Herzing University Week 7 Geriatric Soap Notes Project

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

–          Problem focused visit

–          Chest tightness

–          Behavioral

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

·          None

·         Aclidinium, nicorette

2.      Provider procedure codes

·         94010, 82850

2.      Patient type – outpatient

3.      HPI – shortness of breath, having to clear throat every morning, lack of energy, productive cough, active smoker (half packet per day), COPD

4.      Patients primary language – English

5.      Chart on patient record – yes

6.      Discussed management with the preceptor handled visit independently – yes

7.      Preceptor present during visit – yes

Diagnoses

2.      Plan – lung exam

·         Findings – wheezing, cyanosis, tachypnea, hyperinflation, hyperresonance, coarse crackle with inspiration, diffusely decreased breath sounds

3.      Diagnostic – pulmonary function test (spirometry), arterial blood gas analysis

4.      Therapeutic – aclidinium 400 mcg inhaled PO BID

·         Nicorette 2mg oral chewing gum for 2 weeks

5.      Educational – smoking cessation and general healthy lifestyle, including diet and exercise

6.      Collaboration – collaborated with pulmonologist during patient care.

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

–          Problem focused

–          Shortness of breath

–          Lifestyle

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

·         None

·         aclidinium

2.      Provider procedure codes

·         71260, 94010

2.      Patient type – outpatient

3.      HPI – shortness of breath and inability to do tasks like taking a flight of stairs

4.      Patients primary language – English

5.      Chart on patient record – yes

6.      Discussed management with the preceptor handled visit independently – yes

7.      Preceptor present during visit – yes

Diagnoses

2.      Plan –  pulmonary exam

·         Findings – pink puffers, barrel chest, respiratory distress indicated by use of accessory respiratory muscles, hyperresonance, prolonged expiration, coarse crackle with inspiration, diffusely decreased breath sound

3.      Diagnostic – chest CT-scan, lung function test,

7.      Therapeutic – aclidinium 400 mcg inhaled PO BID

·         Pulmonary rehabilitation

4.      Education – proper nutrition to prevent weight loss, avoid respiratory irritants, prevent respiratory infection through immunization, and regular exercise.

5.      Collaboration – collaborated with

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

–          Wellness visit

–          Weight gain

–          Lifestyle

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

–          None

–          No medication prescribed

2.      Provider procedure codes

–          83718, 10256, 82947, 80091

2.      Patient type – outpatient

3.      HPI – weight gain

4.      Patients primary language – English

5.      Chart on patient record – no

6.      Discussed management with the preceptor handled visit independently – yes

7.      Preceptor present during visit – yes

Diagnosis

2.      Plan – BMI calculation, waist circumference

·         Findings – BMI of 30, central obesity (40 inches)

3.      Diagnostics – cholesterol test, liver function test, fasting glucose test, thyroid test

4.      Therapeutics – no medication prescribed

–          Exercise regime

5.      Educational – exercise, nutritional adjustment to limit carbohydrates and increase lean protein and vegetables, and alcohol cessation

6.      Consultations – consulted nutritional doctor during patient education

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

–          Problem-focused visit

–          Painful skin rush on the left leg

–          Lifestyle

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

·         Lamivudine

·          cephalexin

2.      Provider procedure codes

·         87077, 86361

2.      Patient type – outpatient

3.      HPI – fatigue, fever, sweating, nausea and vomiting, numbness of affected region, HIV, obesity

4.      Patients primary language – English

5.      Chart on patient record – no

6.      Discussed management with the preceptor handled visit independently – yes

7.      Preceptor present during visit – yes

Diagnosis

2.      Plan – skin assessment

·         Findings – red, warm, swollen skin on the left leg

3.      Diagnostic – blood test, T-cells absolute CD4 count

4.      Therapeutic  – oral cephalexin 500mg q6h x 5 for 10 days

·         Care – good hygiene, cleaning, and dressing of the wound

5.      Educational – nutritional education to control obesity

6.      Collaboration – collaborated with dermatologist during patient care

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

–          Wellness visit

–          breathlessness

–          Behavioral

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

–          albuterol

–          albuterol

2.      Provider procedure codes

–          94010, 94150

2.      Patient type – outpatient

3.      HPI – asthmatic, exacerbation

4.      Patients primary language – English

5.      Chart on patient record – yes

6.      Discussed management with the preceptor handled visit independently – yes

7.      Preceptor present during visit – yes

Diagnoses

2.      Plan – respiratory assessment

·         Findings – absence of transverse crease, pro-longed end expiratory wheeze

3.      Diagnostics – spirometry and peak flow test

4.      Therapeutics – nebulization and albuterol q6h

5.      Education – avoid cigarette smoke, avoid intense physical activity, and avoid allergens including fumes, pets, and dust

6.      Collaboration – collaborated with pulmonologist during patient care

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

–          Problem-focused visit

–          Abdominal pain

–          Behavioral

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

–          None

–           Mesalamine

2.      Provider procedure codes

–          36415, 82270, 45378, 45330

2.      Patient type – outpatient

3.      HPI – mucoid bloody diarrhea of gradual onset, rectal urgency, blood on inner wear, weight loss, tenesmus

4.      Patients primary language – English

5.      Chart on patient record – yes

6.      Discussed management with the preceptor handled visit independently – yes

7.      Preceptor present during visit – yes

Diagnoses

2.      Plan – gastrointestinal assessment

·         Findings – absence of tenderness indicating less severe disorder, blood seen on rectal exam

3.      Diagnostic  –  blood test, stool test, colonoscopy, flexible sigmoidoscopy

4.      Therapeutic – Mesalamine 1.5g tid for 2.4 weeks

5.      Educational – avoidance of spicy foods and reduction high fiber foods, consume high protein and high-calorie foods low in fiber

6.      Collaboration – collaborated with gastroenterologist during patient care

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

–          Problem-focused evaluation

–          Extreme fatigue

–          behavioral change

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

–          None

–          Hydrocortisone

2.      Provider procedure codes

–           36415, 80400, 82951, 74150

2.      Patient type – outpatient

3.      HPI – nausea, dizziness, depression, anorexia, extreme fatigue, salt craving, sexual dysfunction, fainting, and joints and muscle pain

4.      Patients primary language – English

5.      Chart on patient record – yes

6.      Discussed management with the preceptor handled visit independently – yes

7.      Preceptor present during visit – yes

Diagnosis

2.      Plan – clinical evaluation

·         Findings – hyperpigmentation, irritability, orthostatic hypotension, fever

3.      Diagnostics – blood test, adrenocorticotropic stimulation test, insulin-induced hypoglycemia test, abdomen and neck adrenal glands CT scan

4.      Therapeutic – Hydrocortisone 100 mg bolus immediately; followed by e100 mg q8h oral maintenance dose 10mg morning, 5mg noon, and 5mg afternoon

5.      Educational – general healthy living habits, including proper nutrition, exercise, and preventive medicine

6.      Consultation – collaborated with endocrinologist during patient care.

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

–          Preventive visit

–          No presenting complaint

–          Lifestyle

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

–          Prednisone

–          None

2.      Provider procedure codes

–           45378

2.      Patient type – outpatient

3.      HPI – Crohn’s disease

4.      Patients primary language – English

5.      Chart on patient record – yes

6.      Discussed management with the preceptor handled visit independently – yes

7.      Preceptor present during visit – yes

Diagnoses

2.      Plan– abdominal assessment

·         Findings – no ascites, absence of mass, no hepatomegaly, no rectal bleeding

3.      Diagnostic – colonoscopy

4.      Therapeutic – no medication prescribed

5.      Education – immunizations, nutritional education including consumption of high fiber foods and general healthy lifestyle including physical exercise and limitation of alcohol use

6.      Collaboration – collaborated with gastroenterologist during screening

2.      Reason for visit

3.      Chief complaint

4.      Social problems addressed

–          Problem-focused visit

–          Fever and headache

–          Lifestyle

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

–          None

–          Oseltamivir

2.      Provider procedure codes

–          87804

2.      Patient type – outpatient

3.      HPI – Nasal congestion, fever, fatigue, sore throat, sweats and chills, and muscle ache that began 4-days ago

4.      Patients primary language – English

5.      Chart on patient record – yes

6.      Discussed management with the preceptor handled visit independently – yes

7.      Preceptor present during visit – yes

Diagnosis

2.      Plan – upper respiratory evaluation

·         Findings- nasal congestion, runny nose, throat erythema, dry cough, focal wheezing, rales

3.      Diagnostic – rapid flu test

4.      Therapeutic – Oseltamivir 75 mg (1×2) for 5 days

5.      Educational – geriatric immunization, general healthy living including moderate exercise, stress reduction, and proper nutrition

6.      Consultation – consulted with pulmonologist during patient management

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

–          Problem-focused visit

–          Anal irritation

–          Nutritional change

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

–          None

–          No drug prescribed

2.      Provider procedure codes

–          46600

2.      Patient type – outpatient

3.      HPI –discomfort in the anus associated with painful swelling, bleeding when passing stool, and itching

4.      Patients primary language – English

5.      Chart on patient record – yes

6.      Discussed management with the preceptor handled visit independently – yes

7.      Preceptor present during visit – yes

Diagnosis

2.      Plan – anal evaluation

·         Findings –  skin tags in the anal verge

3.      Diagnostic – anoscopy

4.      Therapeutic – sitz baths : sit in warm water for 15 minutes q8 for 4 weeks AND cold compresses

5.      Educational – dietary change to a diet high in fiber and ensuring proper hydration to avert constipation

6.      Consultation – consulted with gastroenterologist during patient evaluation

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

–          Wellness visit

–          No presenting complaint

–          Behavioral change

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

–          Abacavir

–          Abacavir

2.      Provider procedure codes

–          87522

2.      Patient type – outpatient

3.      HPI – HIV infection

4.      Patients primary language – English

5.      Chart on patient record – yes

6.      Discussed management with the preceptor handled visit independently – yes

7.      Preceptor present during visit – yes

           Diagnoses

2.      Plan – clinical evaluation

Findings – no thyroid abnormalities, no hepatomegaly, no spider angioma, no palmar erythema

3.      Diagnostic – blood test for hepatitis C virus (HCV)

4.      Therapeutic – Abacavir 1 tablet PO per day

5.      Educational – good dietary habits, exercise, safe sex practices, importance of immunization

6.      Consultation – collaborated with gastroenterologist during patient assessment

2.      Reason for visit

3.      Chief Complaint.

4.      Social problems addressed.

–          Problem focused

–          Warmth in the leg

–          Lifestyle

2.      Prescriptions currently prescribed

3.      New/refilled prescriptions

–          None

–          Fondaparinux

2.      Provider procedure codes

–          85379, 93970

2.      Patient type – outpatient

3.      HPI – cramping in the calf, warmth in the leg

4.      Patients primary language – English

5.      Chart on patient record – yes

6.      Discussed management with the preceptor handled visit independently – yes

7.      Preceptor present during visit – yes

Diagnoses

2.      Plan – lower extremity assessment

·         Findings – unilateral calf redness, pitting edema, calf swelling, palpable cord, localized tenderness of posterior calf, dilated unilateral collateral superficial veins

3.      Diagnostic – D dimer blood test, ultrasound

4.      Therapeutic – fondaparinux 7.5 mg once daily

–          Compression stockings

5.      Education – regular exercise, avoid prolonged sitting or standing

6.      Collaboration – collaborated with vascular doctor during patient care