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SOAP Note Week 10 Assignment: 79-year-old African American female

SOAP Note Week 10 Assignment: 79-year-old African American female

SOAP Note Week 10 Assignment: 79-year-old African American female

Case Study Week 10.1

HPI

This is a 79-year-old African American female presented to the ER via emergency serves after son arrived to check on his mother.  Her son reports he spoke to his mother abound 6 hours ago, and she was fine. Her son received a phone call from his mother, and he could not understand her, so he went to check on her and found that she was unable to speak or walk.  She has a history of a previous stroke two years ago, HTN.

 

The NP will perform an NIH stroke scale score. Ask when the last time patient had normal activities speech.  Ask about symptom onset asses for the degree of neurologic impairment. Check for the fluctuation in her symptoms.  Inquire about neurologic etiologies such as seizure activity or HIV infections. Asses for somatoform/conversion disorder, migraine, hypoglycemia, toxic-metabolic disorders, systemic disease, syncope, tumors, vertigo, dementia, encephalitis. Additional Assessment:  Further questioning regarding any aggravating factors, onset, duration of any previous strokes. Ask a question about recreational drug abuse like cocaine, EtOH abuse. The family history of stroke.  Further questions regarding any recent hospitalizations involving cardiac problems or recent traumas.  

 

Past Medical History

CVA    (according to son)                                                                                                                                                         HTN                                                                                                                                                                                                                                                                                                          Hyperlipidemia (based on medication list provided )

Hypothyroidism (based on medication list provided)

Assess patient for cardiovascular problems and history, hospitalizations, headaches, strokes, drug abuse, cigarette smoking, and length.

 

Home Medications:

Atorvastatin                                                                                                                              Hydrochlorothiazide

Levothyroxine

 

Assess medication needs for Diabetes is well controlled last A1C and questions regarding his HTN and medications.  Assess for herbals and over-the-counter medicine usage. Current antiplatelet / anticoagulant therapy. Ask if the patient is supposed to be on an aspirin or blood thinner after her previous stroke.

 

Medication Allergies:

NKDA

Ask about over the counter and herbal medication use

 

PSH

Additional assessments questions, assess her history for any surgical treatments or hospitalizations and dates. Ask the son about other significant history/risk factors like seizures. Ask about here past stroke type and effects. Ask about previous TIA and if she has any contraindication to thrombolytics. Inquire about family history of stroke.

SOAP Note Week 10 Assignment: 79-year-old African American female

Personal and Social History:

Lives alone

Denies alcohol

Denies smoking

 

Additional Assessment:  Assess for immunizations. Assess substance abuse, recent air travel, inquire about her history two weeks before onset of symptoms.

 

Family History:

No family history reported

Additional assessment:  Assess family history of cardiovascular disease, DM HTN, Strokes, TIAs, Early deaths

 

Review of Systems:

CONSTITUTIONAL:  Ask about fevers, chills, weight loss, appetite changes, night sweats

Eyes, ears, nose, throat: Ask visual changes, hearing changes, nasal congestion/drainage, throat irritation. 

CARDIOVASCULAR:  Ask chest pain, palpitations, LE edema.

Respiratory:  Ask about breathing problems, SOB, hemoptysis, cough

Gastrointestinal: Ask about N/V/D, abdominal pain, flatus, distention, reflux

Genitourinary: Ask about urinary frequency, urgency, and painful urination.

Integumentary: Ask about new rash or lesions.                                                              MUSCULOSKELETAL: RIGHT SIDE WEAKNESS

NEUROLOGIC:  APHASIC,  Ask about dizziness, syncope, seizures, headaches, numbness or tingling of the upper or lower extremities, or paralysis, confusion,

Cranial Nerves:  Ask about full CNs –  Motor Ex: appearance, tone, strength with a graded.  Full extremity assessment Reflex Ex: muscle stretch with a graded, cutaneous, primitive.

Psychiatric: Ask about depression, anxiety, sleep disturbances.

Endocrine: Ask about polyuria, polydipsia or polyphagia.

 

Kasper et al., 2015 pg. 1706; Papadakis & McPhee, 2017 pg. 257-259, Stoller, 2017

 

Objective Findings

BP 155/85, HR 96, respirations 18, pulse oximetry 96%, Normal S1- S2

 

Ask about medication regimen structure. Inquire if the patient is compliant with taking her medications. Ask if the patient keeps her regular scheduled visit with her primary care provider and last visit. Ask about her last appointment with her neurologist.

 

PE:

Perform a Detailed full neuro exam when evaluating for any stroke presentation. Asses the patient for any contraindications before providing any interventions for thrombolytics. A general review of stroke includes checking for ischemia pulses, bruits, cardiac auscultation, hemorrhagic: bleeding, bruising, checking for tenderness, ptosis, lid swelling extremity weakness. Ask when her last eye exam was and perform a visual acuity exam.

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GENERAL: Patient is unable to speak but can follow direction.  Assess if well-developed, well-nourished and appropriate eye contact or any distress is noted.

HEENT: Assess TMs, pupil size/reactivity, oropharynx for narrowing, mouth for lesions, neck for lymphadenopathy

Cardiovascular: S-, S-2 heard, regular rate, no murmurs heard. Assess for Bil edema to lower extremities, check pulses x 4, capillary refill and check for bruits

Lungs:  Lung Sounds Clear, normal respiratory rate.

Abdomen: Assess abdominal soft, BS, organ size, masses, hernias

Endocrine:  Asses for any thyroid enlargement or tenderness, excessive thirst or hunger, any hot or cold intolerance       

Integumentary: Assess for intact skin, rashes, skin color, dry, hair distribution

MUSCULOSKELETAL: Assess muscle strength, RIGHT SIDE WEAKNESS. Asses mobility/gait if appropriate

NEUROLOGICAL: APHASIC and FOLLOWS COMMANDS.  Assess mental status, sensation x 4, coordination, gait, limited CN assessment Sensory Ex: extremity primary senses (light touch, pain, temp, vibration, joint position), cortical sensation, Romberg (proprioception) Coordinationexif the patient can stand (however our patient is unable to walk) we can ask patient to do rapid alternating movements, finger-to-nose, large toe to examiner finger, heel-shin slide gait when not clinically contraindicated. Normal walking, heel/toe, straight line. Mental status Ex: LOC, memory, continue to asses her communication/speech

Cranial Nerves: Complete a  full CNs – Motor Ex: appearance, tone, strength (graded) Full extremity assessment Reflex Ex: muscle stretch (graded), cutaneous, primitive. CNIII, IV, VI primary gaze, check for ptosis, CN V Facial sensation CN V1Facial Symmetrical, corneal intact, CN V11 Hearing, XI head turning and shoulder shrug, XII Tongue midline

Lymphatics:  Assess cervical, axillary and groin for lymphadenopathy

Psychiatric: Assess mood and affect, note if anxiety present.

Case Study Week 10 SOAP Note Assignment

Testing:

Lab testing: Evaluate stroke mimickers

Blood glucose and obtain a finger stick

Evaluate coagulation status and anemia

CBC- PLT- INR-  PT- aPTT

Screen for major disease

Chemistry panel: lytes, renal function

Cardiac enzymes 

Others: drug screen, HIV, syphilis, coagulation disorders

Toxicology/blood alcohol                                                                                                              

ABG

 

Additional Diagnostic:

Non-contrast CT head (obtain first) this is a critical diagnostic tool for evaluating the type of stroke.

Performed BEFORE thrombolysis / antiplatelet therapy

More readily available compared to other neuroimaging techniques

Evaluate non-vascular causes of stroke mimics

Ex: Tumors or masses 

 

MRI

Availability urgently limits utilization

A better tool for acute ischemic stroke assessment

Contraindication with

Certain implanted devices (ex: electronic devices like PPMs)

Certain metals (ex: gun/trauma history)

Medical instability

 

CT angiography, MR angiography, conventional angiography

Evaluate etiology of an ischemic or hemorrhagic stroke

Intervention, when indicated, based on stroke type and modality

 

12 lead EKG

Evaluate for any cardiac ischemia, arrhythmia, other cardiac abnormalities

CXR

 

If suspicious for underlying etiology (ex: HF)

Not always required

Obtain an Echo

Asses for cardiac issues – A fib, valve issues

CSF in certain situations help make a differential diagnosis (ischemic vs. hemorrhagic)

Possible obtain a Lumbar puncture

EEG

Ischemic

Transesophageal echocardiogram

Carotid duplex scan

Hypercoagulable disorders

Obtain Blood Cultures

Labs – Inflammatory markers

Asses for any bleeding disorders

Assessment/Problem List

  1. Aphasic
  2. HTN
  3. Right Side weakness

 

Differential Diagnosis:

  1. Ischemic stroke
  2. Hemorrhagic stroke
  3. Hypoglycemia
  4. Brain tumor
  5. Seizure
  6. A migraine

SOAP Note Week 10 Assignment: 79-year-old African American female

Diagnosis:    Need CT results to make a definite determination of either Ischemic vs. hemorrhagic

  1. Left MCA CVA

 

Plan:

1-2.  Non-Contrast CT- check the type of stroke and confirm

  1. Tissue plasminogen activator (tPA). After CT results if not hemorrhagic stroke and there is no absolute contraindications start aspirin
  2. Blood glucose test- rule out mimics and ABG, CBC, PT, PTT, INR, BMP, Dimer Electrolytes, Cholesterol, HDL, and LDL. Check Iron level secondary low hemoglobin -hypoxia
  3. EEG – MRI
  4. Consult Neurologist

 

Rule out all mimics of strokes quickly. Depending on the type of stroke, ischemic stroke need circulation restored asap, EEG or MRI will rule out the seizure. A hemorrhagic stroke needs the bleeding stopped if possible by a Neuro interventionalist.

 

Case Analysis:

This is a 79-yr-old female patient that presented to ER with right side weakness and aphasia. She can follow commands. She has a previous history of having a stroke per her son two years ago and HTN high cholesterol. She was independent before this event.

 

Educations Topics:

Lifestyle modifications, Medication regimen requirements, Stroke recovery and rehabilitation services.     

Case Analysis Discussion:

The patient has possibly suffered an MCA stroke. She has hemiparesis on the right side and has a speech impairment-aphasia. The stroke has affected her left hemisphere causing problems on the opposite side which are affecting the right side. Her risk factors were high cholesterol, hypertension (HTN) and previous stroke two years ago.  She takes medication for her cholesterol and HTN but is not taking any antiplatelet or any dual antiplatelet therapy (DAPT).  Lab testing and diagnostic need to be done immediately. Rule out all mimics of strokes quickly. Depending on the type of stroke, ischemic stroke need circulation restored asap, the treatment for ischemic stroke is TPA intravenous within 4.5 hours of onset. Performing an EEG or MRI can rule out the possibility of a seizure. A hemorrhagic stroke needs the bleeding stopped.  Consult a neuro-interventionalist in the event there is a bleed. Performing National Institutes of Health Stroke Scale (NIHSS) evaluation will evaluate the severity of the neurological status and changes. 

References

Goolsby, M.J. & Grubbs L. (2015). Advanced assessment interpreting findings and formulating

differential diagnosis (3rd ed.). Philadelphia, PA: F.A. Davis.

Having A Stroke: Signs and symptoms of stroke (n.d.). Retrieved from

https://www.barnesjewish.org/Medical-Services/Neurology-Neurosurgery/Stroke-Cent

Kasper, D.L., Fauci, A.S., Hauser, S.L., Longo, D.L., Jameson, J.L., & Loscalzo, J. (2015).

Harrison’s principles of internal medicine (19th ed.). New York, NY: McGraw Hill

Education.

Papadakis, M.A., & McPhee, S.J. (2017). Current medical diagnosis and treatment (56th ed.).

New York, NY: McGraw Hill Education.

Williams, B.A., & Chang, A. (2014). Current diagnosis and treatment: geriatrics (2nd ed.).

New York, NY: McGraw Hill Education.

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