13 May The patient is an 82-year-old male with a history of coronary artery disease status post stent x2 placement, S/p cholecystectomy 12/25 secondary to gallstones who presents today for referrals to GI, Cardiology, and dermatology
ASSESSMENT: Primary diagnosis provided ICD-10 code. The plan was supported with 1-2 reference(s) and provided at least 2-3 differential diagnosis with rationales with ICD-10 codes in APA format. A reflection note provided.
PLAN: A pertinent plan of care, follow-up instructions, and patient education was developed and supported with at least one to two references in APA format.
SOURCES( please provide pertinent sources.) No Limit.
USE the Soap Template attached for reference
SOAP
CC
REVIEW RESULTS
Subjective
The patient is an 82-year-old male with a history of coronary artery disease status post stent x2 placement, S/p cholecystectomy 12/25 secondary to gallstones who presents today for referrals to GI, Cardiology, and dermatology. He is transitioning care due to his previous PCP’s retirement. Pt c/o intense itching all over. Skin is noted with mild redness to abdomen, arms, and face with scattered areas with noted vesicles from scratching. Patient lives alone Since the surgery, he endorses mild ongoing digestive issues but denies abdominal pain, nausea, or vomiting. He states he is up to date on all vaccinations. Pt reports taking his medications as ordered. He denies shortness of breath, chest pain, palpitations, fever, or chills. He denies suicidal or homicidal ideation at this time.
Medications
Vitamin B-12 500 mcg tablet, 1 tab by mouth daily
Vitamin D3 50 mcg (2,000 unit) tablet, 1 tab by mouth daily
Vitamin D2 1,250 mcg (50,000 unit) capsule, 1 cap by mouth every week
Brilinta 60 mg tablet, TAKE 1 TAB TWICE A DAY
Wellbutrin SR 150 mg tablet, 12 hr sustained-release, TAKE 1 TAB PO DAILY
Lipitor 40 mg tablet, TAKE 1 TAB DAILY
carvedilol 12.5 mg tablet
Allergies
lisinopril (Unknown)
Mental/Functional
The patient’s speech was normal, sharing conversation with normal laryngeal efforts. Appropriate mood and affect. Thought processes were logical, relevant, and thoughts were completed normally. Thought content was normal with no psychotic or suicidal thoughts. The patient’s judgement was realistic with normal insight into their present condition. Mental status included: correct time, place, person orientation, normal recent and remote memory, normal attention span and concentration ability. Language skills included the ability to correctly name objects. Fund of knowledge included normal awareness of current and past events.
Vitals
BP:
127.0 / 62.0
HR:
71.0 bpm
RR:
12.0 rpm
Temp:
98.3 °F
Ht/Lt:
5′ 8″
Wt:
207 lbs 2 oz
BMI:
31.49
SpO2:
95.0%
Comments: PATIENT IS HERE TO REVIEW LABS. IVANNA M.A
Objective
GEN: NAD
NECK: supple, NT, FROM
RESP: lungs clear to auscultation bilaterally, no rales, wheezes or rhonchi, nonlabored breathing, no use of accessory of muscles of respiration
CV: RRR, no m/r/g
GI: +BS, nontender to palpation, no masses, no HSM
DERM: skin warm and dry, (+) redness to abdomen
EXT: no cyanosis/clubbing/edema
NEURO: AO x 3
PSYCH: judgment/insight intact, NL mood/affect
Assessment
Generalized pruritus (L29.9) Pruritus, unspecified
Hypertriglyceridemia (E78.1) Pure hyperglyceridemia
Vitamin B12 deficiency anemia due to dietary causes (D51.3) Other dietary vitamin B12 deficiency anemia
Vitamin D deficiency (E55.9) Vitamin D deficiency, unspecified
Obesity (E66.9) Obesity, unspecified
Coronary arteriosclerosis (I25.10) Athscl heart disease of native coronary artery w/o ang pctrs
Minor depressive disorder (F32.A) Depression, unspecified
Nonfunctioning gallbladder (K82.8) Other specified diseases of gallbladder
Plan
Diagnostics/Orders: CBC, CMP, THYROID Panel
Medications: Claritin 10mg one time per day
Non-pharmacologic/Supportive Measures: Advised to avoid scratching, avoid perfumed soaps and lotions
Specialist Follow-up: GI, Dermatology, cardiology
Patient and Caregiver Education:
ER precautions given: Please call 911 or go to the ER if you’re having any SOB, chest pain,
palpitations, n/v/d, bleeding, dizziness, weakness, slurred speech, numbness, confusion, severe
abdominal or pelvic pain, fever, chills, loss of consciousness, falls, injuries, or any other acute
pain or distress.
Patient verbalized understanding of plan of care. All questions and concerns addressed and
answered.
Preventative care
Vaccination status reviewed; encouraged annual influenza, pneumococcal, and RSV vaccines as
age appropriate.
RTC in 2 weeks for review of labs
Generalized pruritus
-Use mild, fragrance free soaps to prevent dry skin. Avoid harsh chemicals and dyes that could exacerbate itching
-Emphasized staying hydrated to maintain healthy skin
-Take short, lukewarm showers instead of hot baths
-Wear loose fitting, breathable clothing to avoid irritation
-Avoid potential allergens or irritants that could trigger itching
Hypertriglyceridemia
-Encourage 30 minutes of exercise 3-4x per week, as tolerated
-Take statin medication as prescribed
-Avoid smoking tobacco; limit intake of alcoholic beverages
-Encourage Mediterranean diet – whole grains, beans, nuts, seeds and healthy fats
-Eat a low fat, low cholesterol diet; includes cutting back on fatty meats and avoiding saturated & trans fats
-Keep your stress level down
-reinforced the importance of maintaining a healthy weight, normal lipid profile, and consistent daily activity
Vitamin B12 deficiency anemia due to dietary causes
Continue vitamin B12 supplementation
Vitamin D deficiency
-Consume an adequate, balanced diet rich in calcium, vitamin D, and protein
-Vitamin D rich foods include salmon, tuna, trout, egg yolks
-Take Vitamin D supplements as prescribed
-Participate in regular weight-bearing exercises to promote bone formation (20-30 minutes aerobic exercises 3 days/week)
-Educate patient on proper body mechanics to avoid injury
-Encourage exercises to strengthen abdominal and back muscles that improve posture and provide support for the spine.
-Encourage the use of a firm mattress
-Avoid alcohol and coffee consumption
-Provide a hazard-free environment to prevent falls. Remove scatter rugs, provide good lighting, and install handrails in the bathroom as needed.
-50,000 iu weekly for 8 weeks.
-Administer analgesics, muscle relaxants, and anti-inflammatory medications as prescribed.
Obesity
-Pt educated on the importance of maintaining healthy weight & BMI
-Pt educated on risk factors & development of comorbidities w/ obesity
-Pt educated on importance of implementing daily exercise regimen & healthful diet
-Target weight loss 5-10% of bodyweight within 1-2 months
-Target BMI <25
Coronary arteriosclerosis
Follow with Cardiology
Minor depressive disorder
-Continue with medication
-Stay in touch. Don't withdraw from life
-Be more active, utilize some form of exercise as able
-Avoid triggers
-Avoid alcohol
-Incorporate a healthy diet such as the DASH/Mediterranean diet
-Incorporate a daily routine.
Nonfunctioning gallbladder
S/P removal will follow with GI
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