Soap Note x 3 (24 Hours) (Less than 10% plagiarism report)

 

1)  Submit 1 document per part

Part 1: Complete the file “Template” according to:

Diagnosis:  Malaria

Part 2: Complete the “Template ” according to:

   

Diagnosis:  Dengue

 Part 3: Complete the “template ” according to:

    Diagnosis:  Leishmaniasis

   

2)¨****** You must strictly follow the template.

             Will not admit any change           

         Submit 1 document per part

 

3)****************************** It will be verified by Turnitin (Identify the percentage of exact match of writing with any other resource on the internet and academic sources, including universities and data banks) 

********************************It will be verified by SafeAssign (Identify the percentage of similarity of writing with any other resource on the internet and academic sources, including universities and data banks)

4) Minimum 4 references per part not older than 5 years

Follow the rubric (Required):

 

Clinical Case Grading

Criteria

: The evaluation of the presentation is based on the following:

Criteria

 1) Chief Complaint & pertinent history 10 points

2)Pertinent exam and diagnostics 10 points

3)Working diagnosis with supporting criteria 5 points

4)Management plan 5 points

5)Epidemiological data – cited from literature 10 points

6)Evidenced based rationale for treatment (literature based) 10 points

7)Analysis of self-care and family issues r/t diagnosis and treatment plan 20 points

8)Evaluation parameters to be used (or were used) to determine outcomes 10 points

9)Identify major “lessons learned” and how it may affect your future practice 20 points

PATIENT INFORMATION

Name:

Age:

Gender:

Source:

Ethnicity:

Subjective:

Chief Complaint: “It must match the diagnosis”

Patient Mr. TM, 20 years old, male, with a past medical history of Asthma since his infancy. Arrive at the office today complaining that one week ago started to play basketball three times a week and referred feeling shortness of breath, mild dry cough during the exercise, palpitation after routine, feeling tiredness, and not improve with his current treatment. The patient denies another symptom. (It must be narrative addressed onset of symptoms, development and current state. Additionally, it must include the patient’s general condition)

Allergies: None

Current Medications:

· Montelukast 1mg one tablet PO at bedtime.

· Mometasone spray two puffs at bedtime.

· Ipratropium (Atrovent) nasal spray twice a day.

Past medical history: Asthma

Medication Intolerances: None

Chronic Illnesses/Major traumas: None

Hospitalizations/Surgeries: None

Family History

Father: Healthy Mother: Hypertension

Brother: None

Social History: Mr. TM is a young of 20 years old, that lives with his mother, father, and sister. He is a student at the college. He denies alcohol and illicit drug use. Two weeks ago, he started to play basketball three times a week.

ROS:

General: Denies fever or chill. Denies weight loss, fatigue, weakness, or night sweats.

Neurologic: Denies a history of seizure disorder, stroke, head injury, tremors or involuntary movements, vertigo, spinal cord injury, meningitis, blackouts, paralysis, fainting, dizziness, numbness or loss of sensation. Memory is good

HEENT:

Head: Denies any unusually frequent or severe headaches, head injury, dizziness, and lightheadedness.

Eyes: denies eye pain, redness, excessive tearing, double vision, flashing lights, glaucoma, and cataracts.

Ears: Denies earaches, infection, discharge, hearing loss, tinnitus, and vertigo.

Nose and sinuses: Deny nasal stuffiness, discharge or itching, hay fever, nosebleed, sinus trouble, frequent colds.

Throat: Denies mouth pain, frequent sore throats, bleeding gums, dentures, dry mouth, hoarseness, and difficulty swallowing.

Neck: Denies swollen glands, goiter, lumps, pain, or stiffness in the neck.

Lungs: Shortness of breath with wheezing, Mild dry cough and chest pressure, and palpitations. Denies hemoptysis.

Cardiovascular: Denies chest pain or discomfort, rheumatic fever, heart murmurs, palpitations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and edema.

Breast: Denies lumps, pain, or discomfort

GI: Denies anorexia, nausea, vomiting, constipation, diarrhea, rectal bleeding, abdominal pain, food intolerance, excessive belching or passing gas, liver or gallbladder disease, and hepatitis.

GU: Denies frequency of urination, polyuria, nocturia, urgency, burning, pain during urination, hematuria, urinary infections, kidney or flank pain, kidney stones, ureteral colic, suprapubic pain, or incontinence

Musculoskeletal: Denies pain. Denies arthritis, gout, osteoporosis, bone deformity, bone trauma, or fracture.

Skin: Denies rashes, lumps, sores, itching, dryness, moles, and skin color changes such as redness, cyanosis, jaundice, pallor, instability in hair, or nails.

Sleep/Rest: The patient sleeps every day, 6-7 hours a day, with naps.

Changes in vision/hearing: None

Objective:

Height: 5’ ft 4’ in

Weight:128 pounds BMI: 20

Blood Pressure right arm sitting: 110/80 mmHg Pulse: 84 bpm

Resp: 22 rpm

O2 Sat: 96%

Temp: 98.6 F Pain: 0/10

Physical Exam

General: The patient is well-groomed, who responds to questions quickly and appropriately. He is dress appropriate to the occasion and has a normal posture.

HEENT:

Head: Hair with a medium texture. Scalp without lesions. Skull normocephalic/atraumatic.

Eyes: Sclera white, conjunctiva pink. Pupils equally round and reactive to light and accommodation. The extraocular movement is intact. The fundoscopic exam is done and normal.

Ears:XXXXXXXXXXXXXXX (Complet)

Nose: Nasal mucosa pink, septum midline, no sinus tenderness.

Throat: Oral mucosa pink, dentures present upper/lower, pharynx without exudates, tonsils present

Neck: Trachea midline. Neck supple, thyroid isthmus palpable, lobes not felt.

Pulmonary: Shortness of breath with expiration prolonged, audible bilateral wheezing during auscultation.

Cardiovascular: Denies chest pain. No splitting of the heart sounds heard. No murmur. No S3 or S4, no friction rub. S1, S2 with regular rate and rhythm. No extra heart sounds. No SOB, no JVD, no carotid bruits.

Abdomen: Protuberant with active bowel sounds, soft and non-tender, no palpable masses, or hepatosplenomegaly.

Rectal: No perirectal lesions or fissures. Rectal vault without masses.

Musculoskeletal: Mild tenderness on the thoracic and lumbar region upon palpation. Negative straight leg raising.

Neurologic: Mental Status: Alert, relaxed, and cooperative. Oriented to person, time, and place. Though process coherent. Cranial Nerves: II-XII intact. Motor: Good muscle bulk and tone.

Strength 5/5. Cerebellar: Rapid alternating movements, gait with a normal base. Romberg negative. Sensory: pinprick, light touch, position, and vibration intact. Reflexes: 2+ and symmetric.

Skin: Normal skin color. Skin warm and moist. Nails without clubbing or cyanosis. No suspicious nevi or skin lesions. No rash, petechiae, or ecchymoses.

Psychiatric: Alert and oriented. He is dressed in clean clothes. Maintains eye contact. Answers questions appropriately.

Lab and diagnostic test: (minimum 3.You must include CPT Billing Codes and explain the purpose of the exam)

· Complete blood count (CBC)

· Comprehensive metabolic panel (CMP)

· Chest X-Ray

· Airflow analysis by spirometry and peak flow test

Particular test: No ordered at this time.

Diagnosis: (You must include ICD-10 and explain the pathology and the reasons for the diagnosis in 7 lines.) (Include Epidemiological data)

Mild Intermittent Asthma, Uncomplicated. ICD-10 (J45.20): Asthma is a chronic inflammatory disease of the airways that develops under the allergens’ influence, associates with bronchial hyperresponsiveness and reversible obstruction, and manifests with attacks of dyspnea, breathlessness, cough, wheezing, chest tightness, and sibilant crackles more expressed at expiration. Symptoms include shortness of breath, cough, chest tightness, tiredness, wheezing on expiration.

Differential Diagnosis (Minimum 3. You must include ICD-10 and explain the pathology and the reasons for the diagnosis in 6 lines)

· Chronic obstructive pulmonary disease (COPD) ICD-10 (J44.9): Chronic lung disease is a disease that affects the lungs and causes reduced airflow, making it hard to breathe. It is progressive, which means it worsens over time and is irreversible. Symptoms are shortness of breath, chronic coughing, wheezing, coughing up mucus, chest tightness, frequent colds, or respiratory infections. If the disease progresses and becomes more severe, it may experience fatigue and weight loss.

· Cystic fibrosis ICD-10 (E84.9): An inherited life-threatening disorder that damages the lungs and digestive system. This disease affects the cell that produces mucus, sweat, and digestive juices. It causes these fluids to become thick and sticky. They then plug up tubes, ducts, and passageways. Symptoms vary and can include cough, repeated lung infections, inability to gain weight, and fatty stools. Pain in the abdomen, cough can be chronic,with blood, or with phlegm, bulky stools, diarrhea, fat in the stool, heartburn, or severe constipation.

· Bronchitis ICD-10 (J20.9): Inflammation of the lining of bronchial tubes, which carry air to and from the lungs. It can be acute or chronic. An acute attack is often caused by a viral respiratory infection and improves by itself. Symptoms of bronchitis include coughing up thickened mucus and shortness of breath. The cough can be chronic, dry, or with phlegm. Fatigue or malaise, postnasal drip, or runny nose. Other symptoms are chest pressure, headache, sleeping difficulty, or sore throat.

PLAN/THERAPEUTICS:

Pharmacology (minimum 2. should include dose and intake)

(Explain why… According to XXX Smith (2020) Montelukast is…..)

· Montelukast 1mg one tablet PO at bed time.

· Mometasone sprays 2 puffs at bedtime.

· Ipratropium (Atrovent) nasal spray twice a day.

· Albuterol nebulized q 4 hours.

Education: (At least 5 patient education strategies)

· Identify Asthma triggers such as air pollution, dust, fragrance.

· Stay away from the allergens.

· Prevent colds.

· Take Asthma medications as prescribed, before running or any sort of exercise.

Must keep an inhaler in the pocket during any emergency event.

· Use a mask and cover the face while traveling far away to prevent dust and grain particles for causing congestion and narrowing of the nasal pathway.

· Avoid gathering or places of smoking.

· Get your vaccinations.

· Consider immunotherapy allergy shots.

· Follow your asthma action plan.

· Use a home peak flow meter.

Plan:

Follow up: The patient will be contacted with results of inflammation and proper airflow. Return to the clinic two weeks after completing the dosage regimen.

Referral: None

Lessons learned (Minimum 6 lines)

References (Minimo 3 references no older than 5 years)

Bronchial Asthma Treatments, Symptoms, Causes, and More. (n.d.). Retrieved from ht

tps://www.webmd.com/asthma/guide/bronchial-asthma#1

History of Ear Infections and the Prevalence of Asthma in a National. (2004, May 27). Retrieved from ht

tps://www.medscape.com/viewarticle/47534