NRP531 Soap Note & Reflection

See below instruction, attached scenerio, templates, etc…

Week 8 Assignment Instructions

Week 8 Episodic SOAP Note: Maria Álvarez Pt.1

  1. Congratulations, you are ready to share your mastery of skills by completing a comprehensive SOAP note for patient Maria Álvarez.
  2. Review the Maria Álvarez Scenario (see attached).
  3. Use the SOAP Note Template (see attached) and the SOAP Note Structure Guide (see attached) to develop your documentation needed to complete your SOAP Note.
  4. The assessment and plan sections will not be graded but should be completed to ensure documentation of a complete SOAP Note. You will also use this information to complete your E&M coding for the visit.
  5. Make sure to: Document all relevant information using appropriate terminology.
  6. List the appropriate ICD-10 codes and E&M codes using the diagnoses provided.
  7. Assignment is to be done in APA format. References are to be cited in APA format.  Reference page to be done in APA format.  Requires a minimum of 2 scholarly peer reviewed references for part 1 of assignment.

Week 8 Episodic SOAP Note: Maria Álvarez Pt. 2

  1. Excellent work, now that you have completed your SOAP Note for Maria Álvarez, it is time for reflection. This reflection is your opportunity to review what you learned about the patient, the process, and the outcomes in preparation for future patient encounters. The reflection must include a discussion about an evidence-based practice to improve the quality of care the patient receives.
  2. Write a 700-word reflection providing rationale for your completed SOAP Note. Consider the interview information provided in the patient scenario to do the following within your reflection:

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  3. List 5 open-ended questions you would ask using descriptive language familiar to the patient during the HPI exam relevant to the chief complaint, including all pertinent and positive negatives. Provide a rationale for each question you ask by explaining why it is appropriate and how it aligns to the chief complaint.
  4. Provide a minimum of 3 rationales for the physical exam components performed.
  5. Locate and review a current evidence-based article that discusses evidence-based guidelines or new research relating to each diagnosis. Provide a brief summary of the article(s) in your reflection.
  6. Identify a minimum of 2 barriers to quality health care the patient can potentially experience per the information provided in the interview (e.g., cultural, linguistic, economic, previous conditions, etc.).
  7. As the FNP, explain how you can address these barriers to improve the quality of care the patient receives.
  8. Assignment is to be done in APA format. References are to be cited in APA format.  Reference page to be done in APA format.  Requires a minimum of 2 scholarly peer reviewed references to support your answers for part 2 of assignment.

This assignment includes a TOTAL of 4 scholarly peer reviewed references to support your answers in the paper.  Two for part 1 and two for part two.NRP531 Soap Note & Reflection

This is a soap analysis for Maria Alvarez. She is Hispanic and 45 years old. She complains of abdominal pain in the right upper quadrant after meals. She is known to have hypertension and takes losartan. She reveals having had an appendectomy 35 years ago. She is married with two children and works as a call center manager.  In her family, there is a positive history of chronic illness. She declines taking alcohol and smoking cigarettes. Her vitals were; blood pressure at 128/78 mmHg, the pulse rate at 78, temperature at 98, height at 4’5 weight of 180kgs BMI of 30.9. Abdominal ultrasound shows thickening of the gall bladder with sludge, and numerous stones were noted in the gall bladder.

Subjective Data

The patient’s identifying information; Maria Alvarez, 45 years old female and is Hispanic.

Chief Complaint; abdominal pain

History of the Presenting Complaint; Maria presents with abdominal pain at the right upper quadrant. The pain was of acute onset, not radiating and it was so severe that she took Tylenol that slightly relieved the patient from pain. She reports that she has experienced abdominal pain several times though the frequency of the pain has gradually increased over time. She reports that the pain was associated with fatty meals at first but now the pain is triggered by taking all types of food. She reports having reduced appetite, abdominal bloating, and nausea. However, there are no associated symptoms of heartburn, reflux, diarrhea, constipation, and vomiting. She was recently diagnosed with gallstones awaiting surgery.

Past Medical and Surgical History

The patient is known to have hypertension and takes losartan and multivitamin every day. She is reported to have undergone appendectomy what she was age of 10 years. However, there is no known history of food and drug allergy and a history of blood transfusion.

Family Social Economic History

Maria is married with two children and works as a call center manager. She does not take alcohol nor smoke cigarettes. She has a mother and sister who are living with chronic illnesses. They are not in a good relationship with her brother because he doesn’t talk to her. Her mother is suffering from hypertension, hypercholesterolemia, diabetes, and arthritis. Her sister is suffering from diabetes mellitus, hypertension, and breast cancer. Her father was a chronic smoker and passed on due to a heart attack. Both maternal and paternal grandparents are suffering from chronic illnesses.NRP531 Soap Note & Reflection

Review of Systems

The system affected was gastrointestinal with abdominal pain at the right upper quadrant associated with nausea, loss of appetite, and abdominal bloating. Respiratory, cardiovascular, nervous, genital-urinary, and musculoskeletal systems are not affected.

Objective Data

Vitals and Examination

The patient is in a fair general condition. She is not pale, cyanosed, jaundiced, and dehydrated. Her vitals are; blood pressure at 128/78 mmHg, the pulse rate at 78, temperature at 98, height at 4’5 weight of 180kgs BMI of 30.9. Abdominal examination was done through inspection, palpation, auscultation, and percussion. On inspection, the abdomen was of normal skin color, moving with respiration with no therapeutic marks. On palpation, there was rebound tenderness at the right upper quadrant with a positive murphy’s sign. On auscultation, the bowel sounds were reduced. On percussion, a tympanic note was heard all over the abdomen. Other systems had normal findings upon examination.

Diagnostic Data

Laboratory and radiographic workups were done to determine the diagnosis. Complete blood count was normal. A liver function test shows the normal range of the liver enzymes. Abdominal ultrasound shows thickening of the gall bladder wall with sludge and numerous stones.

Assessment

Diagnosis

Huang, et al, (2020) the primary diagnosis for this patient is cholelithiasis or gallstones in a hypertensive patient. This is because the cholelithiasis presents with abdominal pain at the right upper quadrant that is often acute on the onset and is associated with meals. Other symptoms associated with cholelithiasis are; abdominal bloating, reduced appetite, and nausea. On examination, there is rebound tenderness at the right upper quadrant of the abdomen with a positive murphy’s sign.

Differential Diagnosis

Huang, et al, (2020) Differential diagnoses are cholecystitis, cholangitis, and pancreatitis. Cholecystitis presents with colicky abdominal pain at the epigastric region radiating to the right upper quadrant associated with fever, jaundice, and tachycardia. The liver function test shows elevated liver enzymes and there is leukocytosis upon doing a complete blood count. Cholangitis presents with abdominal pain, generalized abdominal tenderness, fever, and jaundice. Cholangitis usually affects patients suffering from untreated cholelithiasis. Pancreatitis presents with abdominal pain that is of gradual onset associated with nausea, vomiting, diarrhea, and anorexia. Upon examination, pancreatitis presents with diffuse abdominal tenderness, jaundice, dyspnea, tremors, and fever.NRP531 Soap Note & Reflection

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Plan

Nagem, et al, (2020) the treatment plan for the patient is both pharmacological and non-pharmacological. Pharmacological treatment entails taking losartan 50 mg once daily to control the blood pressure.  Prescribe Ursodeoxycholic acid 600mg once daily for 16 weeks to reduce the incidence of gallstones. Non-pharmacological treatment entails dietary advice to reduce intake of fatty food to avoid the recurring of gallstones and the patient to involve herself in physical exercise to reduce body weight. The patient will be referred to a surgeon and a gastroenterologist for laparoscopic cholecystectomy and endoscopic retrograde sphincterotomy. After the surgery, the patient should be on long term follow up to monitor complications associated with the surgery.

Part 2

SOAP note; Maria Alvarez reflection

Maria’s reflection

The reason for using an open-ended question during history taking is to gather more information about the presenting complaint. This helps in getting a differential diagnosis as the patient expounds more on the symptoms.

Open-Ended Questions 

  1. Explain more about your abdominal pain? Other symptoms associated with abdominal pain?
  2. Which part of the abdomen has more pain? Where does it start? Does it migrate to any other part of the body?
  3. Explain how the pain starts. Is it acute? Is it gradual?
  4. Describe the severity of the pain. Is it chronic? Or is it mild to moderate pain?
  5. How has been your blood pressure control? Do you have any concerns about your blood pressure medication?

The logic behind asking these questions is to determine the abdominal quadrant affected by the pain, where the pain radiates to, the aggravating factors and relieving factors, to know the onset of the pain, it’s timing, and the duration of the pain as she describes. In the review of the system, past medical and surgical history, family and social history reveal other factors that are related to the illness.

Physical Examination

A comprehensive physical examination from head to toe revealed positive findings for the diagnosis of cholelithiasis with cholecystitis and hypertension. The examination findings are flare-ups at the right upper quadrants at a rate of 5 out of 10. She feels an achy and tight squeeze. According to (Wang, et al, 2020) cholelithiasis presents with pain at the upper right quadrant of the abdomen that is aggravated by meals. It lasts about one hour after meals and is associated with bloating and nausea. These symptoms have gradually increased for over one year. During the examination, Maria pointed out the site of the pain at the right upper quadrant that helps establish the organ affected. The most affected organ is the gall bladder. The symptoms described are cholangitis and cholelithiasis. The pain has persisted for over one year. Therefore, validating the need for a surgical consult and intervention (Wang, et al, 2020) The family history tells more about the risk factors associated with hypertension despite the report of compliance to medication and well-controlled blood pressure (Umemura, et al, 2019).

Evidence-Based Research and Guidelines

Wang, et al, (2020) Cholelithiasis has four stages; the lithogenic state where the gall stones form, the asymptomatic gallstones, symptomatic gallstones, and complicated gallstones. Often the symptomatic state presents with episodic gall bladder pain that is characterized as sporadic and unpredictable constant pain at the right upper quadrant and may radiate to the scapular. Cholelithiasis is more common in women compared to men with a percentage of 8.6% and 5.5% respectively. Cholelithiasis is prevalent in Mexican Americans because of their genes, lifestyle diseases like diabetes, and hypercholesterolemia, obesity, and high intake of processed foods.NRP531 Soap Note & Reflection

Acute Cholecystitis presents with colicky abdominal pain at the epigastric region radiating to the right upper quadrant associated with fever, jaundice, and tachycardia. Upon examination, there is tenderness and positive murphy’s sign. The liver function test shows elevated liver enzymes and there is leukocytosis upon doing a complete blood count. The ultrasound report shows thickening of the gall bladder wall and numerous gall stones. Surgical intervention is the treatment of choice for the symptomatic gall bladder (Wang, et al, 2020).

Hypertension refers to persistently elevated high blood pressure. According to the American heart association, hypertension guidelines conclude that Maria has essential hypertension. Maria has all the risk factors for hypertension like obesity and a family history of hypertension (Umemura, et al, 2019). Other risk factors include diabetes, physical inactivity, and smoking.

Barriers and Improving Quality of Care

Maria is a mother of two who needs to be held and lifted. Following surgery, a patient is advised not to lift more than 10 pounds. This is a great barrier in her treatment if she doesn’t have someone to help her with the children after a surgical procedure. She also needs at least two weeks of bed rest after surgery that seems to be an issue because she is a manager at the call center (Wang, et al, 2020). Having relocated recently, her friends and relatives may not be there to offer emotional support after the surgery.

The nursing officer can help the patient identify the barriers so that they can engage them in self-care. The nurse should offer education and support to meet the needs of the patient. In Maria’s case, education supports include lifestyle modification such as taking a healthy diet, engaging in physical exercise, and weight loss (Umemura, et al, 2019). After identification of the barriers, the practitioner can determine the best treatment modality based on the patient’s family and their quality of life.

References

Huang, Lei, Song, Choe, & Shin, (2020) Cholecystectomy, Gallstones, and the Risk of Hepatobiliary and Pancreatic Cancer: A Population-based Cohort Study Nationwide in Korea. Journal of cancer study and prevention, 25(3), 164

Nagem, Alberti, & Campos-Lobato, (2020) Cholecystectomy in Gallstones Obesity Surgery, 1-6.

Umemura, Asayama, Dohi, Hirooka, & Ito, (2019) Hypertension guidelines and management of hypertension (JSH 2019). Hypertension Research, 42(9), 1235-1481.

Wang, Chow, Joseph, Chan, Rahman, & Shelat, (2020) Improving postoperative care for patients undergoing major surgery. Postgraduate Medical Journal   NRP531 Soap Note & Reflection