Certain groups of patients have concerns that may be specific to their particular population. Conditions related to men’s or women’s health, older adults, college students, LGBTQ individuals, athletes, those with particular cultural beliefs or concerns, or those undergoing palliative or end-of-life care would all fall under this category. Individuals may identify with more than one category.
For this Assignment, you practice assessing, diagnosing, and treating disorders seen in special population patients
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.
Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint): A brief statement identifying why the patient is here, stated in the patient’s own words (for instance “headache,” not “bad headache for 3 days”).
HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form, not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products
Allergies: include medication, food, and environmental allergies separately (A description of what the allergy is, i.e., angioedema, anaphylaxis, etc. This will help determine a true reaction as opposed to intolerance).
PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more information is sometimes needed.
Soc & Substance Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren, if pertinent.
Surgical Hx: prior surgical procedures
Mental Hx: diagnosis and treatment. Current concerns: Anxiety and/or depression. History of self-harm practices and/or suicidal or homicidal ideation.
Violence Hx: concern or issues about safety (personal, home, community, sexual . . . current & historical)
Reproductive Hx: menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any 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.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
REPRODUCTIVE: Not pregnant and no recent pregnancy. No reports of vaginal or penile discharge. Not sexually active.
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
O.
Physical exam: 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)
A.
Differential Diagnoses: List a minimum of three differential diagnoses. Your primary, or presumptive, diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.
Includes documentation of diagnostic studies that will be obtained, referrals to other healthcare 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.
Include a discussion related to health promotion and disease prevention, taking into consideration patient factors such as age and ethnic group; PMH; and other factors, such as socio-economic and cultural background.
The reflection also is included in this section. Reflect on this case and discuss what you learned. Were there any “aha” moments or connections you made?
References
You are required to include at least three evidence-based, peer-reviewed journal articles or evidence-based guidelines that relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.
Focused SOAP Note Template
Patient Information:
Initials Mr. E, Age- 42 years, Sex- male, Race- Hispanic
S.
CC (chief complaint): Mr. E. comes to the clinic with a plan of embarking on a rigorous exercise program with the ultimate goal of losing weight.
HPI:
Location: N/A
Onset: N/A
Character: N/A
Associated signs and symptoms: N/A
Timing: N/A
Exacerbating/relieving factors: N/A
Severity: N/A
Current Medications: No current medications.
Allergies: No known food or drug allergies.
PMHx: The patient’s immunization history is in line with the immunization schedule. His last immunization was a tetanus shot which he was given in November 20th 2021.
Soc & Substance Hx: The patient is a tax accountant. He is a single man who has never been married and lives in a condominium. He denies substance and alcohol use. He has not been physically active for the past 10 years. He is responsible for all his grocery shopping and meal preparation. Has gained a lot of weight due to his nature of work that requires him to sit all day behind his desk.
Fam Hx: His parents are alive. The grandparents died from natural causes of death. He has one sibling aged 36 years who is alive and healthy.
Surgical Hx: Has no prior surgical procedures
Mental Hx: Has had no diagnosis for mental health illnesses like anxiety or depression. Has no ideation for suicide or homicide.
Violence Hx: Has no concerns over his personal, home, community or sexual safety.
Reproductive Hx: He is not dating and is not sexually active.
ROS:
GENERAL: Has too much weight gain. No fever, chills, weakness or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
GENITOURINARY: No burning on urination.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
REPRODUCTIVE: Not sexually active. Has no penile discharge
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
O.
Physical exam:
Vitals: BP 128/80, Temperature 37 Degrees Celsius, R.R 18, Weight 190 pounds, Height 5’3
General: Too much weight gain
Diagnostic results:
Body mass index calculator- a body mass index of between 25 and 30 indicates that a person is overweight.
A.
Differential Diagnoses:
Over weight
Overweight is a condition characterized by a body mass index of or more than 25kg/m2.
Obesity
Obesity is defined as having a body mass index of 30kg/m2 or more (Fruh, 2017).
P
Based on the patient’s medical and social history, the patient is overweight. He has been gaining a lot of weight which has been linked to his nature of work that entails sitting on his desk for many hours. The primary reason why he visited the hospital was to have a medical checkup first before embarking on a rigorous exercise program. He aims to lose 30 pounds by working out at the gym.
Both overweight and obesity are health conditions that can easily be managed with a combination of medications and behavior modifications. The Food and Drug Agency recommends Orlistat for the management of obesity (Qi, 2018).
Non-pharmacological interventions that can be used to manage the patient’s weight besides exercise and activity would involve healthy feeding patterns. Diet-related changes would include cutting calories, consuming more plant-based foods like fruits, whole grains, and vegetables, and lean sources of proteins.
Besides diet-related interventions, the patient should embark on physical activity. The checkup should provide vital information about his overall health and the status of his body organs. Due to staying for so long without engaging in physical exercise, he should begin with low-intensity exercises going up. According to Healthy People 2020, physical exercise lowers an individual’s risk of early deaths, stroke, coronary heart disease, high blood pressure, type 2 diabetes, and depression among others (U.S Department of Health and Human Services, n.d.).
It would be important to educate the patient concerning the need to adhere to a physical exercise schedule and healthy feeding patterns to minimize the chances of relapse. Physical exercise would require that individuals demonstrate discipline to achieve the desired body outcomes. Based on his nature of work, he should engage in physical activity and controlled feeding patterns that align with the body’s utilization of energy.
The patient’s age is 42 years and therefore if his weight is uncontrolled could expose him to chronic diseases in old age which besides resulting in a cost-related burden will also lead to poor quality of life.
Reflection
The patient has an opportunity to improve his health outcomes while at the same time minimizing the risks of developing chronic illnesses. He however needs to adhere to a physical exercise routine that he wants to embark on to achieve consistent results. Working with patients showed how patients can be responsible for their health-related decisions to ensure they achieve positive health outcomes over time.
References
Fruh S. M. (2017). Obesity: Risk factors, complications, and strategies for sustainable long-term weight management. Journal of the American Association of Nurse Practitioners, 29(S1), S3–S14. https://doi.org/10.1002/2327-6924.12510
Qi, X. (2018). Review of the clinical effect of orlistat. In IOP Conference Series: Materials Science and Engineering (Vol. 301, No. 1, p. 012063). IOP Publishing.
U.S Department of Health and Human Services. (n.d.). Physical activity. Physical Activity | Healthy People 2020. Retrieved January 27, 2022, from https://www.healthypeople.gov/2020/topics-objectives/topic/physical-activity/objectives