To Prepare: Review this week’s Learning Resources. Consider preventative health and assessing, diagnosing, and treating special populations. Review the case study provided by your Instructor. Based on the provided patient information, think about the health history you would need to collect from the patient. Consider what physical exams and diagnostic tests would be appropriate in order to gather more information about the patient’s condition. Reflect on how the results would be used to make a diagnosis. Identify three to five possible conditions that may be considered in a differential diagnosis for the patient. Consider each patient’s diagnosis. Think about clinical guidelines that might support this diagnosis. Develop a preventative health treatment plan for the patient that includes health promotion and patient education strategies for special populations. Complete: Use the Focused SOAP Note Template to address the following: Subjective: What details are provided regarding the patient’s personal and medical history? Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities or psychosocial issues. Assessment: Explain your differential diagnoses, providing a minimum of three. List them from highest priority to lowest priority and include their CPT and ICD-10 codes for the diagnosis. What would your primary diagnosis be and why? Plan: Explain your plan for diagnostics and primary diagnosis. What would your plan be for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan. Reflection notes: Describe your “aha!” moments from analyzing this case. this is the case study that I need to do.: Week 9 CASE STUDY Use the following case to complete a focused SOAP note. You should note any questions you would ask to provide information in addition to the standard history and the present illness he volunteers. This is a public health department, he is a walk-in, and you have no medical records. You will be creating a visit record for the patient, one that could be sent to a specialist for a consultation. You have laboratory and radiology on site. You do have a slate of specialists you may refer any patients who need a specialist for consultation. Incorporate answers to the questions into your write up. You would want to include relevant information from the social determinants of health and relate your findings to the patient’s situation. The patient who has no routine health care home. A 32-year-old male comes into the public health clinic stating that he has noticed a “lump” in one of his testicles. It is not painful. He says it is behind the right testicle and just slightly above it. His ROS is negative for anything relevant per the history questionnaire. . He has no history of testicular cancer in the family. He has tried manipulating it to see if anything changes but it does not help. He tried ice but it did not go away. He says for a couple of days it hurt a little and he tried elevating the scrotum and that seemed to make the pain go away. He says, “it is kind of like I have a third testicle!” Upon examination, his vital signs are stable and his exam is unremarkable. You note a painless mass just superior and inferior to the right testicle. You are able to move it and it is freely movable. List three differentials for this mass. List your top differential first and explain why it is your top differential. Name 10 testicular disorders that are important to consider when evaluating a testicular mass. When examining the patient, you examine the scrotum carefully. You note asymmetry with the left hemiscrotum lower than the right. Is this typical? Typically, scrotal pain only affects one side and is not typically bilateral. True or false? When palpating, the normal epididymis is more firm than the testis. True or false? One of the things you can do is translumination of the testes. For this patient, is it extremely important to get a semen analysis? If the patient is having no pain, what is the desired treatment? If the mass is painful, what is the preferred treatment? If a patient had to have an orchiectomy, why might counseling be an important intervention? How often should testicular self-exam be performed? Why is it best to perform the testicular self-exam after a warm bath or shower? The differential diagnosis for any testicular disorder should first exclude the possibility of a ________________. .Explain the difference between a spermatocele and a hydrocele. Testicular malignant neoplasms are very common in the general population. Testicular cancer is the most common form of cancer in men between the ages of _______. When documenting the results of the testicular exam, what should it include? Which of the following require immediate referral? Torsion of the spermatic cord Hydrocele Incarcerated scrotal hernia Why can varicoceles cause infertility? If there is torsion of the spermatic cord, what are two things that can happen if treatment is delayed? Testicular tumors have been associated with scrotal trauma. True or false? What are two things that can result from surgical intervention for testicular tumors? Use the information you have to create a focused SOAP note. please use the following soap note for this course work. Thank you. Preventative Health and Assessing, Diagnosing, and Treating Special Populations SOAP Note Patient Information: A, 32, Male, CC: Patient complains of a non-painful lump just above the right testicle. HPI: A 32-year-old male comes into the public health clinic stating that he has noticed a “lump” in one of his testicles. It is not painful. He says it is behind the right testicle and just slightly above it. His ROS is negative for anything relevant per the history questionnaire. . He has no history of testicular cancer in the family. He has tried manipulating it to see if anything changes but it does not help. He tried ice but it did not go away. He says for a couple of days it hurt a little and he tried elevating the scrotum and that seemed to make the pain go away. He says, “it is kind of like I have a third testicle!” Current Medications: Denies taking any medications. Allergies: Denies any allergies. PMHx: Denies any past medical history. Soc & Substance Hx: Denies any. Fam Hx: Positive for testicular cancer in the family. Surgical Hx: Denies any. Mental Hx: Denies any. Violence Hx: Denies any. ROS: GENERAL: Patient noticed a “lump” in one of his testicles. It is not painful. He says it is behind the right testicle and just slightly above it. Denies weight loss, weakness, nausea, vomiting or diarrhea. HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears: Denies ear pain, hearing loss, ringing in ears, discharge, vertigo, or tinnitus. Nose: Denies having a nosebleed or discharge from his nose. Denies dysphagia, rhinorrhea. Throat: Denies dental disease, hoarseness, or sore throat. SKIN: No rash or itching. CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema. RESPIRATORY: Denies sob upon rest or exertion, cough or phlegm. GASTROINTESTINAL: Denies loss of appetite, nausea, vomiting, or diarrhea. No abdominal pain or blood. GENITOURINARY: States a lump in his right testicle. Denies burning on urination. Denies urgency, frequency or change in color of urine. NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. MUSCULOSKELETAL: Denies fatigue. No muscle, back pain, joint pain, or stiffness. HEMATOLOGIC: Denies anemia or bruising. LYMPHATICS: No enlarged nodes. No history of splenectomy. PSYCHIATRIC: No history of depression or anxiety. ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia. ALLERGIES: No history of asthma, hives, eczema, or rhinitis. Objective. Vital signs: Vital signs are stable. Physical exam: General: A&AOx4, Healthy, thirty-two-year-old male c/o a lump in his right testicle in no acute distress. Looks stated age, is cooperative and answers questions appropriately. Head: Normocephalic and atraumatic. Trachea midline. Eyes: PERRLA, sclera and conjunctiva are clear, no drainage or redness noted. Extraocular muscles intact, upon funduscopic exam red reflex is noted bilaterally, no nicking, or hemorrhage. Ears: Ears are symmetrical. Canals are patent. Bilateral TMs pearly grey with positive light reflex. Landmarks are easily visualized. Nose: Frontal sinuses are not tender on palpation. No tenderness to maxillary sinuses. Bilateral nares are patent. Septum is midline. Mouth/Throat/Neck: No redness or inflammation to gums noted. Teeth are intact, no missing teeth. Tongue is midline, gag reflex is easily elicited. No thyroid nodules or tenderness. Thyroid freely moves with swallowing. No carotid bruits. Full ROM. Respiratory: No SOB. No rales, rhonchi, fremitus, or dullness to percussion. No use of accessory muscles or nasal flaring. Cardiovascular: PMI is in the 5th inter-costal space at the mid clavicular line. Crisp S1 and S2. They are no murmurs or extra sounds. No cyanosis, clubbing, or LE edema noted. Neurologic: Patient is alert and oriented times 4. CN 2-12 intact. No sensory loss. Gait steady without assistance. Diagnostic: ? Assessment: Below are just examples of what I need for the 3 differectial diagnoses and the rest of the soap note that needs competition. Please fill in the gaps from here below, thank you. 1. Pneumonia ICD-10-CM code: Usually, pneumonia is caused by streptococcus pneumonia bacteria, (Buttaro, Bailey, Cook, & Trybulsky, 2021). The gold standard for diagnosing pneumonia is a chest x-ray which can differentiate it from other similar infections of the respiratory tract (Dumas et al., 2018). Besides the chest x-ray that shows left lower lobe consolidation on this patient, a sputum culture should be carried out to identify pathological agents. To get the best sputum, a patient is required to cough up from deep inside their lungs. The best time to do this is immediately they wake up before eating anything. Once they collect the sputum sample, they should take it to the lab. For the lab to determine that the sample is adequate, they must find a sufficient amount of white blood cells, indicating an infection (Murdoch, 2017). Another test that may be considered by a doctor is blood culture. Two sets of blood cultures are obtained, and the results of the blood test are used to confirm the presence of an infection and try to find out the organism causing it. Differential Diagnoses: 1. Covid-19 ICD-10 Code . Despite the amount of clinical research in what constitutes signs and symptoms of COVID-19, most of the clinical practitioners agree that COVID-19 presents most of the time with flue like symptoms. In this case, Edwin presents to the clinic with clinical manifestations of a fever of , chills and a productive cough that epidemiological data suggest the possibility of the COVID-19 virus, (Arunkumar, James, Saleh, & Tinsay, 2021). In addition, Edwin states been fatigue and not feeling hungry which are consistent with flu-like symptoms and possibly covid. Clinical manifestations include a chest X-ray that shows a left lower lobe consolidation which is consistent with pneumonia, (Hanie, Mohsen, & Seyed, 2020). 2. Chronic obstructive pulmonary disease (COPD) ICD-10 Code . COPD is an obstructive disease that affects the lungs resulting in long-term respiratory problems. Its symptoms include coughing with sputum, shortness of breath or pain when taking a deep breath if patient presents with pneumonia, (Herath et al., 2018). The pathophysiology is not well understood but it is characterized with airflow limitation and abnormal inflammatory response to the lungs (Buttaro, Bailey, Cook, & Trybulsky, 2021). 3. Asthma ICD-10 Code J45: Asthma an inflammatory airway disease with symptoms like those of pneumonia, and it affects the lungs’ airways, (Buttaro, Bailey, Cook, & Trybulsky, 2021). Its signs include coughing, wheezing, shortness of breath, and tightening of the chest. 4. Management and interventions 5. The main goal of treating pneumonia immediately is to get rid of symptoms, decide what level of treatment is needed, provide antimicrobial drugs, and prevent complications that may lead to further respiratory compromise, (Buttaro, Bailey, Cook, & Trybulsky, 2021). 6. Non-pharmacological interventions 7. The doctor should recommend the following to the patient. An increased rest, increase fluid intake, especially water, keep the body hydrated, maintain an upright position to breathe easily, and finally stay in humidified air areas to ease irritation on nares and pharynx, (Dumas et al., 2018). 2. Pharmacological interventions 3. The recommended pharmacological interventions for treating s. pneumonia should be in line with Rx files: comparison charts of drugs and anti-infective guidelines. A patient should take a macrolide antibiotic or doxycycline 500mg PO on the first day, followed by a 250mg PO once every day for five days (Postma, 2015). The choice to administer antibiotics should consider the risk of infection to the patient, the susceptibilities of the organisms should be known, and prophylaxis only is given at risky times. 4. Monitoring and follow-up • The doctor should advise the patient to come back after one day for reassessment if the signs and symptoms become worse or if he develops more difficulties in breathing. Also, the patient may develop the following complication if symptoms are not treated early. Hypoxia may cause respiratory failure, sepsis, renal failure, metastatic infection like meningitis, and cardiac arrest (Ramirez, 2019). Plan: Diagnostics: CBC with shift differential, BMP, complement fixation, arterial blood gases, and viral cultures. The gold standard for diagnosing pneumonia is a chest x-ray which can differentiate it from other similar infections of the respiratory tract (Dumas et al., 2018). Besides the chest x-ray that shows left lower lobe consolidation on this patient, a sputum culture should be carried out to identify pathological agents. To get the best sputum, a patient is required to cough up from deep inside their lungs. The best time to do this is immediately they wake up before eating anything. Once they collect the sputum sample, they should take it to the lab. For the lab to determine that the sample is adequate, they must find enough white blood cells, indicating an infection (Murdoch, 2017). Another test that may be considered by a doctor is blood 1. culture. Two sets of blood cultures are obtained, and the results of the blood test are used to confirm the presence of an infection and try to find out the organism causing it. Health promotion and disease prevention: • Influenza vaccine for all persons older than 55-years of age • Pneumococcal Polysaccharide vaccine if older than 65-years-old • Increase fluid intake • Take the hole course of antibiotics prescribed by your MD • Antipyretics for fevers and myalgias • Avoid cough suppressants because of the cough reflex and increase sputum production 5. Follow up within 24 to 48 hours by telephone contact to probe adherence, monitor, progress, and others, (Buttaro, Bailey, Cook, & Trybulsky, 2021). Reflection notes: What would you do differently in a similar evaluation? I will add a complement fixation, arterial blood gases, and viral cultures to confirm the diagnosis and particular bug. What are the EBP guidelines or recommendations for this condition? or doxycycline 500mg PO on the first day, followed by a 250mg PO once every day for five days (Postma, 2015). Were there any barriers that you had to carry out these guidelines? The only barrier might be the patient’s compliance with the following the plan. Was insurance approval a barrier or cost or access to care a barrier? Insurance was not an issue. What did you learn from this encounter? Pathophysiology. Clinical presentation and physical examination. Diagnostic testing. Management. Complications and health promotion. The aha moment would have to be the chest X-ray for me. Follow ups: Follow up within 48 to 72 hours to ensure adherence to treatment. References:
