Soap Note 1 “ADULT”  Wellness check up (10 points)

Follow the MRU Soap Note Rubric as a guide:

Use APA format and must include mia minimum of 2 Scholarly Citations.

Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)

Turn it in’ s Score must be less than 25% or will not be accepted for credit; it must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 25%. Copy-paste from websites or textbooks will not be accepted or tolerated and will receive a grade of 0 (zero) with no resubmissions allowed.

Running Head: SOAP NOTE

SOAP NOTE 1- DEPRESSION

Name of Instructor:

Course Title:

Due Date:

IDENTIFYING DATA

A.D is a 55-year-old Hispanic male who came to the clinic accompanied by one of his daughter due to feeling hopeless and depressed more each day, feeling muscle tension. Both are worried with this condition, and are looking for a close are of of his situation

CHIEF COMPLAINT: “I notice I feel more depressed everyday.”.

FAMILY HISTORY

Mother- passed away 2 months ago, of a Myocardial Infarction. Father alive- history of Colon cancer, patient has 1 daughter healthy with no medical history. Patient has a brother, current with diabetes mellitus type 2. No other conditions reported between those family members.

PERSONAL HISTORY

The patient equation has enjoyed good health throughout his life. He has never been troubled by anything and has been able to handle all the challenges that come his way. He has been able to establish social networks that help him during difficulties. However, the patient in question has been living an isolated life. There is a possibility he has not been getting the support he had before. This possibly worsened his mental status resulting in depression.

MEDICAL HISTORY

That was a point in the past when the patient broke his arm in a minor accident. It is an event that it’s believed to have caused him stress. This is because it made him hard to work for himself as he is used to. His absence from the workplace could have contributed to his feeling of depression. As a person known to love his work, this accident likely caused the depression case in question.

SOCIAL HISTORY

The patient is not a social person. He prefers to be alone in the majority of cases. He is also known to be a private person with his issues. It is suspected there is a possibility that he is undergoing an issue he is afraid to communicate with others (Palgi, Shrira, Ring, Bodner, Avidor, Bergman & Hoffman, 2020). This is why the patient must be approached with care to diagnose his issue and medical conditions.

OCCUPATIONAL HISTORY

Deficient in question has been productive in most of his years. His occupation has been more office-based; therefore, he has spent most of his time indoors. There are a few scenarios where the patient was subjected to fieldwork. As a less going person, the feedback could have gone better with him. He was pushed to the Limit, and at some point, he felt like quitting his job.

PAST PSYCHIATRIC HISTORY

The best psychiatric history of the patient is shallow and needs more information. The limited data provided makes it difficult to ascertain a psychiatric history.

HISTORY OF PRESENT ILLNESS

Patient has been depressed for a couple of months. The patient wanted to seek medical advice and support, but the current case of depression has not allow him. Today came accompanied by his daughter, due to as per patient, he is aware that every day he feels more depressed, hopeless, feeling with muscle tension and constantly. Patient denied any suicidal ideation, but report feeling really bad. This is why the patient needs further medical attention to manage his medical condition. The patient is in direct need of help because of his disturbed mental status. This is why his case has to be considered objectively and treated as the cause of his depression.

IMPRESSIONS

From the diagnosis, the patient seems ready for any medical treatment, he will be subjected to. If it were therapies, the patient would be ready to go through all necessary therapies to recover from his mental status (Strawbridge, Carter, Marwood, Bandelow, Tsapekos, Nikolova & Young, 2019). If the patient has to be treated through medication, he is also ready for all the processes.

PRIMARY DIAGNOSIS

— Depression : A group of conditions associated with the elevation or lowering of a person’s mood. A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life.

According to the DSM5 (American Psychiatric Association, 2013). Patient presents with more than five of the following symptoms:

Combination of biological, psychological, and social sources of distress.

The persistent feeling of sadness or loss of interest.

Changes in sleep, appetite, energy level, concentration, daily behavior, or self-esteem.

Depression can also be associated with thoughts of suicide.

Anxiety may occur as a symptom of clinical (major) depression.

Feeling muscle tension as cause of the stress caused the depression.

Isolation person don’t involve in social activities.

DIFFERENTIAL DIAGNOSIS

1. Social Anxiety Disorder

Focus of the fear involves concerns over being embarrassed and negatively evaluated by others.

Panic sensations are cued by anticipated and actual exposure to social and evaluative situations.

2. Separation anxiety disorder: Anxiety sensations are cued by perceived and actual separation from family members, rather than fears of being negatively evaluated or criticized by others.

3. Panic Disorder: High anticipatory anxiety across various social situations. Recurrent, unexpected panic attacks in the absence of phobic cues. Patients may interpret their intense physical symptoms as threatening or dangerous.

PLAN:

Labs will be drawn: -TSH, -CBC. Exams: ECG.

Safety: -Patient must not be alone, due to suicide risk. This patient has had depression for months. If his sad state persists, the patient can begin thinking about committing suicide.

Pharmacological Treatment: Celexa to 60 mg daily which patient states she has used in the past with good results. The possible side effects are: Headache, nausea, diarrhea, dry mouth, increased sweating, feeling nervous, restless, fatigue, or having trouble sleeping (insomnia).

REFERENCES:

Palgi, Y., Shrira, A., Ring, L., Bodner, E., Avidor, S., Bergman, Y., … & Hoffman, Y. (2020). The loneliness pandemic: Loneliness and other concomitants of depression, anxiety and their comorbidity during the COVID-19 outbreak.  Journal of affective disorders,  275, 109-111.

Strawbridge, R., Carter, B., Marwood, L., Bandelow, B., Tsapekos, D., Nikolova, V. L., … & Young, A. H. (2019). Augmentation therapies for treatment-resistant depression: systematic review and meta-analysis.  The British Journal of Psychiatry,  214(1), 42-51.

Life Transitions Assignment PNUR1165

Assignment: Life Transitions Assignment

Weighting: 20% of final grade

Course Outcomes:

Purpose of Life Transitions Assignment: To interview an older adult (over the age of 65 years) on their late life transitions. Then discuss/analyze the relevant older adult life transitions as it compares/contrasts with the course content.

Instructions for Assignment:

1. Interview an older adult (someone over 65 years of age).  Note their approximate age.  This person can be a friend, relative, neighbor, parent, or grandparent or someone you have met in the community.  Acknowledge that you were instructed to interview an interesting person for your school assignment.

2. Develop your questions based on adult life transitions as it relates to a person’s lived experience.

3. When choosing a time for the interview, consider when the person feels most comfortable.

4. Consider the length of time you will be taking.

5. Assure the interviewee that they may refuse to answer any question.

6. Be empathic and nonjudgmental. Remember that the person is honoring you by sharing his/her life story.

7. Write a 4-6-page paper analyzing the person’s lived experience. Do not use their name or location to maintain confidentiality.

8. Choose 4 or 5 late-life transitions that apply to your interviewee’s lived experience to analyze.

9. Utilize APA format. The resources can be found at: https://lib.conestogac.on.ca/apa-conestoga

10. The essay must include a title page, in-text citations, and a reference page. (Do not reference the course slides).

11. All work is expected to be your original work in your own words. All items copied from other sources must be quoted or paraphrased or summarized with appropriate citations or references. Academic honesty is expected and required of all Conestoga students. It is critical that you familiarize yourself with the Academic Offences Policy found in the Conestoga  Student Guide . 

12. This assignment will be evaluated in terms of how you use the course content to interpret or explain what you described in the interview. What various life transitions occurred during this person’s older adult years?

13. Do not include the interview transcript in this assignment.

14. Review the rubric to ensure you have addressed all elements that will be evaluated.

15. Submit to the Assignment Submission Folder on eConestoga.

Instructions for Submission:

1. To be marked, this assignment must be submitted to the Assignment Submission Folder entitled “Life Transitions Assignment” in the PNUR1165 Adult Development and Aging Shell on eConestoga.

a. Click on “Course Tools” tab

b. Click on “Assignment”

c. Click on the Assignment Submission Folder called “Life Transitions Assignment”

d. Upload your file

e. Click “Submit”

2. Receive verification of a “Dropbox submission receipt” in your eConestoga inbox

a. Only the most recent submission to the Dropbox is kept to be marked

RUBRIC

Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Transcript

All Lines (645)Interview Questions (210)Statements (41)Exam Actions (394)

Subjective Data Collection: 50 of 50 (100.0%)

Hover To Reveal…

Hover over the  Patient Data items below to reveal important information, including  Pro Tips and  Example Questions.

· Found:

Indicates an item that you found.

· Available:

Indicates an item that is available to be found.

Category

Scored Items

Experts selected these topics as essential components of a strong, thorough interview with this patient.

Patient Data

Not Scored

A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.

Current Health Status

· Finding:

Confirmed reason for visit

· Finding:

Reports needing a pre-employment physical

·

Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation(Found)

Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.

Example Question:

Can I confirm that you are here for a physical?

· Finding:

Reports no current acute health problems

(Found)

Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.

Example Question:

Do you have any current health problems?

· Finding:

Asked about last visit to a healthcare provider

· Finding:

Last visit to a healthcare provider was 4 months ago

(Found)

Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history.

Example Question:

When did you see a healthcare provider?

· Finding:

Reason for last visit was annual gynecological exam

(Found)

Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Asking Tina why she saw a healthcare provider might indicate any recent health concerns or problems.

Example Question:

Why did you see a healthcare provider?

· Finding:

Last general physical examination was 5 months ago when she was prescribed metformin and daily inhaler

(Found)

Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history.

Example Question:

When was your last physical exam? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

· Finding:

Asked about current prescription medications

· Finding:

Reports taking diabetes medication

(Found)

Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Asking Tina if she has been taking medication for her diabetes will indicate her treatment plan and the degree to which she is following it.

Example Question:

Have you been taking medication for your diabetes?

· Finding:

Reports using a daily inhaler

(Found)

Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it.

Example Question:

Do you use a daily inhaler?

· Finding:

Reports taking prescription birth control pills

(Found)

Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans.

Example Question:

Are you taking any form of birth control?

· Finding:

Followed up about diabetes medication

· Finding:

Medication is metformin

(Found)

Pro Tip: Follow up questions about Tina’s medication history will help you to understand her treatment plan and recent health history.

Example Question:

What is the name of your diabetes medication?

· Finding:

Started taking metformin 5 months ago

(Found)

Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history.

Example Question:

How long have you been taking metformin?

· Finding:

Reports that eating probiotic yogurt helps with side effects and they have abated over time

(Found)

Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history.

Example Question:

Have you noticed any side effects from the metformin?

· Finding:

Followed up on metformin frequency and dose

· Finding:

Reports taking metformin twice daily

(Found)

Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history.

Example Question:

How many times a day do you take metformin?

· Finding:

Metformin dose is 850 mg

(Found)

Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history.

Example Question:

What is the dose of your metformin?

· Finding:

Asked about asthma medication

· Finding:

Reports using Flovent inhaler twice daily

(Found)

Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina’s been using her inhaler more frequently since exacerbation can indicate how she’s been treating her symptoms since exacerbation. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Example Question:

How often do you use your daily inhaler?

· Finding:

Has a Proventil rescue inhaler

(Found)

Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina if she has a rescue inhaler for her asthma will indicate her treatment plan and the degree to which she complies with it.

Example Question:

Do you have a rescue inhaler?

· Finding:

Last use of Proventil inhaler was three months ago

(Found)

Pro Tip: Soliciting a shallow history of a patient’s medication history can reveal recent exacerbation. Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment.

Example Question:

When did you last use your rescue inhaler?

· Finding:

Has used Proventil inhaler twice in the last year

(Available)

Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina’s been using her inhaler more frequently since exacerbation can indicate how she’s been treating her symptoms since exacerbation.

Example Question:

How often do you use your rescue inhaler?

· Finding:

Followed up about birth control prescription

· Finding:

Started taking birth control 4 months ago

(Found)

Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan.

Example Question:

How long ago did you start taking birth control?

· Finding:

Reason for birth control was to manage PCOS symptoms

(Found)

Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words.

Example Question:

Why did you decide to start taking birth control?

· Finding:

Birth control type is Yaz (drospirenone and ethinyl estradiol)

(Found)

Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Confirming the name of Tina’s birth control pill will solicit information about her health history and current treatment plan. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Example Question:

What type of birth control do you use?

· Finding:

Takes birth control pill daily

(Found)

Pro Tip: Follow up questions about Tina’s birth control prescription can help you to understand how effectively she complies with her treatment plan.

Example Question:

How often do you take your birth control pill?

· Finding:

Takes birth control pill at the same time every day

(Found)

Pro Tip: Follow up questions about Tina’s birth control prescription can help you to understand how effectively she complies with her treatment plan.

Example Question:

Do you take your pill at the same time every day?

· Finding:

Reports no skipped days

(Available)

Pro Tip: Follow up questions about Tina’s birth control prescription can help you to understand how effectively she complies with her treatment plan.

Example Question:

Have you missed any days of your birth control pill?

· Finding:

Asked about current non-prescription medications

· Finding:

Reports rare Advil use for cramps

(Found)

Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes non prescription drugs will indicate her current treatment plan.

Example Question:

Do you take Advil?

· Finding:

Reports no OTC herbal products

(Found)

Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes herbal products will indicate her current treatment plan.

Example Question:

Do you use any herbal products?

· Finding:

Reports no OTC vitamins

(Found)

Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes vitamins will indicate her current treatment plan.

Example Question:

Do you take any vitamins?

· Finding:

Reports no OTC supplements

(Found)

Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes supplements will indicate her current treatment plan.

Example Question:

Do you take any supplements?

· Finding:

Asked about allergies

· Finding:

Confirms allergies

(Found)

Pro Tip: Discerning what’s making Tina’s asthma worse can point to possible triggers like environmental factors, bodily positions, allergies, or movement that may have a bearing on Tina’s breathing. Asking Tina what triggers her allergies will indicate, in part, Tina’s health literacy.

Example Question:

Can you confirm your allergies?

· Finding:

Reports no new allergies

(Found)

Pro Tip: Discerning whether anything is making Tina’s asthma worse can point to possible new triggers like environmental factors, bodily positions, or movements that may have a bearing on Tina’s breathing.

Example Question:

Have you noticed any new allergies?

· Finding:

Followed up on seasonal allergies

· Finding:

Reports no recent seasonal allergy symptoms

(Found)

Pro Tip: Discerning whether anything is making Tina’s asthma worse can point to possible triggers like environmental factors, bodily positions, or movements that may have a bearing on Tina’s breathing.

Example Question:

Have you been having seasonal allergies?

· Finding:

Reports no current medication for allergies

(Found)

Pro Tip: Tina’s response to a question about managing her allergies will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.

Example Question:

Are you taking any medication for your allergies?

· Finding:

Asked about diabetes

· Finding:

Reports managing diabetes with diet and exercise in addition to medication

(Found)

Pro Tip: Tina’s response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Example Question:

How are you managing your diabetes?

· Finding:

Asked about blood glucose monitoring

· Finding:

Reports checking blood sugar once a day

(Found)

Pro Tip: Tina’s response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.

Example Question:

How often do you monitor your blood glucose?

· Finding:

Checks sugar in the morning

(Found)

Pro Tip: Tina’s response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.

Example Question:

When do you check your blood glucose?

· Finding:

Blood sugar number is usually around 90

(Found)

Pro Tip: Tina’s response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.

Example Question:

What is your average blood sugar number?

· Finding:

Reports having adequate supplies

Objective Data Collection: 70 of 73 (95.9%)

Hover To Reveal…

Hover over the  Patient Data items below to reveal important information, including  Pro Tips.

· Found:

Indicates an item that you found.

· Available:

Indicates an item that is available to be found.

Category

Scored Items

Experts selected these examinations as essential components of objective data collection for this patient.

Patient Data

Not Scored

Thorough examinations will yield better patient data. The following actions reveal the objective data of the patient’s case. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

HEENT

·

Finding:

Inspected head and neck

·

Finding:

Scattered pustules on face and facial hair on upper lip

(Found)

Pro Tip: Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems.

Example Question:

·

Finding:

Head is normocephalic, atraumatic

(Found)

Pro Tip: Because your patient may have unknowingly hit her head during her fall, giving special attention to your observation of the size and the shape of your patient’s head can identify any indications of trauma.

Example Question:

·

Finding:

Normal scalp hair distribution

(Found)

Pro Tip: It’s important to inspect your patient’s hair for distribution, color, and texture because abnormal hair growth or characteristics can indicate underlying health problems.

Example Question:

·

Finding:

Acanthosis nigricans noted on neck

(Available)

Pro Tip: Skin changes are common in patients with uncontrolled diabetes. A thorough inspection should be conducted of your patient’s skin, especially in folds around the neck, axilla, and groin.

Example Question:

·

Finding:

Inspected eyebrows and orbital area

·

Finding:

Right eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema

(Found)

Pro Tip: Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions.

Example Question:

·

Finding:

Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema

(Found)

Pro Tip: Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions.

Example Question:

·

Finding:

Palpated scalp

·

Finding:

No masses

(Found)

Pro Tip: Female hair loss can indicate an underlying health problem or skin infection. Inspecting the scalp and hair for texture, distribution, and quantity helps to identify lesions or masses.

Example Question:

·

Finding:

Palpated sinuses

·

Finding:

No frontal sinus tenderness

(Found)

Pro Tip: Palpating the frontal sinuses checks for sinusitis.

Example Question:

·

Finding:

No maxillary sinus tenderness

(Found)

Pro Tip: Palpating the maxillary sinuses checks for sinusitis.

Example Question:

·

Finding:

Palpated jaw

·

Finding:

No clicks, full ROM

(Found)

Pro Tip: Palpating the jaw checks for crepitus can identify TMJ or injury.

Example Question:

·

Finding:

Palpated lymph nodes

·

Finding:

No axillary lymphadenopathy

(Found)

Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy.

Example Question:

·

Finding:

No supraclavicular lymphadenopathy

(Found)

Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Example Question:

·

Finding:

Palpated thyroid

·

Finding:

Thyroid smooth without nodules, no goiter

(Found)

Pro Tip: Palpating the thyroid gland for size, shape, and consistency, and noting any nodules or tenderness, helps to identify signs of a thyroid disorder.

Example Question:

·

Finding:

Inspected eyelids and conjunctiva

·

Finding:

Upper eyelids: conjunctiva pink, no lesions, white sclera

(Found)

Pro Tip: Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition.

Example Question:

·

Finding:

Lower eyelids: conjunctiva pink, no lesions, white sclera

(Found)

Pro Tip: Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition.

Example Question: