Tag: Clinical-Nursing

episodic and comprehensive soap note write up samples

Write Ups

The written History and Physical (H&P) serves several purposes:

It is an important reference document that provides concise information about a patient’s history and exam findings at the time of admission.

It outlines a plan for addressing the issues which prompted the hospitalization. This information should be presented in a logical fashion that prominently features all of the data that’s immediately relevant to the patient’s condition.

It is a means of communicating information to all providers who are involved in the care of a particular patient.

It allows students and house staff an opportunity to demonstrate their ability to accumulate historical and examination-based information, make use of their medical fund of knowledge, and derive a logical plan of attack.

The H&P is not:

An instrument designed to torture Medical Students and Interns.

Meant to cover unimportant/unrelated information.

Should not require so much time to write that by the time it’s submitted, the information contained within is obsolete!

Knowing what to include and what to leave out will be largely dependent on experience and your understanding of illness and pathophysiology. If, for example, you were unaware that chest pain is commonly associated with coronary artery disease, you would be unlikely to mention other coronary risk-factors when writing the history. As you gain experience, your write-ups will become increasingly focused. You can accelerate the process by actively seeking feedback about all the H&Ps that you create as well as by reading those written by more experienced physicians. Several sample write-ups are presented at the end of this section to serve as reference standards.

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The core aspects of the H&P are described in detail below.

Chief Concern (CC):

One sentence that covers the dominant reason(s) for hospitalization. While this has traditionally been referred to as the Chief Complaint, Chief Concern may be a better description as it is less pejorative and confrontational sounding.

“CC: Mr. Smith is a 70 year-old male admitted for the evaluation of increasing chest pain.”

History of Present Illness (HPI):

 

The HPI should provide enough information to clearly understand the symptoms and events that lead to the admission. This covers everything that contributed to the patient’s arrival in the ED (or the floor, if admission was arranged without an ED visit). Events which occurred after arrival can be covered in a summary paragraph that follows the pre-hospital history.

A commonly used pneumonic to explore the core elements of the chief concerns is OLD CARTS, which includes: 
O
nset, 
L
ocation, 
D
uration, 
C
haracteristics, 
A
ggravating/
A
lleviating factors, 
R
elated symptoms, 
T
reatments, and 
S
ignificance.

Some HPIs are rather straight forward. If, for example, you are describing the course of a truly otherwise healthy 40-year-old who presents with 3 days of cough, fever, and shortness of breath as might occur with pneumonia, you can focus on that time frame alone. Writing HPIs for patients with pre-existing illness(es) or a chronic, relapsing problems is a bit trickier. In such cases, it’s important to give enough relevant past history “up front,” as having an awareness of this data will provide the contextual information that allows the reader to fully understand the acute issue. If, for example, a patient with a long history of coronary artery disease presents with chest pain and shortness of breath, an inclusive format would be as follows:

“HIP: Mr. S is a 70 yr old male presenting with chest pain who has the following coronary artery disease related history:

-Status Post 3 vessel CABG in 2008.

-Suffered recurrent chest pain in December 2015, which ultimately lead to catheterization and stent placement in a mid-LAD lesion.

-He was re-cathed in January 2017 for recurrent chest pain at rest; at that time there was no significant change compared to catheterization of 12/15. The patient was therefore continued on medical therapy.

-Known to have an Ejection Fraction of 40% with inferior and lateral akinesis by echo in January 2018

-No prior episodes of heart failure.

-Last Exercise Tolerance Test was performed in January of 2018 and showed no ischemia at 8 METS of activity.

Mr. S was in his usual state of health until last week (~ Saturday, November 18), when he began to experience recurrent episodes of chest pain, exactly like his past angina, after walking only one block. This represented a significant change in his anginal pattern, which is normally characterized as mild discomfort which occurs after walking vigorously for 8 or 9 blocks. In addition, 1 day prior to admission, the pain occurred while he was reading a book and resolved after taking a nitroglycerin tablet. It lasted perhaps 1 minute. He has also noted swelling in his legs over this same time period and has awakened several times in the middle of the night, gasping for breath. In order to breathe comfortably at night, Mr. S now requires the use of 3 pillows to prop himself up, whereas in the past he was always able to lie flat on his back and sleep without difficulty. Mr. S is known to have poorly controlled diabetes and hypertension. He currently smokes 2 packs of cigarettes/day. He denies fevers, chills, cough, wheezing, nausea vomiting, recent travel, or sick contacts.”

That’s a rather complicated history. However, it is obviously of great importance to include all of the past cardiac information “up front” so that the reader can accurately interpret the patient’s new symptom complex. The temporal aspects of the history are presented in an easy to follow fashion, starting with the most relevant distant event and then progressing step-wise to the present.

From a purely mechanical standpoint, note that historical information can be presented as a list (in the case of Mr. S, this refers to his cardiac catheterizations and other related data). This format is easy to read and makes bytes of chronological information readily apparent to the reader. While this data is technically part of the patient’s “Past Medical History,” it would be inappropriate to not feature this prominently in the HPI. Without this knowledge, the reader would be significantly handicapped in their ability to understand the patient’s current condition.

Knowing which past medical events are relevant to the chief concern takes experience. In order to gain insight into what to include in the HPI, continually ask yourself, “If I was reading this, what historical information would I like to know?” Note also that the patient’s baseline health status is described in some detail so that the level of impairment caused by their current problem is readily apparent.

The remainder of the HPI is dedicated to the further description of the presenting concern. As the story teller, you are expected to put your own spin on the write-up. That is, the history is written with some bias. You will be directing the reader towards what you feel is/are the likely diagnoses by virtue of the way in which you tell the tale. If, for example, you believe that the patient’s chest pain is of cardiac origin, you will highlight features that support this notion (e.g. chest pressure with activity, relieved with nitroglycerin, preponderance of coronary risk factors etc.). These comments are referred to as “pertinent positives.” These details are factual and no important features have been omitted. The reader retains the ability to provide an alternative interpretation of the data if he/she wishes. A brief review of systems related to the current complaint is generally noted at the end of the HPI. This highlights “pertinent negatives” (i.e. symptoms which the patient does not have). If present, these symptoms might lead the reader to entertain alternative diagnoses. Their absence, then, lends support to the candidate diagnosis suggested in the HPI. More on the HPI can be found here: 
HPI
.

Occasionally, patients will present with two (or more) major, truly unrelated problems. When dealing with this type of situation, first spend extra time and effort assuring yourself that the symptoms are truly unconnected and worthy of addressing in the HPI. If so, present them as separate HPIs, each with its own paragraph.

Past Medical History (PMH):

This includes any illness (past or present) that the patient is known to have, ideally supported by objective data. Items which were noted in the HPI (e.g. the cardiac catheterization history mentioned previously) do not have to be re-stated. You may simply write “See above” in reference to these details. All other historical information should be listed. Important childhood illnesses and hospitalizations are also noted.

Detailed descriptions are generally not required. If, for example, the patient has hypertension, it is acceptable to simply write “HTN” without providing an in-depth report of this problem (e.g. duration, all meds, etc.). Unless this has been a dominant problem, requiring extensive evaluation, as might occur in the setting of secondary hypertension.

Also, get in the habit of looking for the data that supports each diagnosis that the patient is purported to have. It is not uncommon for misinformation to be perpetuated when past write-ups or notes are used as the template for new H&Ps. When this occurs, a patient may be tagged with (and perhaps even treated for) an illness which they do not have! For example, many patients are noted to have Chronic Obstructive Pulmonary Disease (COPD). This is, in fact, a rather common diagnosis but one which can only be made on the basis of Pulmonary Function Tests (PFTs). While a Chest X-Ray and smoking history offer important supporting data, they are not diagnostic. Thus, “COPD” can repeatedly appear under a patient’s PMH on the basis of undifferentiated shortness of breath coupled with a suggestive CXR and known smoking history, despite the fact that they have never had PFTs. So, maintain a healthy dose of skepticism when reviewing notes and get in the habit of verifying critical primary data.

Past Surgical History (PSH):

All past surgeries should be listed, along with the rough date when they occurred. Include any major traumas as well.

Medications (MEDS):

Includes all currently prescribed medications as well as over the counter and non-traditional therapies. Dosage, frequency and adherence should be noted.

Allergies/Reactions (All/RXNs):

Identify the specific reaction that occurred with each medication.

Social History (SH):

This is a broad category which includes:

Alcohol Intake: Specify the type, quantity, frequency and duration.

Cigarette smoking: Determine the number of packs smoked per day and the number of years this has occurred. When multiplied this is referred to as “pack years.” If they’ve quit, make note of when this happened.

Other Drug Use: Specify type, frequency and duration.

Marital/Relationship Status; Intimate Partner Violence (IPV) screen.

Sexual History, including: types of activity, history of STIs.

Work History: type, duration, exposures.

Other: travel, pets, hobbies.

Health care maintenance: age and sex appropriate cancer screens, vaccinations.

Military history, in particular if working at a VA hospital.

Family History (FH):

This should focus on illnesses within the patient’s immediate family. In particular, identifying cancer, vascular disease or other potentially heritable diseases among first degree relatives

Obstetrical History (where appropriate):

Included the number of pregnancies, live births, duration of pregnancies, complications. As appropriate, spontaneous and/or therapeutic abortions. Birth control (if appropriate).

Review of Systems (ROS):
 As mentioned previously, many of the most important ROS questions (i.e. pertinent positives and negatives related to the chief concern) are generally noted at the end of the HPI. The responses to a more extensive review, covering all organ systems, are placed in the “ROS” area of the write-up. In actual practice, most physicians do not document an inclusive ROS. The ROS questions, however, are the same ones that are used to unravel the cause of a patient’s chief concern. Thus, early in training, it is a good idea to practice asking all of these questions so that you will be better able to use them for obtaining historical information when interviewing future patients. A comprehensive list can be found here: 
ROS

Physical Exam:

Generally begins with a one sentence description of the patient’s appearance.

Vital Signs:

HEENT: Includes head, eyes, ears, nose, throat, oro-pharynx, thyroid.

Lymph Nodes:

Lungs:

Cardiovascular:

Abdomen:

Rectal (as indicated):

Genitalia/Pelvic:

Extremities, Including Pulses:

Neurologic:

Mental Status

Cranial Nerves

Motor

Sensory (light touch, pin prick, vibration and position)

Reflexes, Babinski

Coordination

Observed Ambulation

Lab Results, Radiologic Studies, EKG Interpretation, Etc.:

Assessment and Plan:

It’s worth noting that the above format is meant to provide structure and guidance. There is no gold standard, and there’s significant room for variation. When you’re exposed to other styles, think about whether the proposed structure (or aspects thereof) is logical and comprehensive. Incorporate those elements that make sense into future write-ups as you work over time to develop your own style

SAMPLE WRITE UP #1

ADMISSION NOTE

CC:
 Mr. B is a 72 yo man with a history of heart failure and coronary artery disease, who presents with increasing shortness of breath, lower extremity edema and weight gain.

HPI: 
His history of heart failure is notable for the following:

First MI was in 2014, when he presented w/a STEMI related to an LAD lesion. This was treated w/a stent. Echo at that time remarkable for an EF 40%.

Despite optimal medical therapy, he had a subsequent MI in 2016. At that time, cardiac catheterization occlusions in LAD, OMB, and circumflex arteries. No lesions were amenable to stenting. An echo was remarkable for a dilated LV, EF of 20-25%, diffuse regional wall motion abnormalities, 2+MR and trace TR.

Heart failure symptoms of DOE and lower extremity edema developed in 2017. These have been managed medically with lisinopril, correg, lasix and metolazone.

Over the past 6 months he has required increasing doses of lasix to control his edema. He was seen 2 weeks ago by his Cardiologist, Dr. Johns, at which time he was noted to have worsening leg and scrotal edema. His lasix dose was increased to 120 bid without relief of his swelling.

Over the past week he and his wife have noticed a further increase in his lower extremity edema which then became markedly worse in the past two days. The swelling was accompanied by a weight gain of 10lb in 2 days (175 to 185lb) as well as a decrease in his exercise tolerance. He now becomes dyspneic when rising to get out of bed and has to rest due to SOB when walking on flat ground. He has 2 pillow orthopnea, but denies PND.

Denies CP/pressure, palpitations or diaphoresis. Occasional nausea, but no vomiting. He eats normal quantities of food but does not salt or fluid intake. He also admits to frequently eating canned soup, frozen meals, and drinking 6-8 glasses liquid/day. He has increased urinary frequency, but decreased total amount of urine produced. He denies urinary urgency, dysuria or hematuria. He has not noted cough, sputum, fever or chills. He states he has been taking all prescribed medications on most days – missing a few (? 2-3) doses a week.

PMH:

CHF- as above

MI 2014, 2016

HTM

Chronic renal insufficiency from DM nephropathy: Cr 1.8 1/2018

Diabetes: controlled with Metformin – a1c 6.8 2/2018

PSH:

Appendectomy 1992

Cholecystectomy 2004

MEDS:

Lasix 120 mg BID

Correg 25 bid

Lisinopril 40 qd

KCl 40 meq qd

Dabigatran 200 mg qd

Metformin 1g bid

ASA 81mg qd

Atorvastatin 40 mg/d

Allergies:

No Known Drug Allergies

Social History:

Married for 45 years, sexual active with wife. Three children, 2 grandchildren, all healthy and well; all live within 50 miles. Retired school teacher. Enjoys model car building. Walks around home, shopping but otherwise not physically active. episodic and comprehensive soap note write up samples

Smoking:

None

Alcohol:

None

Other substance use:

None

Military service:

Marine Corp x 4 years, non-combat. Worked logistics.

Family History:

+ sister and mother with DM, father with CAD, age onset 50. Brother with leukemia.

ROS

General: Denies fatigue, fever, chills, weight loss; + weight gain as above

HENT: Denies oral sores, neck masses, nasal d/c, hearing problems

Vison: Denies change in vision, eye pain, redness, discharge

Cardiac: As above

Pulmonary: As above

GI: Denies heart burn, swallowing difficulty, abdominal pain, diarrhea, constipation

GU: As per HPI

Neuro: Denies seizure, weakness, numbness

Endo: Denies heat/cold intolerance, weight changes, polyuria, polydipsia

Heme/Onc: Denies unusual bleeding, bruising, clotting

MSK: Denies join pain, swelling, muscle aches

Mental Health: Denies anxiety, depression, mood changes,

Skin/Hair: Denies rashes, non-healing wounds, ulcers, hair loss

PE:

VS: T 97.1, P65, BP 116/66, O2Sat 98% on 2L NC Weight 187lbs

GEN: elderly man lying in bed with head up, NAD

HEENT: NCAT, multiple telangiectasias on face and nose; EOMI, PERRLA, Oropharynx w/o lesions, mucous membranes moist; thyroid not palpable, no adenopathy

Pulmonary: +dullness to percussion at right base, + crackles 1/2 way up chest bilateral posteriorly

Cardio: RRR, +2/6 holosystolic murmur at apex radiating to axilla, +S3, no S4; PMI displaced laterally toward axilla; carotid pulses 2+ B, no bruits; JVP 12cm

Abdomen: +BS, non-distended, nontender, no hepatomegaly.

Extremities: 3+ edema to sacrum, abdominal wall and scrotum; no clubbing, cyanosis, no skin breaks distally episodic and comprehensive soap note write up samples

Pulses: 2+femoral B, 1+ PT/DP B

Neuro:

Mental status: alert and appropriate

Motor: 5/5 all extremities

Sensory: distal sensation in legs intact to light touch, pin prick; proprioception toes normal bilaterally; vibration intact at IP joint bilateral great toes

Reflexes: 2+ and symmetric bilaterally: biceps, triceps, brachioradialis, patellar, achilles

Gait: not observed

Labs and Data:

Na 128, C1 96, Bun 59, Glucose 92, K 4.4, CO2 40.8, CR 1.4, WBC 7.9, PLT 349, HCT 43.9, Alk phos 72, Total Protein 5.6, Alb 3.5, T Bili 0.5, Alt 17, Ast 52, Troponin < .01, BNP 1610. EKG: Sr at 74, q-waves v1-v5, no st-t wave changes. No change compared with study of 6m ago. CXR: Prominent pulmonary vessels with moderate interstitial edema and right pleural effusion. Cardiomegaly. No parenchymal infiltrates. Assessment and Plan: 72-year-old man with history of HFrEF following multiple Mis, admitted with sub-acute worsening edema and DOE. His symptoms are most consistent with increasing heart failure, which would account for both his pulmonary congestion as well as his peripheral edema. His renal disease is a less likely explanation for his extensive edema as his BUN/Cr have remained stable throughout. Elevated BNP is also consistent w/heart failure. The question is why his heart failure has become refractory to treatment? Possibilities include: 1) worsening LV function, 2) another MI, 3) worsening valvular disease, 4) poor compliance with medications and/or 5) excess salt and water intake. There is no evidence by history, EKG, or enzymes for current ischemia/infarct. And his valvular disease does not appear severe enough to be causing symptoms. Given this, the most likely precipitant of his failure is a combination of dietary indiscretion and poor adherence with medications in a patient with a severely depressed EF. Cardiac: As above his picture is consistent with CHF with the likely precipitant related to dietary and medication non-adherence. Strict I/O’s. Daily weights Fluid restriction to 2L/day Low salt diet Lasix 80mg IV with IV metolazone now and Q8.. With goal diuresis of 2-3 L/day Continue lisinopril 40 qd, correg 25 bid Check electrolytes, renal function bid Education about appropriate diet via nutrition consult Repeat Echo, comparing it with prior study for evidence of drop in LV function Given degree of symptoms and severity of LV impairment, will obtain Cardiology consult. To assist w/management, inquire re use of Entresto and other interventions to improve symptoms. Pulmonary: his crackles and oxygen requirement are all likely due to pulmonary congestion from LV dysfunction. He has no signs, symptoms of another primary pulmonary process (e.g. infection, COPD exacerbation, PE) 02 to maintain sat greater than 95% treat cardiac disease as above, focusing on diuresis Renal: CKD stage 3 from DM (on basis prior elevated protein/creat ratio) and hypertension. Qd chem 7 w/diuresis DM: His sugars have been well-controlled on current regimen Hold metformin in house Low intensity sliding scale insulin coverage ADA 2100 calorie diet FS BS qac and qhs Disposition: Anticipate discharge home in 3 days, with close follow up from heart failure service to assist with maintaining clinical stability, preventing re-admissions. SAMPLE WRITE-UP #2 ADMISSION NOTE CC: Mr. S is a 65-year-old man who presents with 2 concerns: 1. Acute, painless decline in vision 2. Three day history of a cough. HPI: 1. Visual changes: Yesterday morning, while eating lunch, the patient had the sudden onset of painless decrease in vision in both eyes, more prominent on the right. Onset was abrupt and he first noted this when he “couldn’t see the clock” while at a restaurant. He also had difficulty determining the numbers on his cell phone. He denied pain or diplopia. Did not feel like a “curtain dropping” in front of his eyes. He had nausea and vomiting x2 yesterday, which has resolved. He did not seek care, hoping that the problem would resolve on its own. When he awoke this morning, the same issues persisted (no better or worse) and he contacted his niece, who took him to the hospital. At baseline, he uses prescription glasses without problem and has no chronic eye issues. episodic and comprehensive soap note write up samples Last vision testing was during visit to his optometrist 2 year ago. Notes that his ability to see things is improved when he moves his head to bring things into better view. Denies dizziness, weakness, headache, difficulty with speech, chest pain, palpitations, weakness or numbness. No history of atrial fibrillation, carotid disease, or heart disease that he knows of. 2. Cough: Patient has history of COPD with 60+ pack year smoking history and most recent PFT’s (2016) consistent with moderate disease. Over the past few days he has noted increased dyspnea, wheezing, and sputum production. Sputum greenish colored. He uses 2 inhalers, Formoterol and Tiotropium every day and doesn’t miss any dosages. He was treated with antibiotics and prednisone a few years ago when he experienced shortness of breath. He has not had any other breathing issues and no hospitalizations or ED visits. Denies hemoptysis, fevers, orthopnea, PND, chest pain or edema. ED course: given concern over acute visual loss and known vascular disease, a stroke code was called when patient arrived in ER. Neurology service evaluated patient and CT head obtained. Data was consistent with occipital stroke, which occurred > 24 hours ago. Additional details re management described below.

PMH:

COPD (moderate) – PFTs 2014 fev1/fvc .6, fev1 70% predicted

Hypertension dx 2012

GERD

Hyperlipidemia – ASCVD 12%

Obstructive sleep apnea dx 2014, uses CPAP

PSH:

Right orchiectomy at age 5 for traumatic injury

Right cataract removal and lens implant placement on 2014

MEDS:

Asa 81 qd

Lisinopril 40 mg qd

Atenolol 50 mg qd

Pantoprazole 20 mg po qd

Tiotropium 2 puffs qd

Formoterol 2 puffs qd

Atorvastatin 40mg qd

Allergies:

None

Smoking:

60 pack yr history, now 1ppd

Alcohol:

Heavy in past, quit 5 y ago. None currently. No know alcohol related target organ damage

Other substance use:

None

Social:

Lives with roommate in Encinitas. Heterosexual, not currently active. Never married, no children. Worked in past as architect, though currently on disability. Enjoys walking and reading.

Family:

Brother and father with CAD. Brother with CABG at age 55. Father with multiple strokes. Mother with DM.

Military service:

None

ROS:

General: denies fatigue, fever, chills, weight loss, weight gain

HENT: denies oral sores, neck masses, nasal d/c, hearing problems

Vison: as per HPI

Cardiac: as per HPI

Pulmonary: as per HIP

GI: Denies heart burn, swallowing difficulty, abdominal pain, diarrhea, constipation

GU: Denies hematuria, dysuria, nocturia, urgency, frequency

Neuro: Denies seizure, weakness, numbness

episodic and comprehensive soap note write up samples

Endo: Denies heat/cold intolerance, weight changes, polyuria, polydipsia

Hematology/Oncology: Denies unusual bleeding, bruising, clotting

MSK: Denies join pain, swelling, muscle aches

Mental Health: Denies anxiety, depression, mood changes,

Skin/Hair: denies rashes, non-healing wounds, ulcers, hair loss

PE:

VS: T 99 P89, irregularly irregular BP 139/63, RR 20 O2 Sat 98% RA

GEN: Obese, pale man turning his head side to right side in order to see us. No acute distress

HEENT: NCAT, PERRL. Discs sharp. EOMI. Visual acuity/fields as per neuro below

Temporal arteries nontender. Conjunctiva clear.

Neck: No adenopathy. No JVD. Carotid pulses 2+ bilaterally.

Pulmonary: Moves air equally bilaterally, though wheezes on auscultation throughout.

CV: irregularly irregular, II/VI systolic crescendo-decrescendo murmur at LUSB, radiating to carotids. No S3, S4. PMI not-displaced.

Abd: Obese + normal BS. Soft. Nontender. Liver nonpalpable. Liver 8 cm at mid-clavicular line by percussion.

Rectal: brown stool, OB neg in ER

Pulses: Fem R 2+ L +1. DP 2+ B. PT 1+ B

Extremities: no cyanosis, clubbing or edema. Warm, well-perfused.

Neuro:

AOX3; answers questions appropriately

CNs:

I: Able to detect coffee B nares at 10cm

II: Loss of nasal field R eye, temporal field L eye by confrontation – can detect hand movement in those areas, but can’t read vision card at any line; Vision 20/40 B in fields where vision preserved (i.e. if vision card held in front of patients face towards their right)

III, IV, VI: extra-ocular movements preserved in all directions.

V: intact light touch all regions of face; masseter and temporalis muscles 5/5 B

VII: muscles of facial expression intact

VIII: hearing equal bilateral

IX, X: palate symmetric

XI: SCM, Trap 5/5

XII: Tongue midline

Motor: Strength 5/5: biceps, triceps, grip, quad, hamstring, plantarflex, dorsiflex. F-N slight int. tremor on left.

Rapid alternating movements: symmetric and equal

Gait: normal

Sensory: intact light touch, pin prick, vibration, proprioception at feet bilateral.

Romberg negative; gait somewhat unsteady due to visual issues

Reflexes: Biceps, triceps, brachioradialis: 2+ B. Patellar, achilles 2+ B; Toes down going.

Labs, Imaging and other Data:

Na 138, C1 106, Bun 13, Glu 99, K 4.5, CO2 25, CR 1.9, WBC 11, PLT 597, HgB 13.5, MCV 72.5, pulses P73 L16 E3 B0; Alk phos 72, T Protein 7.2, Alb 3.1, ALT 9, AST 14, LDH 123, TB 0.5, INR 1.3, TSH 2

Head CT: several, new well-demarcated infarcts in R occipitoparietal region. No evidence hemorrhage. No midline shift.

CXR: no infiltrate; flattened diaphragms bilaterally consistent with COPD.

EKG: A fib at 72. No acute st-t wave changes or other findings different from study 6m prior.

Assessment and Plan:

65-year old man who presents with acute visual field deficits consistent with embolic stroke. Story of the sudden onset of neurologic deficits while awake, in the setting of newly identified atrial fibrillation, is most consistent with a cardio-embolic event. Artery-artery embolization is also a possibility (e.g. vertebral-basilar). Thrombosis in situ less likely, as multiple occipital infarcts are noted. Carotid stenosis not likely as retinal exam without evidence of local infarct, visual deficits indicate lesion that is after the optic chiasm, and CT w/posterior distribution infarcts. Similarly, temporal arteritis would be consideration given age and visual deficits, though lack of referable symptoms (i.e. no jaw claudication, headache, TA tenderness) and distribution of stroke makes this unlikely.

Of note, as last known normal was > 24 hours ago, he is outside the window to receive TPA or device driven therapy. No evidence of ongoing events or evolution. Focus at this time thus will be on completing diagnostic evaluation, vigilance for progression/complications, and treatment to prevent additional events.

Neuro: story and imaging consistent with embolic stroke affecting visual cortex. Currently no signs of cerebral edema increased ICP.

Admit to step monitored unit level care

Neurology service involved and following

Head of bed elevated 30 degrees; Monitor for change in level of consciousness that would be suggestive increased ICP

Given that atrial fibrillation is the driving etiology, will start unfractionated heparin now to prevent additional events, targeting PTT 80-100. Very close clinical observation to assure no hemorrhagic conversion leading to increased ICP. Neuro service in agreement with this approach.

MRI/MRA asap to fully characterize extent infarct and arterial anatomy

Continue aspirin 81mgd

Occupational therapy for assistance with managing deficits

Physical therapy evaluation for gait safety

Ophthalmology evaluation for formal assessment fields, vision correction options

Pulmonary: Currently afebrile and with increased SOB, cough and sputum production in patient with documented moderate COPD by PFTs. Symptoms are suggestive of acute COPD exacerbation, which is presumed to be of bacterial origin. No evidence pneumonia on CXR.

Continue inhalers

Doxycyline 100 bid x 7d

Prednisone 40 mg qd x 5d

Follow for clinical change

Review smoking cessation options while in hospital

Cardiovascular: Newly identified a fib. Has no symptoms related to tachycardia, impaired ventricular function. Duration unknown. Likely etiology is chronic hypertension and OSA. No evidence of other toxic/metabolic process (e.g. alcohol withdrawal, anemia, heart failure, thyroid disease). Possible that COPD exacerbation could be contributing.

Continue Norvasc, atenolol for hypertension

A Fib well rate controlled at present, continue atenolol, continue telemetry

Anti-coagulation as discussed above w/unfractionated heparin – and ultimately transition to DOAC

Echo to assess LV function, LA size, etiologies for a fib

ID: Currently febrile. COPD flare presumed associated with acute bronchitis.

Treatment as under pulmonary

Disposition: Anticipate discharge 3-4 days. May need rehab stay depending on functional status, safety as relates to ability to care for self while recovering from stroke.

episodic and comprehensive soap note write up samples

Lopes Activity Tracker

Assessment Description

Document your clinical practice hours using the Lopes Activity Tracker (LAT) in your student portal. Once you have opened the app, click on the link for your class to record your hours. Clinical practice hours should be documented and submitted within 48 hours of the clinical experience. After the hours have been submitted, the preceptor will verify the hours, which are then reviewed by the faculty. Students need to meet the required clinical hours in both leadership and community categories. As such, each category will have a hours maximum of 50 hours. Students will not be able to document in excess of 50 hours per category. The clinical requirements remain unchanged.

Download the electronic summary of your practicum experience from the Lopes Activity Tracker. Save the file and submit it though the assignment drop box for faculty approval.

This report is to be submitted in every topic.

Episodic, Comprehensive and Alternative SOAP Note Example

Episodic Write-up:
Episodic visits are mostly encounters which require about one time visit (sometimes with a short follow-up depending on the diagnosis/existing comorbidities), or occurs occasionally.  Episodic visit ROS and physical examination (PE) are targeted and focused on the body system(s) affected.  Examples are URI, bronchitis, seasonal allergic rhinitis, acute pharyngitis, acute gastroenteritis, pneumonia, contact dermatitis, etc.

 

This write-up should be
2-4 pages single spaced
and concentrate on the most pertinent information. Not all the systems or sections from a comprehensive write up will be represented. Only the sections and information that are important to this case need be included. This helps clarify your understanding of using only the best/most important tools and information to justify your critical thinking.

ORDER YOUR PAPER HERE

Comprehensive Write-up:
Comprehensive visits often requires head to toe or extensive ROS and physical examination (PE). Visits which may necessitate a comprehensive ROS, physical exam, and write-up include annual physical, well woman exam(may not always include head to toe, but could be the only preventive care most women receive), well child exam, new or established patients with complex or chronic diseases or comorbidities, non-specific complaints, such as fatigue, generalized weakness or body ache, dizziness, etc.  This episodic, comprehensive and alternative soap note example  should be
5-8 pages single spaced.

You must know how to delineate which visits are episodic versus comprehensive.  Conducting a comprehensive exam on a patient whose chief complaint and ROS support an episodic visit or write-up may paint a picture of a clueless provider; and can constitute a waste of time for you and the patient. Your patient may not trust your clinical reasoning/judgment (diagnosis/plan of care) if they perceive you are all over the place!  Insurance is not going to pay you more because you decided to complete a comprehensive note on an episodic visit or diagnosis!

Alternative Write-up:
Some courses may have specialized write-ups based on a patient with certain demographics or with certain disease process episodic, comprehensive and alternative soap note example. These write ups will follow the same guidelines as comprehensive-write ups.

Case Write-up Outline

 

Following the format of:
https://meded.ucsd.edu/clinicalmed/write.htm
.

 

Subjective:

CC: This should be in quotes: “I’ve had a cough and sore throat for 2 days”

HPI: One of the most important parts of the assessment. Check the list of important questions to ask (OLD CARTS or PQRST). As you become more proficient in physical exam and lab testing, the HPI does not decrease in importance – your ability to use it in diagnostic reasoning just increases.

Past Medical History: Past or present illness. Be careful with “blindly” copying history from a prior clinical note.

Past Surgical History: Past surgeries and rough dates when possible. Should also include traumas and hospitalizations

Medications: List name, dose, frequency and indication (why are they taking it?) Do NOT omit the indication (reason) for a specific drug being taken. Do NOT omit PRN medications and how often the medications are taken. This is one way to check whether you’ve put all important information in your patient history.  If a patient is taking Metformin and there’s no related information on the history and/or diagnoses list, something is missing.

Allergies: Medications. Food allergies when applicable.

Social History: This includes several factors: alcohol use, cigarette use, sexual history, work history are a few examples. Include health promotion information such as exercise and immunizations. Immunization is important – we want to know the date of an adult patient’s last tetanus immunization. Be specific, don’t just say UTD. For children, list dates for all immunizations.

Family History: It is generally appropriate to go back at least two generations.

Obstetrical History: When appropriate, document number of pregnancies and other relevant information.

Review of Symptoms (ROS): For comprehensive visits: should be extensive and include every system. For episodic visits: Think about your likely differential diagnosis list and tailor your ROS to it. Always address growth and development in pediatric patients. In childbearing women, make sure to document date of last menstrual period (LMP) and methods of contraceptive use on
every
visit on any woman capable of becoming pregnant (having menses and has not had a tubal ligation/hysterectomy).
Every visit
– If you order such a medication without documenting the above information,
we have to assume that the patient could be pregnant
(as would any lawyer in a lawsuit).  For a young teen you can put “not sexually active” (but make sure you have asked).  episodic, comprehensive and alternative soap note example This is sometimes tricky with teens being seen for general health problems but so very important.  If in any doubt, ask the parent to step out for a moment so that you can talk to the teen alone.

Objective

Vital signs (BMI should be included on every visit)

Physical examination

Laboratory data, diagnostic tests, imaging: These should be what is available at the time the visit. Do not include testing that was ordered during the visit but not results were not available.

TIP:

Make sure to proper distinguish between subjective and objective data. Subjective data, as the name suggests, is the information you gather by interviewing the patient, family, or significant other. This will include data from chief complaint, Social/family history, and Review of system (ROS). Objective data will include those information or data you elicited through physical examination, vital signs and/or diagnostic test results. Note that statement such as “Denies chest pain, sob, dysuria, vaginal bleeding, diarrhea, etc.” should be in the subjective section (ROS) of your note, and not in PE section.  Do not write “Alert and oriented; no tenderness; no erythema; breath sounds clear; no spine curvature” under ROS or subjective section. These are objective findings. You elicited these data through your physical examination of the patient.

Assessment

List both your differential diagnoses and your presumptive diagnosis. Remember that these should be supported by findings in your history and physical exam episodic, comprehensive and alternative soap note example. For a comprehensive exam, you should document at least three ICD code diagnoses.

Plan

Include medications ordered, labs tests, teaching, referrals, and when the patient needs to follow-up. All write-up plans should include documentation of patient education, especially if medication is prescribed and anticipatory guidance. Health maintenance such as screening for breast or colon cancer, should be addressed.

Coding Resource:

All write ups should include the billing codes.  We do not expect you to memorize these codes. You can get them from the billing form that the physician or NPs uses in the office. You can put the billing codes at the end of the write-up.  You should include both the E&M code (level of service) and the ICD-9 diagnosis codes. Your E&M code should be consistent with your patient visit.

MSN Case Write Up Assignment

The purpose of the Case Write- Up Assignment is for your instructor to “see” what you are doing in clinical and “see” how you are making clinical decisions. For these write-ups, you will select a patient seen in your current clinical rotation. You will “write-up” the visit, omitting any identifying patient factors. Ensure your write-ups demonstrate comprehensive advanced practice thinking and not just the new skills of ordering and prescribing.

Make sure to start “fresh”. Do not copy and paste from any examples, templates, other students work or even your own work. Put all your old case write-ups away and give your brain a chance to formulate the note so that it really becomes a part of what you know. THAT will make you a competent NP.

Be honest in your write up. If you realize that you have forgotten to assess something or forgot a certain part of the teaching, just put a note at the bottom of the write-up saying what should have been done. Your clinical faculty do not expect perfect write-ups, but do expect that you use every patient encounter and subsequent write-up as a time to learn and to evaluate and improve your own practice.

 

If your preceptor orders something that is not appropriate or fails to order something that you believe should have been part of the plan, write a note at the end of the write-up to let your instructor know that you are aware and what you would have done. You are not responsible for what your preceptor orders, but you are responsible for knowing the appropriate plan of care and you are responsible for knowing if a plan of care is inappropriate. You and your faculty are the only ones that see the write-up, so no feelings will be hurt. We all get set in our ways and tend to order the same thing over and over. If your readings and research indicate that another plan is more appropriate, write it as an addendum or in parentheses in the plan.

ORDER YOUR PAPER NOW

You are learning to practice evidence-based practice. Support at least one item in the assessment AND plan with research. This can be your textbook and/or other class readings. The best way to support your research is using a research article.
Make sure that the article is current (5 years or less old).
The article can be used to support the use of the medication (or other therapy) for the presumptive diagnosis. When using an article, please attach the article along with the write-up into the appropriate assignment category. Failure to cite your plan will result in a point penalty reduction (see rubric for additional information)

Note that you
CANNOT redo write-ups
. A grade cannot be improved by redoing a write up. Faculty will not read and comment on rough draft of write-ups

All case write ups are to be submitted to SafeAssign and the appropriate assignment category by the due date. Failure to submit to SafeAssign will incur a penalty of 5 points per day including weekends (maximum deduction of 25 pt.). Late submissions to the appropriate assignment category will incur a 5pt/day penalty (no maximum) including weekends unless an extension has been requested and approved before the due date episodic, comprehensive and alternative soap note example.

MSN Case Write-Up Rubric

 

Criteria

Exceeds Expectations

Meets Expectations

Below Expectations

No Effort

Chief Complaint

(CC)

3 Points

Includes CC that includes the reason for visit, is appropriate for the type of write-up AND is in the patient/

family’s own words.

2 Points

Includes CC that includes the reason for visit, is appropriate for the type of write-up but is not in the patient/family’s own words

 

1 Point

CC is not appropriate for the type of write-up AND is not in the patient/family’s own words

 

0 Points

 Not included

History of Present Illness

(HPI)

10 points

Provides a comprehensive HPI that includes all the pertinent information and excludes irrelevant information.

HPI is focused and detailed.

Does not include any objective data

7 points

Provides a HPI that includes pertinent information but misses 1 -2 key components and/or includes information that is irrelevant to the patient visit. HPI is somewhat focused. Does not include objective data.

4 points

Provides a superficial HPI that misses 3 or more key components and/or does not include all pertinent information, includes irrelevant information OR includes objective data

0 Points

Not included

Medications

3 Points

Documents a comprehensive

Medication list that includes drug name (brand and generic), dosage, route, frequency and indication. Allergies are documented and includes reaction. Includes NDKA, if applicable.

2 Points

Documentation includes medication list but omits 1-2 details. Allergies are documented but does not include reaction.

1 Point

Documentation includes medications but omits 3 or more details. Allergies are not documented

0 Points

Not included

Pertinent History

10 Points

Provides comprehensive past medical history, surgical, family, social, and obstetrical history (when applicable). History is consistent with other documentation. Includes immunization information

 

7 Points

Provides a history but history is superficial AND/OR omits 1 -2 necessary details

 

4 Points

Provides a history but history of superficial and omits 3 or more details

 

0 Points

Not included

Review of Systems

10 Points

Complete ROS that addresses each physical system for a comprehensive visit and includes only necessary (but at least 4 systems) for an episodic visit.

ROS is completed with a clear narrative.

Do not write within normal limit or other variations. If documented abnormalities, states what is considered ‘normal’

7 Points

Incomplete ROS that misses 3 or less components for a comprehensive visit OR includes inappropriate systems for an episodic visit

 

4 Points

Incomplete ROS that misses 4 or more components for a comprehensive visit AND/OR includes objective data

episodic, comprehensive and alternative soap note example

 

0 Points

 No ROS attempted

Objective Data

20 Points

Documents vital signs with documented BMI

Documents physical examination:

Each system addressed completely for comprehensive exam. Includes only necessary (but at least 4 systems) for an episodic visit. Include pertinent positive and pertinent negative findings.

Documents labs, diagnostic tests that are available for that visit.

14 Points

 Documents vital signs but is missing BMI

Documents an
incomplete physical examination:

missing 3 or less components for a comprehensive visit and/or missing up to 3 pertinent positives/negatives OR

includes unnecessary systems for an episodic visit and/or assesses less than 3 systems

Documents labs, diagnostic tests that should be a part of the plan

 

8 Points

Does not document vital signs

Documents an incomplete physical examination:

missing 4 or more of the components for a comprehensive visit and/ or missing 4 or more pertinent positives/negatives

OR

Includes unnecessary systems for an episodic visit and/or assesses less than 2 systems

Fails to document labs, diagnostic tests

 

 

0 Points

Not included

Assessment

14 Points

Provides 3 or more differential diagnoses and a presumptive diagnosis for an episodic visit.

Provides at least 3 diagnoses for a comprehensive visit

ICD-9 codes included with each diagnosis

9 Points

Provides a presumptive diagnosis but only includes 1-2 differential diagnoses

 

Does not include ICD-9 codes

 

4 Points

No differential diagnoses OR no presumptive diagnosis

 

0 Points

No differential diagnosis AND no presumptive diagnosis

Plan

20 Points

Provides a plan that includes appropriate labs/tests ordered that are pending

Includes medications ordered and/or refilled and details about dosing and instructions, and patient teaching are included.

Plan includes both pharmacological and non-pharmacological interventions

Plan includes referrals and follow up details

Orders are appropriate for patient visit. Rationales and citations for sources of interventions

Coding and Billing included

 

14 Points

Missing 3 or more components and/or does not include dosing and instructions for medications and/or does not include Coding and Billing

 

8 Points

Missing 4 or more of the required components OR Plan is not supported by evidence and citations for sources of intervention are missing AND

Does not include Coding and Billing

 

0 Points

Not included or inappropriate to patient visit

Formatting/APA

10 Points

No errors in  grammar and spelling .

No errors in APA format

Write-up is in proper format and adheres to the appropriate page limits.

7 Points

Up to 3 spelling or grammar errors OR 3 APA errors

Write-up is in proper format and adheres to the appropriate page limits

 

4 Points

Up to 3 errors in spelling and/ or grammar AND/OR APA errors AND

Write-up is not in proper format OR does not adhere to the appropriate page limits

episodic, comprehensive and alternative soap note example

0 Points

4 or more errors in spelling and/or grammar

AND/OR 4 or more APA errors

Nursing is a career that has recently gained popularity among college and university students. Most students are driven by different career goals that push them to pursue a career in nursing. Writing a nursing career goals essay is the first step to showcasing your dedication to pursuing this noble career.

Drafting a nursing goals essay is a task that requires diverse skills and commitment to subscribe to the program. If you are stuck on how to start a nursing goals essay, we have taken the step to help you get out of the mud in this article. You can use the guide below to reduce your migraine in writing your nursing career goals essay. 

Definition of
nursing career goals essay

Nursing career goals are vital in the expert existence of a nursing practitioner. As a nursing practitioner, you may be expected to give sharp nursing career goals essay examples on how to deal with different situations. A nursing career goals essay can be defined as a well-detailed document that explains other motives that drive an individual to choose nursing as their career.

Career goals can be defined as objectives that individuals could use to succeed in their careers. Without uncertainty, a decent handle on nursing career goals will be helpful while composing a nursing career goals essay. Any genuine understudy or specialist should have intricate professional goals in a
nursing essay
.

The writing process must be meticulous, where it ought to mirror the target of the career goals essay. Before you begin drafting your paper, it is important to understand the various career fields for nursing practitioners. These careers can be ordered under three significant gatherings that include:

1.     
Direct Patient Registered Nurse

This career way involves working at the patient’s bedside as a feature of an interdisciplinary group. The essential job of the medical caretaker involves working “actively” with patients.

2.     
Indirect Patient Care Registered Nurse

This career way includes working with an interdisciplinary group of various medical services professionals, including the bedside attendant, to help with patient consideration. It emphasizes more working in managerial and the executives’ limits. Work settings for this nurse might include:

Outpatient settings

Insurance companies

Hospitals

Correctional healthcare facilities

Government

Skilled nursing facilities

Clinics

Community health

Physician offices

Universities

3.     
Advanced Practice Registered Nursing

This is viewed as the embodiment of a nursing career. The career way goes about as a scaffold among nursing practitioners and doctors. Such medical attendants perform undeniable level obligations and manage the nursing staff. APRN areas of practice include:

Nurse anesthetist

Nurse practitioner

Clinical nurse specialist

Nurse midwife

How to develop educational goals essay for nursing

Creating reasonable goals is one of the significant areas of concern when composing an essay on nursing career goals. Likewise, there is a heap factor you ought to consider to guarantee that your goals are lined up with your scholarly and professional pursuits. It is, in this way, vital to ensure a first-class essay.

Writing future career goals in
nursing essays
demands a good understanding of the goal development process. Generally, when developing such goals, you should deliberate on several factors, including:

1.     
Factors what drive you to pursue nursing
 

A nurse is considered the first line of contact in healthcare provision and saving of life. As a nurse, you are obliged as the first person to identify any patient who may require emergency attention. Practicing nursing services is demanding in its nature of work, requires high concentration levels, and can be mentally draining practice.

This is more serious in some fields of nursing practice than others. In light of this, drafting a career goals essay for nursing graduate school requires a legitimate individual assessment to decide the explanation that draws you to practicing nursing activities. Recognizing this reason will assist you in making suitable choices to help you follow your dream. 

2.     
A working environment that suits you
 

This is another factor to consider when writing a nursing educational and career goals essay. It is essential to appreciate that respective nursing careers are practiced in different environments.

Other nursing careers might expect you to work from home, travel frequently and broadly, practice in well-known emergency clinics, stroll around in communities delivering healthcare, hold meetings and educative programs, or even work in educating foundations. Consequently, it is fundamental to consider the different work settings while composing your nursing targets and goals. This is key in deciding if you have the essential individual qualities and traits for working in particular conditions and nursing careers. 

3.     
The community you aim at delivering healthcare services to

Close to your environment, the type of society you wish to consistently collaborates with is another significant component to consider while composing a frontier nursing goals essay. This glances at the patients, associates, and individuals you report to. Nursing careers allow you to connect easily with the patients, local area individuals, scholars, and intellectuals.

In some nursing careers, interacting with individuals, either patients or the general population, is restricted. The prerequisites to answer to your superiors vary depending on your nursing career. It would be best to comprehend where your character suits most while fostering your nursing professional goals statement.      

4.     
The requisite academic qualifications
 

Your academic qualifications are essential in every path you take when writing an essay on nursing career goals. All these career paths are more demanding academically than other careers. Other career paths will only require an undergraduate degree, while others require a master’s or a doctorate degree.

This places you in a position to consider factors like your age, financial capacity or plans, and other life issues like craving for additional time with family. The more specific the nursing career is, the higher the academic requests. 

How to set your nursing career goals

To develop proper examples of nursing career goals, you will be expected to have the essential objective setting information and abilities. Note that the method involved laying out attainable nursing career goal requests that you take on the SMART goals approach. The SMART goals are explained in detail below.

It is important to note that SMART is an acronym for:

S
: Specific

M
: Measurable

A
: Attainable

R
: Realistic

T
: Time-bound   

v 
Specific

It is essential to guarantee that the goals you include in your nursing professional goals articulation are not very expansive. All nursing career goals essay examples should be presented in a way that they can be easily translated. It would be best if you comprehended that long-term goals as a nurse practitioner specifically are exposed to pessimistic impacts of progress by the change in environment and individual perspectives.

It would be best to be specific with your nursing career goals enough to avoid situations of outrageous differences. The goals ought to be just about as engaged and point by point as expected. 

v 
Measurable

All nursing career goals should be quantifiable. Measurability is critical concerning how to accomplish nursing goals. This is significant in deciding on advancement in your nursing career.

This progress could be explored using different examples of nursing goals for yearly evaluation. Measurability is also essential in helping demarcate achievements that act as a source of motivation. Your nursing career goals should incorporate clear milestones that have a defined ending.  

v 
Attainable

This pertains to how to achieve nursing goals. There is a significant attainability challenge, mainly when writing a long-term goals nursing essay. This is because such nursing career goals could demand tools and resources beyond the reach of the nurse.

Ensuring that your nursing goals are incognizant of required resources, including time frames, skills, and funds, is essential. This requires you to break down your goals into smaller ones, especially in incidences where the main goal is quite complex. You can begin by exploring the most appropriate examples of nursing goals for yearly evaluation.   

v 
Realistic

About being realistic, you need to guarantee that every one of the examples of nursing career goals you decide to embrace is sensible concerning the setting of nursing practice. You ought to consider various elements to conclude whether your nursing career goals are reasonable. Such factors might include their degree, required abilities, existing frameworks, and individual limits.

Specifically, long-term goals for a nursing specialist can represent genuine difficulties in being practical. As a nurse, you should try to make career goals that are grounded and adjusted to the setting of nursing practice. 

v 
Time-bound

Time-frame is another significant facet regarding how to accomplish nursing career goals essay. It involves joining a particular course of events to achieve your nursing career goals. Every goal should include a study of events inside which the goals are supposed to have been accomplished.

This needs you to develop various examples of nursing goals for the yearly assessment. The timetables should function as signs of progress and a wellspring of inspiration on the direction you should take as a nurse. 

Steps to take when writing career goals essay for nursing graduate school

Step 1: Planning your essay 

Before composing, begin by brainstorming your goals and what you need to achieve as a medical caretaker. This stage is tied in with gathering different ideas.

a.       Brainstorm different nursing career paths

Every registered nurse can work in a specialist’s office, clinics, schools, long-term care offices, facilities, prisons, and traveling nursing all around the United States and other foreign nations.

b.       Plan your nursing career content

After you have narrowed your ideas about your career as a nurse, it is time to plan how to get your message across. Here is a list of factors you should consider before writing your nursing education and career goals essay:
 

Who is your audience? 

A list of items that interest you as a nursing student and why you find them interesting

Why did you select the nursing program that you did?

Prior preparation for becoming a good nurse

What makes you stand out?

Any medical training or patient care

What traits do you have that will make you a good nurse?

Why the nursing school should accept you as a student

What work environment do you prefer? Hectic and fast-paced? Slow and steady and quiet?

Step 2: Outlining your essay

Usually, you will start with the introduction, write the main content in your essay’s body paragraphs, and finish with a conclusion. To write an outstanding essay about nursing career goals, you can consider the following steps as your
cheat sheet
:

Develop eye-catching essay topics on career goals in nursing.

Draft a powerful personal statement or an introduction to hook your audience. You can make it enjoyable by writing a personal story.

Begin to draft your essay’s body by highlighting your long-term and short-term goals. You can take it further by writing about what drives you to pursue a nursing career.

Every essay has a beginning and ending, so does a nursing career goals essay. You should emphasize your discussion topic and leave an impression on your audience.

Step 3: Writing your nursing career essay 

It’s time to put your pen to work. Even if you develop a rough draft, you have to begin writing your essay. 

Ø  Title

The title of an essay is one of the essential pieces of a paper. While making your title, think about your crowd. If you decide to draft an admission essay, it is always important to understand that your crowd will be an admissions committee.

Ø  Essay introduction 

Your introduction is an essential facet of your work. To showcase your expertise, you should develop a solid personal statement. The personal statement should be a novel or recount an individual diminutive story. The presentation is where you arouse your audience’s curiosity and catch their consideration, so they need to continue to peruse.

One answer that should shine through is
why
you want to be a nurse
. This question’s answer serves as a great transition between your career goals essay’s introduction and body.

Ø  Body of your nursing career goals essay

A nursing school essay’s body tells the nursing school administrators why they want to be a nurse and why they should select you to be a student in their program. You can incorporate a real-life story if you have one.

Long-term goals and short-term goals 

This will be the primary piece of your essay. You ought to devote most of your paper to your nursing career goals. You will have goals that you can accomplish quicker than different goals. One method for seeing it is to have momentary goals and long-term goals. Momentary goals will be goals you can accomplish in under one year, though long-term goals require a touch more determination and vision.

Presenting your short-term and nursing career goals in 5 years shows that you are aggressive and have a dream for your career. These goals should underline the effect you wish to make once you enter the nursing force. Here is a cheat sheet to introduce your goals:

State your goal clearly

Describe how this goal connects to your personal life

What motivates you to achieve this goal?

Explain your plan on how you will accomplish this goal

Write about the challenges that you may face and how you will overcome them

Examples of short-term goals 

Passing Nursing school and board certification

Taking classes to gain more certifications such as the Advanced Certified Life Support(ACLS) or Critical Care Registered Nurse(CCRN)

Taking classes to increase to improve your current knowledge. For example, EKG classes as a cardiac nurse or mother-baby classes as a labor and delivery nurse.

Improving communication skills with patients and colleagues

 Examples of long-term goals 

A relatively common career goal is advancement. If you are looking for a more challenging nursing position or getting burned out, look into becoming an educator or a family nurse practitioner.

Another good move up the nursing ladder is to obtain an administrative position. This is an excellent option if you seek to move away from the bedside. The ideal people for the jobs are nurses because they already have vast knowledge in the nursing field. 

Step 4: Conclude your essay

This part will stay with your crowd the most because it’s the last part they read. Your conclusion should comprise your strengths and accomplishments.

A phenomenal method for being unique is to give your crowd a something worth mulling over and end your essay with the accompanying:

Connect your personal experience/story with your goal of becoming a nurse

Return to the introduction for your paper to come full circle

End your essay with an intriguing question

End your essay with an impactful statement

How to answer the question “Why do you want to be a nurse?” in your essay

Frequently, a potential nursing understudy has a particular explanation far over the affection for dealing with individuals. It is typically a heartbreaking story, yet one that gives a powerful urge and drives you as a student.

Likewise, you ought to consider what you will be “dealing” with as a nurse, like blood, organic liquids, death of infants, children, teenagers, youths, grown-ups, and the elderly. Engine vehicle mishap casualties are gripping to life, sick individuals who are so debilitated they will most likely be unable to talk or continue alone, misfortune and the circle of life gone haywire.

There are also happy endings in hospitals such as: babies’ birth and parents being discharged in good conditions, patients who have gone through long periods in the emergency clinic being discharged, and careful patients who are presently not in torment leaving return home.

Other situations that can define your goals

If you have worked or volunteered in a doctor’s office or hospital, you can draw from what you observed and add any positive experiences.

If you were a patient in a hospital for at least a few days, you could again draw from that experience about how you felt as you watched the doctors and nurses take care of you and even other patients. Of course, your experience would need to be a positive one.

You can use a situation where you volunteered in a pediatric unit to read to the children. You could make sense of how that affected you and how the nursing practitioners communicated with the child.

Final remarks

Setting your goals as a nurse is the first staircase to a successful nursing career. To show case your credibility and competency, you must complete an outstanding nursing career goals essay. The above guide will help you get the flowers you deserve by writing a top-quality nursing goals essay.

If you are stuck choosing the best essay topics on career goals in nursing, you can always consult our experts. When you place your first order with us, you are guaranteed access to a free sample essay on nursing career goals. Allow our experts to mold you into the nurse you always dreamt of becoming.

As a student in the field of nursing, you might be tasked with various concepts to research. Among these is the middle-range nursing theory. This article will equip you with the best content you need to capture about the middle-range nursing theory. However, how can you define a nursing theory? Read on for more ideas.

What is a nursing theory?

Before you define middle-range theory in nursing, it would be vital for you to know what a nursing theory is. A thorough and creative organization of concepts with the aim of profound comprehension of an incident is termed nursing theory. Nursing care theories, mid-range theories of nursing, and grand theories of nursing are examples of nursing theories.

Middle-range nursing theories are more narrowly focused than grand theories in nursing, and they also provide a useful link between
professional nursing
and grand theories in nursing. As a result, middle-range theories include concepts and propositions, as well as nursing practices and a growing theory-based perspective. The middle-range theory nursing definition is expounded below :

What is a middle-range nursing theory?

The middle range nursing theory is a sub-discipline of nursing that emphasizes the discipline’s prospective knowledge by broadening phenomena associated with patient
health care
.

The middle range theory of nursing is carefully defined using the abstraction ladder, which asserts that as we move down the ranks, the level of abstraction falls while the conciseness increases (empirical level), and vice versa as we move up the ladder (philosophical level).

The middle range theory in nursing practice is the empirical level’s sub-discipline.

This theory of nursing provides a solid foundation for dealing with difficult situations. It is a more narrowly defined phenomenon. It contains less abstraction and more empirical testing, as well as more concrete phenomena. Descriptions, predictions, and explanations are presented in the middle range nursing theory to answer questions that are not addressed in other nursing theories.

This theory gives students viewpoints that prepare them to deal with difficult and emergency circumstances, as well as nursing solutions. This idea is more useful in nursing scenarios where justifications and implementations are required.

Who developed the middle-range nursing theories?

Roberts and Roy are the proponents of the middle-range nursing theory. Their groundbreaking work set the foundation for the development of several other mid-range theories in nursing. The model of nursing cognitive processing focuses on the core cognitive arousal processes and attentiveness, sensations and coding, perception and idea development, memory, planning, language, as well as motor responses.

The paradigm suggests that neurological and neurochemical functions are required for basic cognitive processes that occur within the sphere of awareness. The concept goes on to say that cognitive functions are geared toward coping with the focused stimulation of the current sensory experience, while also taking into account contextual and lingering cues from an individual’s experience and education.

Categories of middle-range nursing theories

Middle-range nursing theories are divided into three categories:

Middle-range descriptive theory

The most basic type of descriptive theory is the middle-range descriptive theory. It locates commonalities among individuals, groups, situations or events. Typology or taxonomy are terms used to describe the middle-range descriptive theory. They are developed and tested using descriptive research techniques, which might be qualitative or quantitative in nature.

Peplau’s interpersonal relations theory

Peplau’s interpersonal relations theory is a nice example of the middle-range descriptive theory. The middle-range explanatory ideas are the second category. They look for connections between concepts. The degree to which one thought is tied to another is explained by middle-range explanatory theory.

Correlation research

Correlation research, which is often quantifiable in nature, is used to establish and test them. Watson’s notion of human compassion and attachment is a good illustration of this philosophy. Predictive theories are the third category of middle-range nursing theories. It addresses the changes that take place in a phenomenon.

These theories are formulated and experimented with through experiments. It is a quantitative research design and a great example of the theory is the deliberative process of nursing by Orlando.

What are the characteristics of the middle-range nursing theories

Conceptual models, meta-theories tiny theories, and middle-range are several types of nursing science theories. Each phase of theory comprises distinct qualities that distinguish it from the others. In the 1960s, the discipline of sociology saw a requirement for the middle-range nursing theory.

It has been utilized to bridge the gap that links nursing science ideas and practice in nursing science. The creation of mid-range theories became very prevalent on the international scale, notably in the 1990s.

Middle-range nursing theories are more constrained in character than meta-theories or conceptual models, and they may be descriptive or predictive. They also have fewer concepts and are located somewhere between practical/practical theories and conceptualizations. Among the characteristics of middle-range theory nursing are the inductive and deductive phases. A deductive or inductive technique can be used to build a mid-range theory and unlike meta-theories or conceptualizations, it could be empirically validated into a form that is measurable. The two phases are as elaborated below:

The inductive phase

The first stage of theory formation was idea formulation, and conceptions were generated through concept synthesis. The goal was to use an inductive technique to observe the concept in a disciplined and systematic way. Since the fundamental ideas ( environment and well-being) are abstract, an inductive technique was selected. Furthermore, there is very little existing research on the environment that promotes wellness in the setting of aging, and also the idea of the surrounding has generally been defined based on results by investigators and theoreticians in domains apart from nursing science.

Synthesis of concepts utilizes the qualitative approach, with data used in the interview as the basis. Concept synthesis was employed after the transcription of the interview material to create concepts depending on the information acquired from individual observed data by organizing and grouping information about the phenomena. The goal was to find out what characteristics of the physical surroundings contribute to happiness.

The goal of idea synthesis was to create models that represented the event under investigation in a concentrated manner by generating concepts that described it. Based on the study’s goals, the analysis began with the selection of a tool for data collection a word, a phrase, a larger semantic unit, or a letter.

The deductive phase

Assumptions for testing the idea (theory) are set and tested in the deductive stage. The physical surroundings hypothesis was as follows:  the frameworks of the primary notions linked to the natural setting can be indicated:

The northern environment

The enjoyable physical environment

The environment which allows safe activity

There should be equipment that could be utilized to assess the concepts offered as hypotheses to enable hypotheses to be verified. The notions of the competing hypotheses were operationally defined in such circumstances.

Following the definition of a concept, its links with other ideas were studied by constructing statements. A total of 100 phrases were used to link the concepts together. The statements are placed in a certain order (five-point scale).

Practical application of the middle-range nursing theory

The application of a theory in practice is a widely utilized criterion in assessing a practiced theory. A theory established in the way of middle-range nursing theories could be utilized in the nursing curriculum and also as an instrument for nursing staff to think about.

The ideas can be applied to defining and analyzing an environment t which promotes geriatric well-being. The theory’s implications include directing practical activity and research, generating new ideas, and distinguishing nursing’s primary focus of concern from other fields.

A mid-range theory that can be applied to other disciplines is the notion of an environment that supports the well-being of senior persons. In such circumstances, the theory’s concepts serve as a guide for additional research of many kinds. Further research could look into how the various settings wherein the aged live contribute to overall well-being. The concept can then be utilized as a guide in actual professional nursing or for creating multiple recommendations to help it develop.

Correlation analysis was used to examine the theory’s reliability and validity, which revealed that it was pretty sound. In all of the models evaluated, the quantitative values and the indicators of significance to the information compiled as a consequence of the study are satisfactory. Factor analysis was considered to be a viable technique for evaluating the theory, and indices acquired in the study verified the researcher’s hypothetical models formed via qualitative analysis.

The middle range nursing theory’s reliability

Convergent validity and discriminant validity analysis was used to assess the theory’s reliability and validity. It revealed that it was both credible and accurate. In all models evaluated, the quantitative values and the indicators of usefulness towards the data supplied as a consequence of the study are satisfactory.

Factor analysis was considered to be an effective technique for evaluating the theory, and the scores acquired in the study verified the scientist’s hypothetical models created via qualitative analysis.

What is the importance of middle-range nursing theory?

Theories of nursing provide the principles which underpin a new student’s practices and help in generating knowledge in nursing. Middle-range theory of nursing is vital for nursing students since it gives them a middle view of reality and more precisely generalized areas of practice for nurses. It also gives nurses concrete ideas that are limited and of use to them. The qualities of the arguments are clearly articulated in middle-range nursing theory, allowing a better judgment to be made for the patient’s health care. 

The amount of validation provided by the middle-range nursing theory can be used to develop a hypothesis for the test. Since the grand nursing theory, as well as the theory of nursing practice, influenced the creation of middle-range nursing theory, this theory encompasses all literature reviews, clinical experience, and recommendations that nurses should follow.

A suitable instrument is required for a theory to be reliable. Pretesting is an important aspect of determining the indicator’s validity.

Meta-paradigm of nursing

The meta-paradigm of nursing is a collection of large models that depict the evident connection between recent theoretical practices in nursing. Many nursing practices are currently being investigated in understanding the link between four meta-paradigm key aspects. The following are four key meta-paradigms in the nursing field:

Person

 The people who receive nursing care; in this paradigm could be unwell person who is regarded as a topic in the treatment process. In between an individual and his surroundings, there is a constantly evolving process. Nursing care can be provided to an unwell person, entire families, or entire communities.

Health

Health is described as an individual’s level of well-being. It is a dynamic process that an individual describes throughout his or her life. The nature of aesthetic, physical social, and moral boundaries are the key focuses on the subject’s health. Sickness or illness is described as the perspective of a person who has suffered from health-care-related dysfunctions.

The state of a person’s mental health incorporates interacting processes that occur between the person and their surroundings.

Environment

 Internal plus external elements that influence an individual’s level or degree of health are referred to as the environment. It focuses on the influence of geography and scenery on a person’s life.

The effect of physiological, psychological, economic, and social elements, as well as cultural, historical, and developmental factors that are common in the society where the individual lives, are all factors that may bring harm to the individual.

Nursing

Nursing is the vocation responsible for providing healthcare services in hospitals. Nursing interventions provide care for sick patients. The nursing meta-four paradigm’s ideas make a coherent comprehensive knowledge of the occupation.

These four themes encapsulate the fundamental understanding of the theory of nursing, education, philosophy, experience, and research.

How will the middle-range nursing theory impact nursing practice?

The middle-range theory in nursing practice is very significant for nurses, and it can help them enhance their nursing practice.

This theory’s foci help nurses construct practical and conceptual ideas in a way of concepts that they may use to practice their vocation effectively.

The breadth of the medium-range nursing theory is, nevertheless, constrained; but the ideas and material that it contains are concrete, which aids in the advancement of patient care.

Examples of the middle-range nursing theories

The middle range theory for nursing is more focused on a single topic and provides more explicit linkages between the grand theories of nursing as well as the nursing practice. The middle-range nursing theories have less abstract concepts that can be verified through testing.

These ideas frequently attempt to explain, describe, or anticipate certain clinical phenomena. The middle-range nursing theory examples are as listed below:

Marie-Louise Friedemann’s framework for the systemic organization

Christina Sieloff’s organizational group power theory

Katharine Kolcaba’s comfort theory

Ramona Thieme Mercer’s maternal role achievement theory

Marion Conti O’hare’s wounded healer nurse

Dorothy Johnson’s behavioral system model -The AACN synergy model AACN behavioral systems model

June H Larrabee’s nursing care quality theory

Blanche Mikhail’s model of health belief

Theory of undesirable symptoms – Elizabeth R Lenz & Linda C Pugh

Rozzano C Locsin’s advancing technology, nursing, and caring

Middle-range nursing theory of acute pain management in adults

Merle Mishel’s theory of confusion in illness

The above listed are samples of the middle-range nursing theories. Middle range nursing theory acute pain management adults are expounded below:

Middle range nursing theory acute pain management adults

The acute pain theory of pain management is the normal reason for individuals to seek treatment. Pain management that is inadequate leads to a delay in the process of healing. It could also lead to longer hospital stays. The middle-range nursing theory of acute pain management in adults illustrates how nurses can manage pain with the least effects from pharmacological interventions and the utilization of alternative ways of managing pain.

The major factors in pain management are non-pharmacological, pharmacological, education, participation of the patient, and different interventions. To manage pain effectively, non-pharmacological interventions and the use of painkillers should be considered.

A comparison between middle-range nursing theory and grand-range nursing theory

There are various theories in the nursing field. People tend to focus more on getting the difference between grand theory and middle range theory in nursing. Nursing theoretical approaches are structured paradigms of ideas and objectives to direct nursing practice. Grand theories in nursing and middle-range theories in nursing are two sorts of theories in nursing. Grand theories in nursing cover all types of diversity and may be applied broadly, while middle-range nursing theories may be less conceptual and more focused.

Although these two theories have parallels and distinctions, both varieties of theories can be valuable in enhancing advanced practice in nursing. Grand nursing ideas are wide in scope and apply to a broader range of nursing issues, like health promotion for all members of society. Read on to get a detailed comparison between the grand nursing theory vs the middle-range nursing theory.

Grand theories in nursing

Grand theories in nursing, despite being wide and non-specific, have various consequences for developed practice in nursing. It is common knowledge how healthcare is growing highly complicated at an accelerating rate.

The critical nature of the grand theories can be beneficial for complicated phenomena pertinent to nursing, like population aging and complex illness states, due to continually increasing complexities. Grand theories help to illuminate the intricacies of these plus other issues that affect advanced clinical nursing in a
globalized world
.

Grand theories in nursing comprise existing theories that can provide wide insight beneficial for general nursing practice. Due to the obvious abstraction level, they are generally not empirically verified. Enlightening appraisal and thoughts are frequently used to build grand theories.

Middle-range nursing theories

Middle-range nursing theories, like grand theories in nursing, have significant repercussions for advanced nursing practice. The link between practice and research can be summarized as a middle-range nursing theory.

The scope of middle-range concepts is narrower, and they serve as a link between grand nursing theories and patient care. Hypothesis testing is easier with middle-range nursing theories since they are less concrete. Their ideas are also operationalized more easily.

Middle-range nursing theories are mostly an evolution of the grand theories, clinical practice, and literature reviews. This makes them more precise to the nursing practice.

Middle range nursing theories vs the grand range nursing theories

Each has a role in educating as well as guiding advanced practice in nursing. These theories might be descriptive, predictive, or explanatory. When opposed to grand theories in nursing practice, middle-range nursing theories contain more specificity, narrower scope, and are easier to apply concepts.

Both grand and middle-range nursing theories are collections of interconnected concepts that underlie advanced nursing practice thinking. There are, however, numerous distinctions between these two sorts of hypotheses.

These theories both play a significant role in educating and empowering advanced practice in nursing, despite their distinctions. Grand theoretical approaches in nursing expound on the nursing role and distinguish nurses from other health care practitioners, whilst the middle-range theories of nursing guide them through clinical decision-making.

The varying sorts of theories each have their own set of benefits in practice. These two forms of ideas complement one other, and each can help enhance the nursing practice and understanding

Mid-range holistic care theory application

Holistic care refers to a modern nursing technique that encompasses all aspects of a patient’s care, including mind, body, and spirit. Recognizing a person’s well-being and health is a good start. It is accomplished through offering a patient mental, physical, and spiritual medical services.

This significantly improves the patient’s and his/her family’s standard of living. This service is covered to promote healthy living by promoting a sustainable lifestyle and preventing and curing any sickness that a patient may be suffering from. Nursing entails assisting somebody through a tough situation. As a result, individuals desire professional counseling whenever they require assistance or are unable to deal with a circumstance on their own.

Holistic counseling in health, also known as Holism, is a counseling method that involves recognizing and assessing a condition as well as delivering healthcare that understands and provides answers to the patient’s well-being and general health. The model is normally regarded as morally superior, implying a differentiated perspective on the past biomedical usage of drugs in the treatment of diseases and disorders.

The bottom line

The middle-range nursing theory helps the respondents and nurses (who are medical professionals) recognize the specific contribution which should be provided to the care center and even the patients by providing a sense of identification. This article would therefore be of many benefits to you as an aspiring nurse or a professional nurse.

Providing enough knowledge and advice to nurses in accordance with the ideas put out by this theory would serve to strengthen the quality of their profession, as well as the patient’s health.

Alcohol Use Disorder Rachel Adler shadow health Subjective Data Collection

Subjective Data Collection: 51 of 51 (100.0%)

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Pro Tips
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Example Questions
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Found:

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Available:

 Indicates an item that is available to be found.

Category

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

Patient Data

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

Chief Complaint

Finding:

Established chief complaint and reason for admittance

Alcohol Use Disorder Rachel Adler shadow health Subjective Data Collection

Finding:

Reports car accident

(Found)

Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.

Example Question:

Why were you admitted?

Finding:

Reports injury

(Found)

Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.

Example Question:

What caused your injury?

Finding:

Reports passive suicidal ideation

(Found)

Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.

Example Question:

What brings you in today?

History of Present Illness

Finding:

Followed up on details of car accident

Finding:

Reports loss of consciousness

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Did you lose consciousness during the car accident?

Finding:

Reports being unsure of how the accident happened

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Do you know what caused the car accident?

Finding:

Reports wearing seatbelt

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Were you wearing a seatbelt?

Finding:

Reports being the driver – no other passengers in car

(Available)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Who was driving before the car accident?

Finding:

Reports was told she would get a ticket for DUI

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

What caused the car accident?

Finding:

Followed up on alcohol use just prior to car accident

Finding:

Reports drinking before accident

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Were you drinking before the accident?

Finding:

Reports being unsure of how many drinks – “at least 5”

(Available)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

How much did you drink before the accident?

Finding:

Reports was drinking with friends at a party

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Who were you drinking with?

Finding:

Reports left party to drive home because she was mad at her girlfriend and could not take any more

(Available)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Why did you leave the party?

Finding:

Asked about driving impaired

Finding:

Reports knew she was driving under the influence but did not care

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Did you know you were too drunk to drive?

Finding:

Reports have driven in past after drinking, but this time she did not care if she injured herself

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Did you care that you were driving under the influence?

Finding:

Followed up on impaired driving – risk for self harm

Finding:

Reports has had enough of life and did not care if she got hurt/died

(Available)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Did you drive under the influence in order to hurt yourself?

Finding:

Reports had not thought about self harm before accident

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Have you ever wanted to hurt yourself before the accident?

Finding:

Reports since accident, not sure what to think about what she did

(Available)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

How do you feel since the accident?

Finding:

Asked about onset and duration of pain

Finding:

Reports pain started immediately after accident

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

When did you last experience the pain?

Finding:

Reports accident was last night

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

When did the car accident happen?

Finding:

Reports accident was at 10 pm

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

When did the car accident happen?

Finding:

Asked about location of pain

Finding:

Reports pain is in right wrist

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Alcohol Use Disorder Rachel Adler shadow health Subjective Data Collection Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Does your wrist hurt?

Finding:

Asked about aggravating factors of pain

Finding:

Reports increased pain when bending or twisting (R) wrist

(Available)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Is your pain worse with movement?

Finding:

Reports increased pain when trying to lift items, even small ones such as a hairbrush Alcohol Use Disorder Rachel Adler shadow health Subjective Data Collection

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Is your pain worse with movement?

Finding:

Asked about treatment and relieving factors of pain

Finding:

Reports rest improves pain

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Does lying down help your pain?

Finding:

Reports ibuprofen has significantly reduced pain

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Has ibuprofen helped your pain?

Finding:

Reports wearing sling helps

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Alcohol Use Disorder Rachel Adler shadow health Subjective Data Collection Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Has wearing the sling helped your pain?

Finding:

Asked about characteristics of pain

Finding:

Reports pain is aching

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Is the pain aching?

Finding:

Denies sharp or shooting pain

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness Alcohol Use Disorder Rachel Adler shadow health Subjective Data Collection. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Do you have shooting pain?

Finding:

Asked about severity of pain

Finding:

Reports current pain level is 2/10

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

How would you rate your pain?

Finding:

Reports pain without medication was 8/10

(Available)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

How would you rate your pain without medication?

Past Medical History

Finding:

Asked about existing health conditions

Finding:

Reports no known health problems

(Found)

Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

Example Question:

What health problems do you have?

Finding:

Asked about history of mental health

Finding:

Denies previous history of mental illness diagnoses

(Found)

Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

Example Question:

Do you have a history of psychiatric illness?

Finding:

Denies past depression

(Found)

Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

Example Question:

Have you experienced any depression or sadness?

Finding:

Reports feeling anxious over the past six months – has not sought treatment/counseling

(Found)

Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

Example Question:

Have you felt anxious?

Finding:

Reports can not deal with stress of school and life in general

(Found)

Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

Example Question:

Is your life stressful?

Finding:

Reports that she does not care what happens to her anymore (passive suicidal ideation)

(Found)

Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

Example Question:

How do you cope with stress?

Finding:

Followed up on stress issues

Finding:

Reports stress over parental relationships

(Found)

Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

Example Question:

How do you get along with your parents?

Finding:

Reports stress over school

(Found)

Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

Example Question:

Can you tell me about school?

Finding:

Reports stress over grades

Rachel Adler Alcohol Use Disorder shadow health transcript

Transcript

Started:
Jun 11, 2022 | 
Total Time:
 172 min

All Lines (164)
Interview Questions (119)
Statements (14)
Exam Actions (31)

Hello. My name is xxx, I will interview you and conduct a physical exam

Greet

06/16/22 10:13 PM EDT

Hi. Thanks for being here.

What brings you here? Rachel Adler Alcohol Use Disorder shadow health transcript

Question

06/16/22 10:17 PM EDT

I don’t know what happened. They told me I was in a car accident, that I hit a pole and I’m getting a DUI. That’s how I hurt my wrist. I don’t care what happened, I kind of wish it had been worse.

Did you get an injury?

ORDER HERE

Question

06/16/22 10:18 PM EDT

Other than my wrist? No, I don’t think so.

Were you attempting suicide? (Clarified to Have you ever attempted suicide?.)

Question

06/16/22 10:22 PM EDT

No, I’ve never attempted suicide. I’ve never planned anything. Before last night, I wasn’t trying to hurt myself. I just wish things were easier, and if I’d died last night, I’d be free of being so sick and tired of everything Rachel Adler Alcohol Use Disorder shadow health transcript. (Clarified to if I have ever attempted suicide.)

Did you lose consciousness?

Question

06/16/22 10:30 PM EDT

I passed out in the car crash. I don’t remember how it happened.

Were you wearing a seatbelt?

Question

06/16/22 10:34 PM EDT

I always wear my seatbelt. Even when I’m drunk driving, apparently.

Did you drink before the accident?

Question

06/16/22 10:34 PM EDT

Yeah. I was. I think I had at least five drinks. I was at a party with my friends, so, I didn’t think it was a big deal. Shows you where that gets you, I guess.

Did you drive carefully?

Question

06/16/22 10:35 PM EDT

Honestly, I didn’t care that I was driving drunk. I mean, I’ve done it before, all my friends do it, I didn’t think it was a big deal. I was too upset to care, anyway. I didn’t really think I was going to get hurt, but, like, at the same time, I didn’t care what happened to me.

When did the pain start?

Question

06/16/22 10:36 PM EDT

The pain probably started around the moment when I passed out and my car hit that pole.

Where is your pain located?

Question

06/16/22 10:37 PM EDT

My wrist hurts the most. The right one, in the brace.

What makes your pain worse?

Question

06/16/22 10:37 PM EDT

It hurts pretty bad when I move it. If I bend or twist it, or if I try to pick something up, it hurts a lot.

Am sorry about that

Empathize

06/16/22 10:38 PM EDT

Ha, thanks.

What relieves your pain?

Question

06/16/22 10:38 PM EDT

The ibuprofen has helped the pain. That, and the sling.

Does rest improve your pain?

Question

06/16/22 10:39 PM EDT

Yeah, resting here does help.

What is your pain like?

Question

06/16/22 10:40 PM EDT

It’s kind of this constant ache Rachel Adler Alcohol Use Disorder shadow health transcript.

Any sharp pain?

Question

06/16/22 10:40 PM EDT

No, I wouldn’t describe it that way. It’s more of an ache.

How would you rate your pain level? Rachel Adler Alcohol Use Disorder shadow health transcript

Question

06/16/22 10:40 PM EDT

I’d say my pain is about a two out of ten.

Does your medication improve the pain?

Question

06/16/22 10:41 PM EDT

The ibuprofen has helped the pain. That, and the sling.

Do you have any other health problems?

Question

06/16/22 10:42 PM EDT

I don’t have any illnesses.

Any history of mental disorder?

Question

06/16/22 10:42 PM EDT

I’ve never been diagnosed with a mental illness.

Any history of depression?

Question

06/16/22 11:14 PM EDT

No, no one’s ever told me I have depression.

Any stress?

Question

06/16/22 11:15 PM EDT

The last year has been hard, but I’ve been especially stressed out for the last six months. It’s been so tough to keep my grades up at school, to deal with my parents, and then to have problems with my friends . . . I wish I could be a normal carefree college student, but that’s never going to happen now.

Am sorry about that

Empathize

06/16/22 11:16 PM EDT

Thanks. Wish I were kind to myself like that.

Any suicidal thoughts?

Question

06/16/22 11:17 PM EDT

I don’t have a plan, if that’s what you mean. Before last night, I didn’t want to kill myself. Right now . . . I don’t know. Everything is so hard, and I wish it would all just stop.

Have you ever attempted suicide?

Question

06/16/22 11:17 PM EDT

No, I’ve never attempted suicide. I’ve never planned anything. Before last night, I wasn’t trying to hurt myself. I just wish things were easier, and if I’d died last night, I’d be free of being so sick and tired of everything.

do you feel confused about your life?

Question

06/16/22 11:18 PM EDT

I don’t know. I haven’t thought about physically killing myself or how I would do it or anything. It’s more just wishing not to be here. Rachel Adler Alcohol Use Disorder shadow health transcript It would be so much easier.

Am sorry about that

Empathize

06/16/22 11:40 PM EDT

Thanks for getting it.

Why do you wish you had died? (Clarified to Why do you think it would be better if you had died in the car accident?.)

Question

06/16/22 11:43 PM EDT

Well, it would be so much better if I didn’t have to put up with the stress of life anymore. Like, I didn’t care if I could’ve hurt myself last night, even though I know drinking and driving is bad . . . in some ways, it might have been better if I had just died last night. Then I wouldn’t have to go through all this. I wouldn’t have to face the court for this DUI, wouldn’t have to face my parents . . . (Clarified to why I think it would be better if I had died in the car accident.)

What makes you think about dying? (Clarified to Why do you think life is not worth living?.)

Question

06/16/22 11:45 PM EDT

Well, it would be so much better if I didn’t have to put up with the stress of life anymore. Like, I didn’t care if I could’ve hurt myself last night, even though I know drinking and driving is bad . . . in some ways, it might have been better if I had just died last night. Then I wouldn’t have to go through all this. I wouldn’t have to face the court for this DUI, wouldn’t have to face my parents . . . (Clarified to why I think life is not worth living.)

Am sorry about that

Empathize

06/17/22 12:40 AM EDT

Thanks. Wish I were kind to myself like that.

 Assess vitals

Exam Action

06/17/22 12:40 AM EDT

 Inspected right eye

Exam Action

06/17/22 12:40 AM EDT

 Inspected left eye

Exam Action

06/17/22 12:40 AM EDT

 Inspected right eye

Exam Action

06/17/22 12:40 AM EDT

 Inspected left eye

Exam Action

06/17/22 12:40 AM EDT

 Inspected left arm

Exam Action

06/17/22 12:40 AM EDT

 Inspected right arm: right hand is normal, right wrist has redness and swelling

Exam Action

06/17/22 12:40 AM EDT

 Inspected left arm: no visible abnormalities Rachel Adler Alcohol Use Disorder shadow health transcript

Exam Action

06/17/22 12:41 AM EDT

 Inspected left wrist: no visible abnormalities

Exam Action

06/17/22 12:41 AM EDT

 Inspected left hand: no visible abnormalities

Exam Action

06/17/22 12:41 AM EDT

 Inspected right arm: no visible abnormalities

Exam Action

06/17/22 12:42 AM EDT

 Inspected right wrist: no visible abnormalities

Exam Action

06/17/22 12:42 AM EDT

 Inspected right hand: no visible abnormalities

Exam Action

06/17/22 12:42 AM EDT

 Inspected left arm: no visible abnormalities

Exam Action

06/17/22 12:43 AM EDT

 Auscultated breath sounds

Exam Action

06/17/22 12:44 AM EDT

 Auscultate heart sounds

Exam Action

06/17/22 12:44 AM EDT

 Palpated radial arteries

Exam Action

06/17/22 12:44 AM EDT

 Tested capillary refill

Exam Action

06/17/22 12:44 AM EDT

 Assessed general appearance: indirect eye contact, tension and rigidity, clean clothing, and appropriate level of grooming Rachel Adler Alcohol Use Disorder shadow health transcript

Exam Action

06/17/22 12:45 AM EDT

 Assessed attitude: suspicious, guarded, or evasive

Exam Action

06/17/22 12:45 AM EDT

 Assessed speech: expected rate of speech, loud speech volume, and no appreciable issues with articulation

Exam Action

06/17/22 12:45 AM EDT

 Assessed mood and affect: stable mood and a balanced affect

Exam Action

06/17/22 12:45 AM EDT

 Assessed thought process: no presence of thought disturbances

Exam Action

06/17/22 12:46 AM EDT

 Assessed thought content: suicidal ideation but no perceptual disturbances

Exam Action

06/17/22 12:46 AM EDT

 Confirmed orientation

Exam Action

06/17/22 12:46 AM EDT

What is your name and date of birth?

Question

06/17/22 12:46 AM EDT

Rachel Adler and I was born. . . [Ms. Adler reports her correct date of birth.]

What building are you in now?

Question

06/17/22 12:47 AM EDT

We’re in Shadow General Hospital.

What is the date and year?

Question

06/17/22 12:47 AM EDT

Yeah, it’s . . . [Ms. Adler reports the correct date and year.]

 Assessed cognition

Exam Action

06/17/22 12:48 AM EDT

Count backwards from 100 by 7 until you get to the 60s

Question

06/17/22 12:49 AM EDT

Uh, sure . . . 100, 93, 86, 79… (Ms. Adler finishes the sequence)

 Assessed cognition

Exam Action

06/17/22 12:49 AM EDT

How are apples and oranges alike?

Question

06/17/22 12:49 AM EDT

Those are both types of fruit.

How are a lake and an ocean alike?

Question

06/17/22 12:50 AM EDT

Obviously those are both bodies of water.

How are a trumpet and a flute alike?

Question

06/17/22 12:50 AM EDT

Those are both instruments. Wind instruments.

 Assessed cognition

Exam Action

06/17/22 12:50 AM EDT

Repeat and remember burger, tulip, nose, and tea.

Question

06/17/22 12:51 AM EDT

Burger, tulip, nose, tea. Got it.

How did you celebrate your last birthday?

Question

06/17/22 12:51 AM EDT

It was pretty low key actually. I went to dinner with some friends, then we watched movies at my place. It was nice.

Repeat the four words from before

Question

06/17/22 12:52 AM EDT

Burger, tulip, nose, and tea.

Copy the shapes exactly as you see them

Question

06/17/22 12:52 AM EDT

I’ll have to do it with my other hand because of my wrist, but luckily I’m pretty good with both.

 Assessed insight: demonstrates limited or no awareness of illness and/or is unwilling to seek treatment

Exam Action

06/17/22 12:53 AM EDT

 Assessed judgment: demonstrates good judgment

Exam Action

06/17/22 12:53 AM EDT

What would you do if you found a stamped envelope on the sidewalk?

Question

06/17/22 12:54 AM EDT

Uh, I guess I’d try to drop it in a post box somewhere.

Ken Fowler ihuman soap note

Patient Information

Name:
Ken Fowler

Age:
70 years

Sex:
Male

Subjective

CC (chief complaint):
Nausea and vomiting

HPI:
Ken Fowler is a 70-year-old male who presents at the ED for evaluation of elevated creatinine having being referred by his PCP (Primary Care Provider) Ken Fowler ihuman soap note.  Prior before his visit to the PCP, Fowler experienced nausea and vomiting lasting 24 hours, which begun after taking  a painkiller (naproxen) for lower back pain he experienced after hurting his  back while carrying a load. The vomitus was clear with only residual food properties; it aggravated with meals and was relieved with decreased oral intake. As a result, for the past three days, he has not taken anything orally. The nausea and vomiting are associated extreme fatigue, decreased urinary output, and decreased oral intake.

Current medications:
HCTZ, lisinopril, and metroprolol

Allergies:
None

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Vaccinations:
Up to date

Pertinent PMHx:
He is a hypertensive on HCTZ, lisinopril, and metroprolol. H is also on follow-up, he has a history of mild chronic renal disease creatinine 1.1 and microalbuminuria (400mg) Ken Fowler ihuman soap note

Social hx:
He consumes a glass of wine with dinner either once or twice every week.

Questions:

What is your name?

Where are you?

What time is it?

What happened?

How can I help you today?

Have you had nausea and vomiting like this before?

What does your vomit look like?

Has there been any change in your nausea and/or vomiting over time?

Have you been vomiting anything that looks like blood or coffee grounds?

Do you have any pain or other symptoms associated with your nausea and/or vomiting?

Does anything make your nausea and/or vomiting better or worse?

How severe is your nausea and/or vomiting?

Have you lost weight?

Do you have any pain in your abdomen?

Do you have frothy urine?

Do you have any other symptoms or concerns we should discuss?

Can you tell me about any current or past medical problems you have had?

Are you taking any over-the-counter herbal medications?

Do you have any allergies?

Are you taking any prescription medications?

Do you drink alcohol? If so, what do you drink and how many drinks per day?

ROS

General:
Ken fowler presents for evaluation independently. He reports nausea and vomiting but denies chills, fevers, night sweats, or sore throats.

Cardiovascular/Peripheral Vascular
: the patient denies palpitations, lower limb/upper limb edema, facial edema, chest pains/pressure, SOB, cold/blue fingers

Respiratory:
the patient denies cough, wheezing, SOB, DIB

Gastrointestinal:
patient acknowledges nausea, vomiting, and decreased appetite. He however denies constipation, diarrhea, or change in stool color.

Genitourinary
: patient denies any pain, burning, dribbling, difficulty starting or stopping, urgency, frequency, or incontinence with urination. He reports decreased urine output

Musculoskeletal:
the patient denies back pain, muscle and joint pain/swelling, and joint stiffness

Psychiatric:
the patient denies feeling sad, depressed, mood changes, lack of interest, and nervousness.

Neurologic:
the patient denies tremors, numbness, tingling, weakness, fainting, or dizziness. Ken Fowler ihuman soap note

Endocrine:
the patient denies increased sweating, increased thirst, he reports decreased appetite, but denies cold/heat intolerance.

Hematologic/lymphatic
: the patient denies easy bleeding or bruising, bleeding from gums or nosebleeds.

Allergic/immunologic
: the patient denies environmental, food, or drug allergies.

Physical Exam

General: 
Patient is A&O x4, in no acute pain or respiratory distress

VS
: BP- 108/62 HR-98 (apical), RR-17, O2 sat-99% LA

HEENT:
Eyes:
PERRLA, there is no conjunctival pallor. Ear: no discharge, sharp optic disks, bilateral red reflex,
Nose/Mouth/Throat:
m
ucous membranes are dry

Cardiovascular/Peripheral Vascular:
normal S1, S2 heard, no gallops, rubs, or murmurs.  PMI slightly displaced downwards and laterally

Respiratory
: the chest moves symmetrically, bilaterally clear lungs, and bronchial breath sounds auscultated no crackles, wheezes, or rhonchi.

Gastrointestinal
: soft and non-distended, bowel sounds present in all four abdominal quadrants no palpated masses or lumps, there is mild periumbilical tenderness
Musculoskeletal/Peripheral Vascular:
no lower or upper extremity edema, 5/5 muscle strength across all groups.

Neurologic:
  A&O x4 to person, place, time, and situation, MMSE 30/30, deep tendon reflexes

Integumentary/Skin: 
dry and warm skin, no pallor, jaundice, ulceration, or scaling, 3-4 seconds blanching time

Genitourinary:
normal external genitalia, no urethral discharge, no tenderness, or masses

Test Ordered and Diagnostic Results

Renal Ultrasound

Ken Fowler ihuman soap note

Complete Blood Count

Eosinophils urine

Sodium (Na+), urine

Basic Metabolic Panel

Urinalysis

Pelvic Ultrasound

List the Differential Diagnosis You Identified In Ihuman

Medication-Related (Side Effect)

Uremia (intrarenal azotemia)

Uremia (prerenal azotemia)

Urinary Obstruction

List your primary dx with ICD code. Briefly explain/ discuss your primary dx and the rational

Acute Kidney Failure, Unspecified (N17.9) (
Uremia-prerenal azotemia)
–
Ken Fowler presented with complaints of elevated creatinine, nausea, and vomiting following an intake of naproxen, an NSAID. The nausea and vomiting were associated with fatigue, reduced oral intake, and decreased appetite. The sequence of occurrence of these events indicates that the most likely diagnosis would primarily be acute kidney injury with the drug naproxen as the primary causative factor. Naproxen is highly nephrotoxic and is a pre-renal cause of kidney failure (Hoste et al., 2018). The physical exam findings of an elevated heart rate, dehydration, tenderness at the periumbilical region, and hypotension also support this diagnosis.

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List the Differential Dx with ICD and A Brief Explanation the Rational

Medication-Related Side Effect (ICD 10 995A) –
Ken Fowler reports that prior to visiting his PCP, he experienced severe nausea, and vomiting that just preceded the intake of naproxen, an NSAID for Backpain. Naproxen acts by inhibiting COX enzymes to decrease prostaglandins synthesis, which can primarily result in renal ischemia, reduce glomeruli pressure, and increase the risk of acute kidney injury.

Acute Nephritic Syndrome (ICD 10 N00.9) –
Patients with ANS will demonstrate high levels of creatinine, oliguria, fatigue, vomiting, and nausea, pain at the periumbilical region, and anorexia (Bhalla et al., 2019). It however follows a recent systemic illness, which lacks in the case of Ken Fowler. On physical exam, the clinician is likely to find pedal and facial edema, and periorbital edema.

Urinary Obstruction (ICD 10
9
) –
patients with urinary obstruction report symptoms such as; decreased urine output (oliguria), hesitancy, and abdominal pain. Ken Fowler ihuman soap note Its risk factors are: advanced age, a previous history of mild chronic renal disease, decreased urinary output, and underlying chronic diseases such as hypertension (Serlin, Heidelbaugh & Stoffel, 2018).

Assessment/Plan

Admit to:
med-surge

Allergy:
None

Diet:
low-sodium

Activity:
mild physical activity such as walking

Consult/ specialty services and rational:
consult with a renal specialist

Nursing Orders:

IV Rehydration therapy with NS (normal saline) till the return of intravascular volume (Moore, Hsu & Liu, 2018).

Medication/intervention:
dose, route, time

Hold the patient’s HCTZ and lisinopril

Discontinue the patient’s NSAIDs

LABS:
none

Ancillary orders:
insert Foleys catheter to monitor input-output

Supportive services:
consult with a dietician on appropriate dietary forms for a patient with hypertension and mild chronic renal disease.

Patient education:

Next time do not self-medicate. Since you are taking drugs for high blood pressure, it is important to understand that drugs interact with each other. If you have to take any OTC drug, prescription drug, or herbal medication, you must first inform and obtain the consent of your PCP (Moore, Hsu & Liu, 2018).

Maintain a DASH diet and adhere to your hypertensive drug regimen for adequate blood pressure control as  guided

Follow up or disposition:

return immediately when you experience similar symptoms or  new onset of symptoms

follow up in 2 weeks post-discharge for evaluation of progress Ken Fowler ihuman soap note

Health maintenance and Preventive health:
advice on the need to maintain upto date immunizations

 

References

Bhalla, K., Gupta, A., Nanda, S., & Mehra, S. (2019). Epidemiology and clinical outcomes of acute glomerulonephritis in a teaching hospital in North India. 
Journal of Family Medicine and Primary Care
, 
8
(3), 934.

Hoste, E. A., Kellum, J. A., Selby, N. M., Zarbock, A., Palevsky, P. M., Bagshaw, S. M., & Chawla, L. S. (2018). Global epidemiology and outcomes of acute kidney injury. 
Nature Reviews Nephrology
, 
14
(10), 607-625.

Moore, P. K., Hsu, R. K., & Liu, K. D. (2018). Management of acute kidney injury: core curriculum 2018. 
American Journal of Kidney Diseases
, 
72
(1), 136-148.

Serlin, D. C., Heidelbaugh, J. J., & Stoffel, J. T. (2018). Urinary retention in adults: evaluation and initial management. 
American family physician
, 
98
(8), 496-503 Ken Fowler ihuman soap note.

Oppositional defiant vs Conduct disorder and post traumatic stress vs Adjustment disorder essays

DISCUSSION 1

Discuss and answer questions related to the case presentation.

Please include the time consideration for differentiating adjustment disorders from PTSD.

According to the American Psychiatric Association (2013), posttraumatic stress disorder is when the duration of the disturbance last more than one month. Adjustment disorder is when the person has developed emotional or behavioral symptoms that occur within three months of the start of the stressor (American Psychiatric Association, 2013) Oppositional defiant vs Conduct disorder and post traumatic stress vs Adjustment disorder essays.

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What is the difference between an Oppositional defiant disorder and Conduct disorder?

According to the American Psychiatric Association (2013), oppositional defiant disorder is when the patient meets at least four of the symptoms lasting at least six months and the interaction occurs with at least one individual who is not a sibling. The symptoms are under the categories of angry/irritable mood, argumentative/defiant behavior, and vindictiveness (American Psychiatric Association, 2013). Conduct disorder is when the patient meets three of the 15 criteria within the past 12 months and at least one criterion present in the past six months (American Psychiatric Association, 2013). With conduct disorder, the patient is physically destructing property or committing theft and bullying/physical fights (American Psychiatric Association, 2013). Oppositional defiant vs Conduct disorder and post traumatic stress vs Adjustment disorder essays On the other hand, oppositional defiant disorder the patient isn’t destroying anything but is just displaying acts of defiance (American Psychiatric Association, 2013). Oppositional defiant disorder patients aren’t physically defiant just verbally (American Psychiatric Association, 2013).

For the discussion boards this term please include:

Any differential diagnoses

Acute stress disorder is a differential diagnosis for this patient due the stress she was under during the event but, acute stress disorder only last from 3 days to 1 month following the exposure to the traumatic event therefore if her symptoms don’t resolve in one month then the diagnosis couldn’t be acute stress disorder (American Psychiatric Association, 2013).

Other posttraumatic disorders and conditions could be a differential diagnosis for the patient depending on her symptoms in the days following the traumatic event (American Psychiatric Association, 2013). The patient does have symptoms at this time due to the traumatic event but, if her symptoms resolve then her diagnosis could be another mental disorder and not PTSD (American Psychiatric Association, (2013).

Your diagnosis and reasoning

The diagnosis for the patient is posttraumatic stress disorder. According to the American Psychiatric Association (2013), to diagnose this patient with posttraumatic stress disorder, the patient does meet the criteria A which is exposure to actual or threatened death, serious injury, or sexual violence in one or more ways. The patient meets criteria A1: directly experiencing the traumatic event (American Psychiatric Association, 2013).

Any additional questions you would have asked

I would ask the patient if she were having any flashbacks or nightmares of the incident. Is there anything that triggers memories of the traumatic event? Have you told anyone else about the traumatic event? Are you able to sleep and are you eating? Have you been able to maintain your cleanliness?

Medication recommendations along with your rationale. Note possible side effects or issues to address if attempting to obtain consent.

For this patient I would start her out on sertraline (Zoloft) 25 mg po daily for her PTSD. The notable side effects for Zoloft are gastrointestinal such as decreased appetite, nausea, diarrhea, constipation, or dry mouth (Stahl, 2021). Zoloft can often affect the central nervous system with insomnia, sedation, agitation, tremors, headache, or dizziness (Stahl, 2021). Other rare side effects are hyponatremia, hypotension, and seizures (Stahl, 2021). The black box warning for Zoloft is that it could cause suicidal ideation in children and young adults (Stahl, 2021) Oppositional defiant vs Conduct disorder and post traumatic stress vs Adjustment disorder essays.

Any labs and why they may be indicated

There are no labs that need to be started to start on Zoloft. Getting a baseline CBC, and urine tox screen would be good for this patient. Checking the patients’ labs for electrolyte imbalances because Zoloft can cause hyponatremia. Also, a urine tox screen to make sure the patient isn’t using any other substances before starting on Zoloft.

Screener scales or diagnostic tools that may be beneficial

There are numerous scales and questionnaires that can be conducted to diagnose PSTD. Those scales and questionnaires are the brief trauma questionnaire, trauma assessment for adults-self report, and traumatic life events questionnaire (Lancaster et al., 2016). There are other scales that can be used for symptom severity which are PTSD checklist for DSNM-5 and posttraumatic diagnostic scale for DSM-5 (Lancaster et al., 2016).

Additional resources to give (Therapy modalities, support groups, activities, etc.)

Psychotherapeutic interventions for PTSD are behavior therapy, cognitive therapy, and hypnosis (Sadock et al., 2017). Other types of therapy that is relatively novel and somewhat controversial is eye movement desensitization and reprocessing (EMDR) (Sadock et al., 2017) Oppositional defiant vs Conduct disorder and post traumatic stress vs Adjustment disorder essays. Group and family therapy have proven to be effective in cases of PTSD as well (Sadock et al., 2017). Therapists need to overcome the patient’s denial of the traumatic event, encourage them to relax, and remove them from the source of the stress (Sadock et al., 20170.

 

DISCUSSION 2

Please include the time consideration for differentiating adjustment disorders from PTSD.

Adjustment disorder symptoms rarely last longer than 6 months and the symptoms start within 3 months while post-traumatic stress disorder (PTSD) symptoms last longer than how long adjustment disorder symptoms last. PTSD is usually not diagnosed until six months after the trauma even though the symptoms may begin immediately after the trauma.

According to the DSM-5, by definition, the disturbance in adjustment disorders begins within 3 months of the onset of a stressor and lasts no longer than 6 months after the stressor or its consequences have ceased (American Psychiatric Association, 2013, p. 287).

According to Kaplan and Sadock (2017, p. 137), for PTSD, “by definition, the symptoms must begin within 3 months of the stressor”.

What is the difference between an Oppositional defiant disorder and Conduct disorder?

The oppositional defiant disorder is seen in children and adolescents with enduring patterns of negativistic, disobedient, and hostile behavior toward authority figures, as well as an inability to take responsibility for mistakes, leading to placing blame on others (Kaplan and Sadock, 2017, p. 814).

Conduct disorder is an enduring set of behaviors in a child or adolescent that evolves over time, usually characterized by aggression and violation of the rights of others (Kaplan and Sadock, 2017, p. 816).

The difference between the two is with conduct disorder, individuals violate other people’s rights or what is considered a norm by the society while in oppositional defiant disorder, people with this disorder may have irritable or angry moods, may have argumentative or defiant behavior, and may be vindictive. Oppositional defiant vs Conduct disorder and post traumatic stress vs Adjustment disorder essays

 

References

American Psychiatric Association. (2013). Adjustment Disorder. In
Diagnostic and Statistical Manual of Mental Disorders DSM-5
(5th ed., pp. 287). American Psychiatric Publishing.

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2017).
Kaplan & Sadock’s Concise Textbook of Clinical Psychiatry
(Fourth ed.). Wolters Kluwer.

 

Module 5 case study

Brief Summary:
The patient is a 33year old male who was brought into the psychiatric hospital by police after he attacked a man in the bar after he saw the man putting his arm around his girlfriend. He wrapped his hands around his throat and threatened to rip his throat out. The patient admitted to a history of similar episodes multiple times a year since he was in his late adolescence. He was arrested two months prior for road rage and had been fired from several jobs in his late 20s due to being hot-tempered. According to his girlfriend apart from his outbursts and anger which leads to destroying things, he is fun-loving and charming. The patient stated that he regrets the episodes, and they usually subside within a half-hour, and he feels an instant sense of relief. The patient denies any past psychiatric history or prescription drug use and denies current use of illicit or recreational drug use but admitted to marijuana experimentation in his late teens.

His physical examination and all of his diagnostic testing, and labs were all normal.

Any differential diagnoses

Disruptive mood dysregulation (DMD):
I did not choose this because his outbursts are intermittent while DMD requires that he has a persistent negative mood state most of the day and nearly every day between the outbursts (American Psychiatric Association, 2013, p. 468).

Antisocial personality disorder or borderline personality disorder:
I did not pick this because his outbursts and aggression are much higher than the outbursts seen with antisocial and borderline personality disorder which are much lower (American Psychiatric Association, 2013, p. 468).

Delirium, major neurocognitive disorder, and personality change due to another medical condition, aggressive type
: I did not pick this because based on his physical examination, imaging, and lab testing, there were no medical conditions noted (American Psychiatric Association, 2013. p. 468).

Substance intoxication or substance withdrawal:
I did not pick this because his drug and alcohol screening were negative (American Psychiatric Association, 2013, p. 469).

Attention-deficit/hyperactivity disorder, conduct disorder, oppositional defiant disorder, or autism spectrum disorder:
I did not pick this because the patient did not have any childhood diagnosis of any of these disorders (American Psychiatric Association, 2013, p. 469). v

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Your diagnosis and reasoning

My diagnosis for this patient is Intermittent Explosive Disorder 312.34 (F63.81) (American Psychiatric Association, 2013, p. 466-469).

My reasoning is he has had multiple similar episodes since his late adolescent years. He clearly meets the diagnostic criteria as listed in the DSM-5. The patient meets the following diagnostic criteria:

A: He has had recurrent behavioral outbursts and an inability to control his aggressive impulses as manifested by three behavioral outbursts involving damage or destruction of property and or physical assault involving an injury to an individual (American Psychiatric Association, 2013, p. 466).

B: The magnitude of aggressiveness expressed during the recurrent outbursts is grossly out of proportion to the provocation or to any precipitating psychosocial stressors (American Psychiatric Association, 2013, p. 466).

C: His recurrent aggressive outbursts were not premeditated (APA, 2013, p. 466).

D: His outburst caused marked distress in the individuals involved and he’s been fired from multiple jobs (American Psychiatric Association 2013, p. 466).

E: His chronological age meets his developmental level (American Psychiatric Association, 2013. P. 466).

F: His recurrent aggressive outburst is not due to any other mental disorder (American Psychiatric Association, 2013, p. 466).

Any additional questions you would have asked

Any family history of intermittent explosive disorder or mental health disorder?

Any stressors or precursors that trigger the violence?

I will ask about the patient’s sleep pattern to determine if he is getting enough sleep because not getting enough may be a trigger of his symptoms.

I will ask the patient if he exercises and encourage this as this may help relieve some of his stress and aggressions.

Medication recommendations along with your rationale. Note possible side effects or issues to address if attempting to obtain consent.

Consent for treatment obtained from the patient prior to prescribing the medications. The medications I recommend are Sertraline and Buspirone. SSRI combined with Buspar has been proven to be effective for the treatment of intermittent explosive disorder particularly in reducing impulsivity and aggression (Sadock et al., 2017).

Sertraline 25mg one by mouth every day with food or milk.

Side effects of the medication such as headache, nausea, diarrhea, drowsiness, dry mouth, anxiety, nervousness, vomiting, constipation, and sexual dysfunction discussed with the patient. Adverse effects of sertraline such as serotonin syndrome (seizures, arrhythmias, high fever), neuroleptic malignant syndrome (muscle rigidity, cognitive changes), and suicidal ideation were discussed with the patient (Kizior and Hodgson, 2019, p. 2378).

The patient was told that the dry mouth may be relieved by drinking sips of water and chewing sugarless gum and should avoid alcohol while taking sertraline. Should report any worsening depression or suicide ideation immediately (Kizior and Hodgson, 2019, p. 2379).

Buspirone 5mg one by mouth twice a day (Kizior and Hodgson, 2019, p. 518).

The side effect of the medication such as dizziness, drowsiness, nervousness, fatigue, insomnia, dry mouth, and diarrhea were discussed with the patient, and also made aware that in rare cases muscle pain/stiffness, chest pain, and involuntary movements can occur (Kizior and Hodgson, 2019, p. 518). The patient was told to avoid tasks that requires alertness, and motor skills until the effect of the medication is established (Kizior and Hodgson, 2019, p, 518). The patient was also told to avoid alcohol, and grapefruit products and be consistent if taking it with food (Kizior and Hodgson, 2019, p. 518).

Any labs and why they may be indicated

Baseline labs complete blood count (CBC), renal function, and liver function tests (LFT) will be obtained prior to starting Sertraline and periodically for both medications if the patient remains on the medications long-term (Kizior and Hodgson, 2019, pp. 518 and 2379) Oppositional defiant vs Conduct disorder and post traumatic stress vs Adjustment disorder essays.

Screener scales or diagnostic tools that may be beneficial

The intermittent explosive disorder screening questionnaire (IED-SQ) was used.

According to Coccaro et al., (2017), “a study was designed to develop and test a screening approach to identify individuals with DSM-5 Intermittent Explosive Disorder (IED), a disorder of recurrent, problematic, impulsive aggression and a screening approach to diagnose DSM-5 IED (IED-SQ) was developed by combining items related to life history of aggression and items related to the DSM-5 diagnostic criteria for IED”.  Based on the result of their study, the data suggested that the IED-SQ is a useful screening tool that can quickly identify the presence of IED by DSM-5 criteria in adults (Coccaro et al., 2017).

Additional resources to give (Therapy modalities, support groups, activities, etc.)

The patient was referred to therapy for cognitive behavioral therapy to help with cognitive restructuring to help him identify his triggers and learn how to deal with and manage difficult situations he finds himself in (Mayo Clinic, 2018).

Group therapy and family therapy were also recommended to help him learn coping skills and mechanisms from other people who are dealing with the same diagnosis and to help his family learn how to deal and cope with his diagnosis (Sadock et al., 2017, p. 254).

Diversionary activities and relaxation techniques such as deep breathing exercises and yoga were also discussed with the patient (Mayo Clinic, 2018).

The patient was told that the medications may take several weeks before the effect is felt (Stahl, 2021).

The patient was told to return for a follow-up in four weeks for medication assessment.

The patient was told to report any suicidal thoughts or ideations immediately.

The patient was told to call 911 or go to the emergency room if any increased suicidal thoughts, ideations, or plans. Patient given information on Delaware Suicide & Crisis Hotlines 1(800) 345-6785, 1(800) 262-9800 or 1(800)-SUICIDE (1-800-784-2433) and 1-800-273-TALK (1-800-273-8255) for USA National Suicide Hotlines if any suicidal ideations/plans or thoughts Oppositional defiant vs Conduct disorder and post traumatic stress vs Adjustment disorder essays.