Pick Any Adult Acute Or Chronic Disease Must Use The Sample

Pick Any Adult Acute Or Chronic Diseasemust Use The Sample Template

Pick any "ADULT" Acute or Chronic Disease. Must use the sample template for your soap note. The assessment section must clearly document the progress note from the encounter with the patient, and this section should be highlighted and underlined. Follow the MRU SOAP Note Rubric as a guide. Use APA format and include at least two scholarly citations. The Turnitin score must be less than 20%, and the Patient History, CC, HPI, Assessment, and Plan should be original and individualized to your made-up patient. The template provided must be completed within your SOAP note #1, adhering to these instructions.

Paper For Above instruction

Introduction

The SOAP (Subjective, Objective, Assessment, Plan) note is a fundamental clinical documentation tool used by healthcare professionals to organize patient encounters systematically. It facilitates clear communication among providers and ensures comprehensive patient care. This paper demonstrates the application of a SOAP note template for a hypothetical adult patient diagnosed with hypertension, an example of a chronic disease prevalent in adults. The encounter documentation emphasizes adherence to guidelines, originality, and integration of scholarly resources to support clinical decisions.

Patient Background and History

The patient, a 55-year-old male, presents with complaints of persistent headaches and episodes of dizziness over the past two weeks. His medical history indicates a diagnosis of hypertension for five years, managed intermittently with medications. The patient reports inconsistent medication adherence and a sedentary lifestyle. Family history reveals that his father had a stroke at age 65. The patient’s lifestyle includes a diet high in sodium and fats, and he smokes approximately half a pack of cigarettes daily.

Chief Complaint (CC) and History of Present Illness (HPI)

The chief complaint is "frequent headaches and dizziness." The HPI notes that symptoms began about two weeks ago, with headaches described as pressure around the temples, rated 6/10 in intensity, worse in the mornings, and occasionally associated with blurred vision. The dizziness is described as lightheadedness, particularly after standing quickly. The patient reports no chest pain, palpitations, or shortness of breath but admits to stress related to work.

Objective Examination and Findings

Vital signs reveal a blood pressure of 152/94 mm Hg, heart rate 88 bpm, respiration rate 16, temperature 98.6°F, and oxygen saturation 98%. Physical examination shows no neurological deficits; however, the fundoscopic exam displays mild arteriolar narrowing. Cardiovascular and respiratory examinations are unremarkable. Laboratory results, including renal function tests, lipid profile, and fasting blood glucose, are pending but have been ordered given the clinical suspicion of poorly controlled hypertension.

Assessment (Progress Note)

The patient’s presentation is consistent with hypertensive urgency, considering elevated blood pressure and associated symptoms such as headaches and dizziness. The ongoing risk factors, including non-adherence to medication, unhealthy lifestyle behaviors, and family history, contribute to his hypertension management issues. It is essential to reassess the current antihypertensive regimen and address modifiable risk factors through lifestyle modifications and patient education. The primary concern is preventing end-organ damage, notably to the cerebrovascular system, indicated by the symptoms and fundoscopic findings.

Plan

The management plan involves multiple facets:

1. Medication Review and Adjustment: Re-initiate antihypertensive therapy with an ACE inhibitor and consider adding a thiazide diuretic.

2. Lifestyle Modifications: Counsel on low-sodium diet, increased physical activity, smoking cessation, and weight reduction.

3. Monitoring and Follow-up: Schedule weekly BP monitoring, with a goal BP

4. Patient Education: Educate about medication adherence, recognizing symptoms of hypertensive crises, and lifestyle impacts.

5. Further Tests: Await laboratory results to inform ongoing management; consider echocardiogram if symptoms persist.

6. Referral: Refer to a dietitian and consider referral to a hypertension specialist if blood pressure remains uncontrolled.

The focus of this encounter is on optimizing blood pressure control to prevent complications such as stroke and myocardial infarction. Continuous monitoring and patient engagement are critical in managing hypertension effectively.

Conclusion

This case illustrates the importance of systematic documentation using the SOAP note template for managing chronic diseases like hypertension. Proper assessment and individualized planning, combined with patient education and follow-up, are essential components of effective chronic disease management in adults. Using evidence-based guidelines ensures that interventions are appropriate and targeted, improving long-term health outcomes.

References

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