NURS 6565 Focused SOAP Note For Hispanic Female

NURS 6565 Focused SOAP Note For Hispanic Female

Patient Information:

VD, 43, Female, Hispanic

S.

CC “I felt a lump in my left breast”.

HPI: Patient VD is a 43 year old Hispanic female who presents for evaluation for the complaint of a left breast lump. She reports that she first felt the lump about a month ago which she thought was due to a tight sport bra. She then felt the lump about a week ago again. It is the same size and it is not painful. She denies any breast skin changes or nipple discharge. She denies any axillary lumps. She reports a recent 30 lbs weight loss. She has a Mirena IUD since 2015. No menses to date and no family history of breast cancer. She denies fever chills. She rates the severity of her symptoms at 6/10. NURS 6565 Focused SOAP Note For Hispanic Female

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Current Medications:

1. Albuterol HFA 108 (90 base) MCG/ACT 2 puffs in to the lungs as needed for wheezing,
2. Flovent HFA 110 MCG/ACT 1 puff into the lungs 2 times daily
3. Budesonide 90 MCG/ACT 2 puffs into the lungs 2 times daily
4. Escitalopram 10 mg daily
5. Levonorgestrel (Mirena, 52 mg) IUD since 2015.

Allergies: Cat Dander- Shortness of breath, Shellfish derived products-Shortness of breath. Asthma, anxiety. No past surgeries.

PMHx: Covid -19 (Janssen) 3/19/21, Covid-19 (Pfizer-purple cap) 10/31/2021, influenza 10/19/2021, PPSV23 6/2/2022, Td 10/19/2020.

Soc & Substance Hx: She is a stay home mother. She lives with her husband with a 4 year old autistic son in an apartment with working smoke detectors. She does not drink or smoke. She usually uses a seatbelt at all times when driving. She does not text and drive. She feels safe and has no concerns for domestic violence. She has support from family and friends.

Fam Hx:  Paternal and maternal grand-parents all deceased with unknown causes in Brasil. The mother is alive with hypertension. The father is also alive with hypertension. She has one sister who is alive and healthy. She has a 4 year-old son living with autism.

Surgical Hx: No past surgical history.

Mental Hx: History of anxiety- well controlled on escitalopram. No current concerns, no history of self- harm, SI or HI.

Violence Hx: Feels safe. She denies concerns or issues about violence.

Reproductive Hx: Mirena IUD since 2015. No menses. She has vaginal intercourse and sexual concerns. NURS 6565 Focused SOAP Note For Hispanic Female

ROS:

ROS::

GENERAL: Admits to intentional weight loss but denies fever, chills, weakness, or fatigue.

HEENT: Eyes: Denies vision changes or yellow sclerae. No decreased hearing or hearing loss, no nasal congestion, runny nose, sneezing or sore throat.

SKIN: Denies itching, dryness, rashes or bruises.

CARDIOVASCULAR: Denies chest pain/pressure, tightness or any chest discomfort. Denies palpitations, dizziness or LE edema

RESPIRATORY: Denies SOB, orthopnea, cough.

GASTROINTESTINAL: Denies abdominal pain, anorexia, nausea, vomiting, black or bloody stools.

GENITOURINARY: Denies urinary symptoms such as burning, pain, frequency or urgency. Has had Mirena IUCD since 2015. No menses.

NEUROLOGICAL: Denies dizziness, headache, syncope, weakness, paresthesia, bowel or bladder incontinence.

MUSCULOSKELETAL: No muscle pain or stiffness. No back or joint pain.

HEMATOLOGIC: No bleeding or bruising. No anemia.

LYMPHATICS: Negative for enlarged lymph nodes.

PSYCHIATRIC: History of anxiety. No SI/HI.

ENDOCRINOLOGIC: Denies increased thirst or urination. Also denies diaphoresis, heat or cold intolerance.

REPRODUCTIVE: Denies unusual vaginal discharge, itching or odor. She is sexually active with her husband. She has had Mirena IUD since 2015.

ALLERGIES: History of asthma. No rhinitis, hives or eczema. NURS 6565 Focused SOAP Note For Hispanic Female

O.

Physical exam:

VS: Temp 97.1; Pulse 71; RR 20; BP 116/71; SpO₂ 97%; Height: 5’5” Weight: 147 lbs; BMI 24.46 kg/m²

General: Well appearing, no apparent distress.

HEENT: Head: normocephalic, EYES: PERRLA, sclera clear. Ears: Nose: nares patent, throat: no redness or exudate, uvula midline.

NECK: Supple, no LAD, thyroid not enlarged.

Breast: Palpable lump on left breast measuring approximately 2 cm by 1 cm.

RESP: Lungs clear to auscultation, without rales, rhonchi or wheezing.

CV: Regular rhythm, normal sounds S1 & S2 and absence of murmurs, rubs or gallops.

Skin: clear with no rashes.

GI: The abdomen is soft and non-tender. There are positive bowel sounds in all quadrants. No evidence of organomegaly or masses. No guarding.

GU: No pv discharge noted (Ball et al., 2019; Bickley, 2017)NURS 6565 Focused SOAP Note For Hispanic Female

Diagnostic results:

• WBC 7 x 10⁹
• Hb 13.6 g/dL
• CRP 3
• Biopsy taken for microscopic studies.
  

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A.

Differential Diagnoses:

1. Fibroadenoma: This is the most likely primary diagnosis for this 43 year-old Hispanic female. Fibroadenomas are non-cancerous breast tumors that are benign. They are primarily made up of glandular and connective tissue and they are nothing to be concerned about. Fibroadenomas can affect women of any age and usually diminish after menopause (Hammer & McPhee, 2018; Huether & McCance, 2017). To avert intrusive interventions on this 43-year-old woman who is already exhibiting menopausal symptoms (no periods), she may only need to be reassured.
2. Breast lymphoma: This is the second most likely differential diagnosis for this patient. Breast lymphoma is a type of non-Hodgkin lymphoma (NHL) that is extremely rare. A growing, innocuous and painless growth in the breast is typically the only sign (Hammer & McPhee, 2018; Huether & McCance, 2017)NURS 6565 Focused SOAP Note For Hispanic Female. Chemotherapy is frequently successful in treating the lymphoma.
3. Breast Cancer: Breast cancer is more common in women than in men. A mass in the breast, bloody leakage from the nipple, and abnormalities in the form or consistency of the nipple or breast are all signs of breast cancer (Hammer & McPhee, 2018; Huether & McCance, 2017). Chemotherapy, radiotherapy, and surgical resection are all used in the treatment of cancer.

The plan includes finding out if the growth is cancerous, intervening, and following up. These measures therefore are:

1. Fine needle aspiration to obtain a specimen for evaluation for cancer.
2. If cancerous, radiotherapy and chemotherapy after staging.

• Consideration for mastectomy (complete surgical resection) if lymph nodes not yet involved (Hammer & McPhee, 2018; Huether & McCance, 2017).

1. Psychoeducation to help her cope with stigma and the aesthetic deficiencies in case of mastectomy. This will require referral to a therapist.
2. If the mass is a non-cancerous Fibroadenoma, lumpectomy will be performed.
3. If non-Hodgkin lymphoma intensive chemotherapy with vincristine, doxorubicin, cyclophosphamide, and prednisone followed by field radiation (Hammer & McPhee, 2018; Rosenthal & Burchum, 2018)NURS 6565 Focused SOAP Note For Hispanic Female.

• Follow up after two weeks to reveal biopsy results and evaluation/ treatment.

Reflection:

This case study was one of those from which I learnt a lot concerning cancers and benign breast growths. Given my cognitive domain knowledge on patient examination and history taking (subjective and objective information), it is my opinion that all that was required was done for this patient. I therefore agree generally with my preceptor’s treatment. The main reason for this or why I agree is that all are evidence-based practice (EBP) interventions (Melnyk & Fineout-Overholt, 2019). What I therefore learnt from this case is that the diagnosis of a breast lump requires great clinical acumen and physical examination skills. If given another chance I would still do things the same way. For health education and promotion, I would focus the patient on acceptance of their current situation especially if they have to undergo surgery to remove the breast (mastectomy)NURS 6565 Focused SOAP Note For Hispanic Female. Their image of self will also change if they start chemotherapy and they develop alopecia. This means I will counsel them or refer them for therapy. Education on a healthy diet rich in fruits and vegetables as well as frequent exercise are other health considerations that I will discuss with the patient.

References

Ball, J., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2019). Seidel’s guide to physical examination: An interprofessional approach, 9^th ed. Elsevier.

Bickley, L.S. (2017). Bates’ guide to physical examination and history taking, 12th ed. Wolters Kluwer.

Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8^th ed. McGraw-Hill Education.

Huether, S.E. & McCance, K.L. (2017). Understanding pathophysiology, 6^th ed. Elsevier, Inc.

Melnyk, B.M., & Fineout-Overholt, E. (2019). Evidence-based practice in nursing & healthcare: A guide to best practice, 4^th ed. Wolters Kluwer.

Rosenthal, L.D., & Burchum, J.R. (2018). Lehne’s pharmacotherapeutics for advanced practice providers. Elsevier.

Focused SOAP Note Template

 Patient Information:

VD, 43, Female, Hispanic

S.

CC “ I felt a lump in my left breast”

HPI: VD  is a 43 year old Hispanic female presents to for evaluation left breast lump. She reports that she first felt the lump about a month ago which thought was due to a tight sport bra. She then felt the lump about a week ago.it is the same size and it is not painful. She denies any breast skin changes or nipple discharge. she denies any axillary lumps. She reports a recent 30 lbs weight loss. She has a Mirena IUD since 2015. No menses on this.no family history of breast cancer. She denies fever chills. NURS 6565 Focused SOAP Note For Hispanic Female

Current Medications: Albuterol HFA 108 (90 base) MCG/ACT 2 puffs in to the lungs as needed for wheezing, Flovent HFA 110 MCG/ACT 1 puff into the lungs 2 times daily, Budesonide 90 MCG/ACT 2 puffs into the lungs 2 times daily, Escitalopram 10 mg daily, Levonorgestrel (Mirena, 52 mg) IUD since 2015.

Allergies: Cat Dander- Shortness of breath, Shellfish derived products-Shortness of breath.

PMHx: Covid -19 (Janssen) 3/19/21, Covid-19 (Pfizer-purple cap) 10/31/2021, influenza 10/19/2021, PPSV23 6/2/2022, Td 10/19/2020. Asthma, anxiety. No past surgeries.

Soc & Substance Hx: Stay home mom. Lives with husband with 4 year old autistic son in apartment with working smoke detectors. She does not drink or smoke. Uses seatbelt at all times. She does not text and drive. She feels safe and has no concerns for domestic violence. She has support from family and friends.

Fam Hx:  Paternal and maternal grand-parents all deceased with unknown causes in Brasil. Mother alive with hypertension, father alive with hypertension, 1 sister alive and healthy. 4 year old son with autism. NURS 6565 Focused SOAP Note For Hispanic Female

Surgical Hx: No past surgical history.

Mental Hx: History of anxiety- well controlled on escitalopram. No current concerns, no history of self- harm, SI or HI.

Violence Hx: Feels safe. Denies concerns or issues about violence.

Reproductive Hx: Mirena IUD since 2015. No menses. Vaginal intercourse and sexual concerns.

ROS: Cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

ROS::

GENERAL: intentional weight loss, no fever, chills, weakness, or fatigue.

HEENT: Eyes: Denies vision changes or yellow sclerae. ENT:  No decreased hearing or hearing loss, no nasal congestion, runny nose, sneezing or sore throat.

SKIN: denies itching, dryness, rashes or bruises.

CARDIOVASCULAR: Denies chest pain/pressure, tightness or any chest discomfort. Denies palpitations, dizziness or LE edema

RESPIRATORY: Denies SOB, orthopnea, cough.

GASTROINTESTINAL: Denies abdominal pain, anorexia, nausea, vomiting, black or bloody stools.

GENITOURINARY: Denies urinary symptoms such as burning, pain, frequency or urgency. Mirena since 2015. No menses.

NEUROLOGICAL: Denies dizziness, headache, syncope, weakness, paresthesia, bowel or bladder incontinence.

MUSCULOSKELETAL: No muscle pain or stiffness. No back or joint pain.

HEMATOLOGIC: No bleeding or bruising. No anemia.

LYMPHATICS: no enlarged lymph nodes.

PSYCHIATRIC: history of anxiety. No SI/HI.

ENDOCRINOLOGIC: Denies increased thirst or urination. Denies diaphoresis, heat or cold intolerance.

REPRODUCTIVE: Denies unusual vaginal discharge, itching or odor. Sexually active with husband. Has Mirena IUD since 2015. NURS 6565 Focused SOAP Note For Hispanic Female

ALLERGIES: History of asthma. No rhinitis, hives or eczema.

O.

Physical exam:

VS: Temp 97.1 Pulse 71 RR 20 BP 116/71 O2sat 97% Height:5’5” Weight: 147lbs BMI 24.46 kg/m

General: Well appearing, no apparent distress.

HEENT: Head: normocephalic, EYES: PERLLA, sclera clear. Ears: Nose: nares patent, throat: no redness or exudate, uvula midline.

NECK: supple, no LAD, thyroid not enlarged.

Breast:

RESP: Lungs clear to auscultation, wihtout rales , rhonci or wheezing.

CV: regular rhythm, normal sounds S1 S2 and absence of murmurs, rubs or gallops.

Skin:

GI: adb soft nontender, positive bowel sounds in all quadrants. No evidence of organomegaly or masses. No guarding.

GU:

From head to toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format (i.e.) General: Head: EENT: etc.

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidence and guidelines)NURS 6565 Focused SOAP Note For Hispanic Female

A.

Differential Diagnoses:

1.Fibroadenoma

2. Fibrocystic mass
3. Breast Cancer

You must have at least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.

Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s treatment of the patient and why or why not. What did you learn from this case? What would you do differently?

Also include in your reflection, a discussion related to health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.)NURS 6565 Focused SOAP Note For Hispanic Female.

 References

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

 

Please follow the rubric and instructions below carefully. I am uploading the soap note template. I completed most of the note. I needed it to be reviewed corrected. I also need the 3 differential diagnoses with the instructions ( please review in instructions and rubric to complete)NURS 6565 Focused SOAP Note For Hispanic Female.

Review this week’s Learning Resources, including the Focused SOAP Note Template.
Select a patient who you saw at your practicum site during the last 3 weeks. With this patient in mind, consider the following:
Subjective: What details did the patient provide regarding his or her 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 and psychosocial issues.
Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 code for the diagnosis. What was your primary diagnosis and why?
Plan: What was your plan for diagnostics and primary diagnosis? What was your plan 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: What was your “aha” moment? What would you do differently in a similar patient evaluation?

Rubric Detail

A rubric lists grading criteria that instructors use to evaluate student work. Your instructor linked a rubric to this item and made it available to you. Select Grid View or List View to change the rubric’s layout.

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Name: PRAC_6565_Week3_Assignment1_Rubric
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Create documentation in the Focused SOAP Note Template about the patient you selected.

In the Subjective section, provide: NURS 6565 Focused SOAP Note For Hispanic Female

• Chief complaint

• History of present illness (HPI)

• Current medications

• Allergies

• Patient medical history (PMHx), including immunization status, social and substance history, family history, past surgical procedures, mental health, safety concerns, reproductive history

• Review of systems–
Levels of Achievement:
Excellent 9 (9.00%) – 10 (10.00%)
Good 8 (8.00%) – 8 (8.00%)
Fair 7 (7.00%) – 7 (7.00%)
Poor 0 (0.00%) – 6 (6.00%)
In the Objective section, provide:

• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history

• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses–
Levels of Achievement:
Excellent 9 (9.00%) – 10 (10.00%)
Good 8 (8.00%) – 8 (8.00%)
Fair 7 (7.00%) – 7 (7.00%)
Poor 0 (0.00%) – 6 (6.00%)
In the Assessment section, provide:

• At least 3 differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.– NURS 6565 Focused SOAP Note For Hispanic Female
Levels of Achievement:
Excellent 23 (23.00%) – 25 (25.00%)
Good 20 (20.00%) – 22 (22.00%)
Fair 18 (18.00%) – 19 (19.00%)
Poor 0 (0.00%) – 17 (17.00%)
In the Plan section, provide:

• A detailed treatment plan for the patient that addresses each diagnosis, as applicable. Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient, and any planned follow up visits.
• Reflections on the case describing insights or lessons learned.

• A discussion related to health promotion and disease prevention taking into consideration patient factors, PMH, and other risk factors.–
Levels of Achievement:
Excellent 27 (27.00%) – 30 (30.00%)
Good 24 (24.00%) – 26 (26.00%)
Fair 21 (21.00%) – 23 (23.00%)
Poor 0 (0.00%) – 20 (20.00%)
Provide at least three evidence-based, peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than five years old) and support the treatment plan in following current standards of care.–
Levels of Achievement:
Excellent 9 (9.00%) – 10 (10.00%)
Good 8 (8.00%) – 8 (8.00%)
Fair 7 (7.00%) – 7 (7.00%)
Poor 0 (0.00%) – 6 (6.00%)
Written Expression and Formatting – Paragraph Development and Organization: NURS 6565 Focused SOAP Note For Hispanic Female

Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.–
Levels of Achievement:
Excellent 5 (5.00%) – 5 (5.00%)
Good 4 (4.00%) – 4 (4.00%)
Fair 3.5 (3.50%) – 3.5 (3.50%)
Poor 0 (0.00%) – 3 (3.00%)
Written Expression and Formatting – English writing standards:

Correct grammar, mechanics, and proper punctuation–
Levels of Achievement:
Excellent 5 (5.00%) – 5 (5.00%)
Good 4 (4.00%) – 4 (4.00%)
Fair 3.5 (3.50%) – 3.5 (3.50%)
Poor 0 (0.00%) – 3 (3.00%)
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.–
Levels of Achievement:
Excellent 5 (5.00%) – 5 (5.00%)
Good 4 (4.00%) – 4 (4.00%)
Fair 3.5 (3.50%) – 3.5 (3.50%)
Poor 0 (0.00%) – 3 (3.00%)
Name:PRAC_6565_Week3_Assignment1_Rubric