Patient Name HARRIS, EDMOND (75yo, M) ID# 2008 02/16/1942 DONALD W. ROBERTSON, DO DOB Provider Insurance Appt. Date/Time 04/13/2017 01:45PM Service Dept. Main Office Med Primary: MEDICARE-FL (MEDICARE) Insurance # : 291369457A Med Secondary: AARP (MEDICARE SUPPLEMENT) Insurance # : 03334882111 Prescription: ARGSDIR - Member is eligible. Chief Complaint abdominal pain intermittent pain rt side that started 3 days ago chronic cough since last August runny sinus Patient's Care Team Other: DONALD W ROBERTSON DO: 2828 S MCCALL RD STE 21, ENGLEWOOD, FL 34224, Ph (941) 474-8154, Fax (941) 473-3583 NPI: 1164405007 Patient's Pharmacies WAL-MART PHARMACY 1874 (ERX): 2931 SOUTH MCCALL ROAD, ENGLEWOOD FL 34224, Ph (941) 475-8899, Fax (941) 473-8949 Vitals Pain Scale: 5 04/13/2017 02:02 Pulse: 65 bpm regular pm T: 98.1 F° oral 04/13/2017 02:02 pm Wt: 156 lbs 04/13/2017 04/13/2017 02:01 pm BMI: 23.7 04/13/2017 02:01 pm 02:01 pm RR: 20 04/13/2017 02:01 pm BP: 116/71 sitting R arm 04/13/2017 02:02 pm Ht: 5 ft 8 in 04/13/2017 02:00 pm Measurements None recorded. Allergies Reviewed Allergies PENICILLINS: - BUT CAN TAKE CEPHALOSPORINS allery to PCN Medications Reviewed Medications ALPRAZolam 1 mg tablet Take 1 tablet(s) twice a day by oral route as needed. 04/13/17 prescribed carvedilol 12.5 mg tablet Take 1 tablet(s) twice a day by oral route. 01/03/17 entered Cipro 500 mg tablet Take 1 tablet(s) every 12 hours by oral route. 04/13/17 prescribed clonazePAM 1 mg tablet Take 1 tablet(s) twice a day by oral route. Internal Note: now once daily at bedtime 02/16/17 prescribed clopidogrel 75 mg tablet Take 1 tablet(s) every day by oral route. 04/13/17 prescribed DONALD W. ROBERTSON DO, PA • 2828 SOUTH MCCALL RD SUITE 21, ENGLEWOOD FL 34224-9517 HARRIS, EDMOND (id #2008, dob: 02/16/1942) metroNIDAZOLE 500 mg tablet Take 1 tablet(s) every 8 hours by oral route. 04/13/17 prescribed omeprazole 20 mg capsule,delayed release Take 1 capsule(s) every day by oral route. 12/01/16 prescribed PARoxetine 10 mg tablet Take 1 tablet(s) every day by oral route. 12/12/16 prescribed potassium chloride ER 20 mEq tablet,extended release Take 1 tablet(s) every day by oral route. 01/03/17 entered raNITIdine 150 mg tablet Take 2 tablet(s) twice a day by oral route. 02/16/17 prescribed simvastatin 20 mg tablet Take 1 tablet(s) every day by oral route. 01/03/17 entered tamsulosin 0.4 mg capsule Take 1 capsule(s) every day by oral route. Internal Note: HELD 04/13/17 prescribed citracel, MVI w/ iron, magnesium Vaccines Vaccines not reviewed (last reviewed 01/03/2017) Vaccine Type Date Amt. Route Site Lot # Mfr. 1413101 Novartis Pharmaceutical Corporation Exp. Date Date on VIS VIS Given Vaccinator Influenza influenza, seasonal, injectable 09/24/14 influenza, seasonal, injectable 10/05/13 novel Influenza-H1N1-09, all formulations 01/21/10 Intramuscular Some vaccines listed in Documents: #45545, #46572, #47504, #50533, #60869, #76533 could not be added to this patient's chart. Please review these documents and add these vaccines to the patient's chart manually as needed. Problems Reviewed Problems History of cholecystectomy - Onset: 04/13/2017 Anemia - Onset: 02/16/2017 Acute sinusitis - Onset: 09/19/2016 Generalized anxiety disorder - Onset: 09/15/2016 Depressive disorder - Onset: 12/12/2016 Chronic hypokalemia - Onset: 09/15/2016 Large bowel obstruction - Onset: 09/15/2016 - 9/16 WITH A RESECTION Mixed hyperlipidemia - Onset: 09/08/2016 Benign prostatic hyperplasia - Onset: 09/08/2016 Gastritis - Onset: 09/08/2016 Essential hypertension - Onset: 09/08/2016 Diverticulitis - Onset: 09/08/2016 - WITH 2 COLON RESECTIONS Coronary arteriosclerosis - Onset: 09/08/2016 - with 5 stents and CABG Family History Family History not reviewed (last reviewed 09/30/2016) Father - No current problems or disability Mother - No current problems or disability Social History Social History not reviewed (last reviewed 09/30/2016) Smoking Status: Never smoker DONALD W. ROBERTSON DO, PA • 2828 SOUTH MCCALL RD SUITE 21, ENGLEWOOD FL 34224-9517 HARRIS, EDMOND (id #2008, dob: 02/16/1942) Surgical History Surgical History not reviewed (last reviewed 09/30/2016) Past Medical History Past Medical History not reviewed (last reviewed 09/30/2016) HPI BROUGHT IN MEDS AND WE REVIEWED NOTS AND LABS STILL HAS A COUGH SWALLOWING IS BETTER HE HAD A CARDICC CATHETERIZATION AND AN ANGIOPLASTY 3/31/17 NOW HE HAS PAIN IN THE RUQ SINCE THEN AND HE CAN FEEL A KNOW NOT RELATED TO MEALS MAYBE RE;LATED TO MOVEMENT NO NAUSEA 3 DAYS OF PAIN HE HAS HAD THE GALLBLADDER OUT ROS Patient reports difficulty hearing and ear pain; RIGHT. He reports cough but reports no shortness of breath; CHRONIC. He reports anxiety but reports no depression, no sleep disturbances, feeling safe in a relationship, no alcohol abuse, no hallucinations, and no suicidal thoughts. He reports no fever. He reports no dry eyes, no vision change, and no irritation. He reports no frequent nosebleeds, no nose problems, and no sinus problems. He reports no sore throat, no bleeding gums, no snoring, no dry mouth, no mouth ulcers, no oral abnormalities, and no teeth problems. He reports no chest pain, no arm pain on exertion, no shortness of breath when walking, and no palpitations. He reports no abdominal pain, no nausea, and no vomiting. He reports no incontinence, no difficulty urinating, no hematuria, and no increased frequency. He reports no muscle aches and no muscle weakness. He reports no abnormal mole, no jaundice, no rashes, and no laceration. He reports no loss of consciousness, no weakness, no numbness, no seizures, no dizziness, no migraines, no headaches, and no tremor. He reports no fatigue. He reports no swollen glands, no bruising, and no excessive bleeding. Additionally reports: NO HEARTBURN PAin does not wake him at night RADIATES AROUND TO THE BACK NO URINARY SYMPTOMS THE RIGHT EAR FELS FULL HE IS NOT CONSTIPATED Physical Exam Patient is a 75-year-old male. Chaperone: Chaperone: present. Constitutional: General Appearance: healthy-appearing, well-nourished, and well-developed. Level of Distress: NAD; PALE. Ambulation: ambulating normally. Psychiatric: Insight: good judgement. Mental Status: active and alert; BETTER. Orientation: to time, place, and person. Memory: recent memory normal and remote memory normal; BETTER. Head: Head: normocephalic and atraumatic. ENMT: Ears: no lesions on external ear, EACs clear, TMs clear, andTM immobile; RETRACTED RIGHT AND HE HAS A MYRINGOTOMY TUBE ON THE LEFT. Hearing: no hearing loss and Rinne AC>BC. Nose: no lesions on external nose, septal deviation, sinus tenderness, or nasal discharge and nares patent and nasal passages clear. Lips, Teeth, and Gums: no mouth or lip ulcers or bleeding gums and normal dentition. Oropharynx: no erythema or exudates and moist mucous membranes and tonsils not enlarged. Neck: Neck: supple, FROM, trachea midline, and no masses. Lymph Nodes: no cervical LAD, supraclavicular LAD, axillary LAD, or inguinal LAD. Thyroid: no enlargement or nodules and non-tender. Lungs: Respiratory effort: no dyspnea. Percussion: no dullness, flatness, or hyperresonance. Auscultation: no wheezing or rhonchi and breath sounds normal, good air movement, and dry rales/crackles; MILD. Cardiovascular: Apical Impulse: not displaced. Heart Auscultation: normal S1 and S2; no murmurs, rubs, or gallops; and RRR. Neck vessels: no carotid bruits. Pulses including femoral / pedal: normal throughout. Abdomen: Bowel Sounds: normal. Inspection and Palpation: no guarding, masses, rebound tenderness, or CVA tenderness and soft and non-distended; THE COLON IS TENDER AND SLIGHTLY SWOLLEN AND PALPABLE IN THE RIGHT MID LATERAL ABDOMEN AND I FEEL HE HAS SOME EARLY INFLAMMATION OR DIVERTICULITIS. Liver: non-tender and no hepatomegaly. Spleen: non-tender and no splenomegaly. Hernia: none palpable. Musculoskeletal:: Motor Strength and Tone: normal. Joints, Bones, and Muscles: no contractures, malalignment, tenderness, or bony abnormalities and normal movement of all extremities. Extremities: no cyanosis, edema, varicosities, or palpable cord. Neurologic: Gait and Station: normal gait and station. Cranial Nerves: grossly intact. Sensation: grossly intact and monofilament test intact. Reflexes: DTRs 2+ bilaterally throughout. Coordination and Cerebellum: finger-to-nose intact and no tremor. Skin: Inspection and palpation: no rash, lesions, ulcer, induration, nodules, jaundice, or abnormal nevi and good turgor. Nails: normal. DONALD W. ROBERTSON DO, PA • 2828 SOUTH MCCALL RD SUITE 21, ENGLEWOOD FL 34224-9517 HARRIS, EDMOND (id #2008, dob: 02/16/1942) Back: Thoracolumbar Appearance: normal curvature. Assessment / Plan 1. Diverticulitis - CHECK HEMOCCULTS AND STOOL FOR C DIFF K57.92: Diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding DIVERTICULITIS: CARE INSTRUCTIONS LEARNING ABOUT DIVERTICULOSIS AND DIVERTICULITIS metronidazole 500 mg tablet - Take 1 tablet(s) every 8 hours by oral route. Qty: 30 tablet(s) Refills: 9 Pharmacy: WAL-MART PHARMACY 1874 Cipro 500 mg tablet - Take 1 tablet(s) every 12 hours by oral route. Qty: 20 tablet(s) Refills: 2 Pharmacy: WALMART PHARMACY 1874 2. Chronic hypokalemia E87.6: Hypokalemia 3. Essential hypertension I10: Essential (primary) hypertension HIGH BLOOD PRESSURE: CARE INSTRUCTIONS LEARNING ABOUT HIGH BLOOD PRESSURE 4. Coronary arteriosclerosis I25.10: Atherosclerotic heart disease of native coronary artery without angina pectoris clopidogrel 75 mg tablet - Take 1 tablet(s) every day by oral route. Qty: 90 tablet(s) MART PHARMACY 1874 Refills: 9 Pharmacy: WAL- 5. Serous otitis media - Right H65.91: Unspecified nonsuppurative otitis media, right ear 6. Benign prostatic hyperplasia N40.0: Benign prostatic hyperplasia without lower urinary tract symptoms BENIGN PROSTATIC HYPERPLASIA: CARE INSTRUCTIONS tamsulosin 0.4 mg capsule - Take 1 capsule(s) every day by oral route. Qty: 90 capsule(s) WAL-MART PHARMACY 1874 7. Generalized anxiety disorder - CLONAZEPAM DOES NOT WORK F41.1: Generalized anxiety disorder ANXIETY DISORDER: CARE INSTRUCTIONS alprazolam 1 mg tablet - Take 1 tablet(s) twice a day by oral route as needed. Pharmacy: WAL-MART PHARMACY 1874 Refills: 9 Qty: 60 tablet(s) Refills: 2 Patient Goals CBC CMP RTO NEXT WEEK Return to Office Donald W. Robertson, DO for ESTABLISHED PATIENT 30 at Main Office on 04/18/2017 at 02:30 PM Encounter Sign-Off Encounter signed-off by Donald W. Robertson, DO, 04/13/2017. Encounter performed and documented by Donald W. Robertson, DO Encounter reviewed & signed by Donald W. Robertson, DO on 04/13/2017 at 2:33pm Pharmacy: Name: Pt. Encounter Number: Date: Age: SUBJECTIVE CC: Reason given by the patient for seeking medical care “in quotes” Sex: HPI: Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness. Medications: (list with reason for med ) PMH Allergies: Medication Intolerances: Chronic Illnesses/Major traumas Hospitalizations/Surgeries “Have you ever been told that you have: Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.” Family History Does your mother, father or siblings have any medical or psychiatric illnesses? Anyone diagnosed with: lung disease, heart disease, htn, cancer, TB, DM, or kidney disease. Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, marijuana. Safety status ROS General Weight change, fatigue, fever, chills, night sweats, energy level Cardiovascular Chest pain, palpitations, PND, orthopnea, edema Skin Delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles Respiratory Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB Eyes Corrective lenses, blurring, visual changes of any kind Gastrointestinal Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools Ears Ear pain, hearing loss, ringing in ears, discharge Genitourinary/Gynecological Urgency, frequency burning, change in color of urine. Contraception, sexual activity, STDS Fe: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx Male: prostate, PSA, urinary complaints Nose/Mouth/Throat Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain Musculoskeletal Back pain, joint swelling, stiffness or pain, fracture hx, osteoporosis Breast SBE, lumps, bumps or changes Neurological Syncope, seizures, transient paralysis, weakness, paresthesias, black out spells Psychiatric Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx Heme/Lymph/Endo HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance OBJECTIVE Weight BMI Temp BP Height Pulse Resp General Appearance Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first, then brighter later. Skin Skin is brown, warm, dry, clean and intact. No rashes or lesions noted. HEENT Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair. Cardiovascular S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema. Respiratory Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally. Gastrointestinal Abdomen obese; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly. Breast Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin. Genitourinary Bladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness. No adnexal masses or tenderness. Ovaries are non-palpable. (Male: both testes palpable, no masses or lesions, no hernia, no uretheral discharge. ) (Rectal as appropriate: no evidence of hemorrhoids, fissures, bleeding or masses—Males: prostrate is smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm). Musculoskeletal Full ROM seen in all 4 extremities as patient moved about the exam room. Neurological Speech clear. Good tone. Posture erect. Balance stable; gait normal. Psychiatric Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately. Lab Tests Urinalysis – pending Urine culture – pending Wet prep - pending Special Tests Diagnosis Include at least 3 differential diagnosis Final Diagnosis ▪ Evidence for final diagnosis should be documented in your Subjective and Objective exam. PLAN including Education o Plan: ▪ Further testing ▪ Medication ▪ Education ▪ Non-medication treatments ▪ Follow up o o The following outlines what should be included in the extended SOAP note: I. SOAP Evaluation 1. Sign and symptoms/Clinical presentation of disease process a. How did your patient present: include history 2. Diagnostic workup: both typical and what was done with your patient a. Physical findings b. Testing c. Imaging studies 3. Differential Diagnosis a. Minimum of 3 b. How did you rule in/rule out the diagnosis 4. Final Diagnosis a. What factors from your history and physical led to this diagnosis 5. Management a. Pharmacologic b. Non-pharmacologic 6. Education II. Disease Background 1. Anatomy 2. Etiology a. Risk factors 3. Pathophysiology a. Consequences: adult and Geriatric 4. Epidemiology a. Cultural, age, race, gender, US, International 5. Prognosis 6. Patient Education III. Treatment Evaluation 1. Approach considerations a. Guidelines and literature referenced 2. Complications 3. Health promotion and risk reduction 4. Medicolegal Concerns 5. Future Research needed 6. Consultation 7. Long term monitoring 8. Ethical and cultural consideration 9. Cost IV. Critical Reflection of interaction and investigation. V. Minimum of five test questions based on objectives and presentation. 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Explanation & Answer

Attached.

Physical and Health assessment
I. SOAP Evaluation
1. Sign and symptoms/Clinical presentation of disease process
a. patient present: include history
2. Diagnostic workup: both typical and what was done with your patient
a. Physical findings
b. Testing
c. Imaging studies
3. Differential Diagnosis
a. Minimum of 3
4. Final Diagnosis
a. factors from your history and physical led to this diagnosis
5. Management
a. Pharmacologic
b. Non-pharmacologic
6. Patient Education
7. Education
II. Disease Background
1. Anatomy
2. Etiology
a. Risk factors
3. Pathophysiology
a. Consequences: adult and Geriatric
4. Epidemiology
a. Cultural, age, race, gender, US, International
5. Prognosis
III. Treatment Evaluation
1. Approach considerations
a. Guidelines and literature referenced
2. Complications
3. Health promotion and risk reduction
4. Medicolegal Concerns
5. Future Research needed
6. Consultation
7. Long term monitoring
8. Ethical and cultural consideration
9. Cost


Running head: PHYSICAL AND HEALTH ASSESSMENT

Physical and Health Assessment
Student’s Name
Institutional Affiliation

1

PHYSICAL AND HEALTH ASSESSMENT

Name: Harris Edmond
Date: 04/13/2017

Pt. Encounter Number: ID#2008
Age: 75
Sex: Male
SUBJECTIVE

CC:
Pt. has abdominal pain
Pt. experiences internment pain at the right side, which started 3 days ago
Chronic coughing since August 2016 with a runny nose
HPI:
Pt. brought his current medications, still experiencing cough
Pt. swallowing is better
Pt. had cardiac catheterization as well as angioplasty
Pain in the right upper quadrant
Pt. has no nausea
Pt. experienced 3 days of pain since he has had his gallbladder out
Medications:
ALPRAZolam 1 mg tablet
Take 1 tablet(s) twice a day by oral route as needed.
carvedilol 12.5 mg tablet
Take 1 tablet(s) twice a day by the oral route. entered on 01/03/17
Cipro 500 mg tablet
Take 1 tablet(s) every 12 hours by the oral route. prescribed on 04/13/17
clonazePAM 1 mg tablet
Take 1 tablet(s) twice a day by the oral route.
Internal Note: now once daily at bedtime prescribed on 02/16/17
clopidogrel 75 mg tablet
Take 1 tablet(s) every day by the oral route.
metroNIDAZOLE 500 mg tablet
Take 1 tablet(s) every 8 hours by the oral route. prescribed on 04/13/17
omeprazole 20 mg capsule, delayed the release
Take 1 capsule(s) every day by the oral route. prescribed on 12/01/16
PARoxetine 10 mg tablet
Take 1 tablet(s) every day by the oral route. prescribed on 12/12/16
potassium chloride ER 20 mEq tablet,extended release
Take 1 tablet(s) every day by the oral route. entered on 01/03/17
raNITIdine 150 mg tablet
Take 2 tablet(s) twice a day by the oral route. prescribed on 02/16/17
simvastatin 20 mg tablet
Take 1 tablet(s) every day by the oral route. entered on 01/03/17
tamsulosin 0.4 mg capsule
Take 1 capsule(s) every day by the oral route.
Internal Note: HELD
PMH

2

PHYSICAL AND HEALTH ASSESSMENT

3

Allergies:
Pt. has allergy to penicillin
Medication Intolerances:
Pt. has penicillin intolerance
Chronic Illnesses/Major traumas
✓ History of cholecystectomy - Onset: 04/13/2017
✓ Anemia - Onset: 02/16/2017
✓ Acute sinusitis - Onset: 09/19/2016
✓ Generalized anxiety disorder - Onset: 09/15/2016
✓ Depressive disorder - Onset: 12/12/2016
✓ Chronic hypokalemia - Onset: 09/15/2016
✓ Large bowel obstruction - Onset: 09/15/2016 - 9/16 WITH A RESECTION
✓ Mixed hyperlipidemia - Onset: 09/08/2016
✓ Benign prostatic hyperplasia - Onset: 09/08/2016
✓ Gastritis - Onset: 09/08/2016
✓ Essential hypertension - Onset: 09/08/2016
✓ Diverticulitis - Onset: 09/08/2016 - WITH 2 COLON RESECTIONS
✓ Coronary arteriosclerosis - Onset: 09/08/2016 - with 5 stents and CABG
Hospitalizations/Surgeries
Pt. surgical history was not reviewed
Family History
✓ Father - No present problems or disability
✓ Mother - No present issues or disability
Social Hi...


Anonymous
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