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Assignment: Preventative Health and Assessing, Diagnosing, and Treating Special Populations

 

To Prepare:

  • Review this week’s Learning Resources. Consider preventative health and assessing, diagnosing, and treating special populations.
  • Review the case study provided by your Instructor. Based on the provided patient information, think about the health history you would need to collect from the patient.
  • Consider what physical exams and diagnostic tests would be appropriate in order to gather more information about the patient’s condition. Reflect on how the results would be used to make a diagnosis.
  • Identify three to five possible conditions that may be considered in a differential diagnosis for the patient.
  • Consider each patient’s diagnosis. Think about clinical guidelines that might support this diagnosis.
  • Develop a preventative health treatment plan for the patient that includes health promotion and patient education strategies for special populations.

Complete:

Use the Focused SOAP Note Template to address the following:

  • Subjective: What details are provided regarding the patient’s personal and medical history?
  • Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities or psychosocial issues.
  • Assessment: Explain your differential diagnoses, providing a minimum of three. List them from highest priority to lowest priority and include their CPT and ICD-10 codes for the diagnosis. What would your primary diagnosis be and why?
  • Plan: Explain your plan for diagnostics and primary diagnosis. What would your plan be for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
  • Reflection notes: Describe your “aha!” moments from analyzing this case.

 

Please complete the SOAP note with Diagnostic test/labs, Assessment (Primary Diagnosis and Differential diagnosis), Plan and reflection.

 

FOCUS SOAP Note

Patient Information:

Patient Initials: ML              Age: 28                                 Gender: Female  

S.

CC (chief complaint):”I have milky discharge from my right nipple.

HPI: ):Marcia is a 28 year old Hispanic female who comes in with a complaint of nipple drainage on her right  breast.  She says that the discharge started about three months ago and it appears milky.  She says that she has also felt tired, experienced occasional headaches and has been constipated lately.She also reports breakout of Acne on her upper back and forehead.  Her periods have been very light.  She is worried that she “might have cancer”.Her symptoms are not associated with breast tenderness or pain, no fever and no visual changes.

 

Location: Bilateral breast.

Onset:  3 months ago

Characteristic: Milky-

Associated with:

Time:

Exacerbating/ relieving factors:

Radiates: upper back

Current Medications:

1.Lutera (Oral contraceptive pills)

2.Sertraline 50 mg PO OD for depression.

 

Allergies: No known drug allergies

PMH:

1.Depression-well controlled with medication

.

Soc & Substance Hx: Right-handed, married and has 1 children who are living with them. Social history is negative for tobacco, alcohol, and recreational drugs. She practices healthy eating habits and uses a seatbelt while in the vehicle.

Fam Hx: Her parents are both alive. Father has a Heart disorder. Mother has Hypothyroidism.

Surgical Hx:  

Mental Hx: H/o depression well-controlled with medication, no suicidal, self-harm, or homicidal thoughts.

Violence Hx: Denies history of domestic violence.

 

REVIEW OF SYSTEM:

CONSTITUTIONAL: Patient denies chills, fever, weight loss, diminished appetite, unusual thirsty, or unexpected generalized weakness.

NEUROLOGIC: Denies headache, tremors, seizures or gait imbalance, denies tics or numbness in lower extremities, no dizziness, no visual disturbances or speech problems.

PSYCHIATRIC:Reports h/o depression we’ll controlled with medication. Patient denies felling of sadness or diminished appetite, denies anxiety, denies exposure to violence, or sleeping problems. No suicidal ideation.

HEENT: Denies odontalgia, difficulty swallowing, sore throat, hoarseness, ear pain/pruritus or hearing loss.

RESPIRATORY: Denies shortness of breath, cough or chest pain.

CARDIOVASCULAR: No chest pain, palpitations or intermittent claudication, no recent skin rashes, petechiae or unexpected bleeding.

GASTROINTESTINAL: Denies heartburn or regurgitation, no diarrhea, no other kind of abdominal discomfort including any kind of pain, no colicky-like painful sensation after eating grassy food, no history of abdominal surgery, denies constipation or rectal bleeding.

GENITOURINARY: Bowel and bladder continent, denies dysuria, polyuria, cloudy or foul urine recently, no evident blood in urine, denies history of ulcers, vesicles, genital discharge/pain, denies sexual dysfunction.Reports shorter menstrual cycle.

SKIN:Reports worsening acne breakout in her upper back and forehead since starting birth control 6 months ago.

MUSCULOSKELETAL: Denies muscle or joint pain, no muscle weakness or spasms.

 

O

Physical Exam:

 

CONSTITUTIONAL: Blood pressure is 128/77; heart rate is 81; respiration rate is 16; O2 saturation is 98% on room air; and temperature is 98, weight 152 pounds, height 5’6”, BMI 24.5 NEUROLOGIC: AAOx4, no central or peripheral focal neurological deficit, gross sensation, muscle tone and grip strength intact, reflexes intact, no gait disturbances, Romberg test negative, negative Kernig’s and Brudzinski’s signs.Reports occasional headaches.

PSYCHIATRIC: Clear speech, normal rate and answers to questions appropriately. Normal and logical rate of thoughts. Keeps eye contact.

HEENT: EOMs intact, PERRLA, no redness or discharge noted in the ear canal, pearly and non- bulging tympanic membrane bilaterally, no jugular veins distention, no neck mass or enlarged lymph nodes. No white/yellow plaques or ulcers noted on palate, uvula or tonsils, no erythema noted on oropharynx. Normal results obtained after performing Rinne and Weber tests. CARDIOVASCULAR: S1 and S2 RRR, no murmurs, no collateral circulation, no peripheral edema, carotid, apical, radial femoral and pedal pulses present and strong, no carotid murmur bilaterally. RESPIRATORY: No cyanosis, rhonchi or crackles noted, vesicular murmur present bilaterally. GASTROINTESTINAL: Oral cavity with no lesions suggestive of malignancy, wet oral mucosa, abdomen soft, non-tender, non-distended, no hernias, no organomegaly, bowel sounds present in all four quadrants.

GENITOURINARY: States milky-like nipple discharge for the last  3 months. This is first time episode. Symptoms aren’t associated with breast tenderness or pain, no fever, no AMS or visual changes, no dizziness but reports headache, light menstrual period. Upon pelvic PE no vulvar erythema is evident, no vesicles or ulcers, speculum exam shows no ulcers or vesicles, no excoriations. Pregnancy test negative.

MUSCULOSKELETAL: Joints without swelling, increased temperature or redness.

INTEGUMENTARY: Intact skin, warm, pink, no alopecia or desquamative lesions on lower

 

Diagnostic results:

 

Lab tests  

 

 

Diagnostic test

 

 

 

A.

Primary Diagnosis-

1.

 

Differential Diagnoses:

 

Plan:

 

 

Reflection:

 

 

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