Acquifer Case study SOAP notes Utilize the SOAP guidelines to assist you in creating your SOAP note and building your plan of care. You are expected to develop a comprehensive SOAP note based on the given assessment, diagnosis, and advanced nursing interventions.
Reflect on what you have learned about care plans through independent research and peer discussions and incorporate the knowledge that you have gained into your patient’s care plan.
If the information is not in the provided scenario please
consider it normal for SOAP note purposes, if it is abnormal please utilize what you
know about the disease process and write what you would expect in the subjective
and objective areas of your note.
Format
Your care plan should be formatted as a Microsoft Word document. Follow
the current APA edition style. Your paper should be no longer than 3-4 pages
excluding the title and the references and in 12pt font.
Needs running head, proper and correct citation, make sure to include all the
citations in reference page.
Work B.(2 pages)
This week, complete the Aquifer case titled “Family Medicine 03: 65-year-old
woman with insomnia”(attached)
Apply information from the Aquifer Case Study to answer the following discussion
questions:
Discuss the Mrs. Gomez’s history that would be pertinent to her difficulty
sleeping. Include chief complaint, HPI, Social, Family and Past medical history
that would be important to know. What is insomnia and what causes it.
Describe the physical exam and diagnostic tools to be used for Mrs. Gomez.
Are there any additional you would have liked to be included that were not?
Please list 3 differential diagnoses for Mrs. Gomez and explain why you chose
them. What was your final diagnosis and how did you make the
determination?
What plan of care will Mrs. Gomez be given at this visit, include drug therapy
and treatments; what is the patient education and follow-up?
Work C (2 pages)
Discussion:
Angela is a 54-year-old married woman with three adult children. She has been the
office
manager of a small law firm for 20 years and has enjoyed her work until this past
year. She has
rheumatoid arthritis with minimal impairment that has been managed well with
NSAIDs. She has
been taking conjugated estrogens for 8 years and decided to stop taking them
because of her
concern of their risks without sufficient medical benefit. She has tolerated the
discontinuation
without difficulty.
Assessment:
At her annual medical checkup appointment, she told her primary care provider
that she seemed
to be tired all the time, and she was gaining weight because she had no interest in
her usual
exercise activities and had been overeating, not from appetite but out of boredom.
She denied
that she and her husband have had marital difficulties beyond the ordinary and she
was pleased
with the achievements of her children. She noticed that she has difficulty falling
asleep at night
and awakens around 4 a.m. most mornings without her alarm and cannot go back to
sleep even
though she still feels tired. She finds little joy in her life but cannot pinpoint any
particular
concern. Although she denies suicidal feelings, she does not feel that there is
meaning to her life:
“My husband and kids would go on fine if I died and probably wouldn’t miss me that
much.”
The primary care provider asks Angela to fill out a Beck’s Depression Scale, which
indicated she has moderate depression.
1. What medication would you first prescribe to this patient?
2. She comes back in 2 weeks and states she has not noticed and change in her
mood since starting on the medication. What would be your response?
3. What are the possible problems with the medication you prescribed?
4. How long should you continue the treatment regimen? What is rheumatoid
arthritis, what is the advantage and disadvantage of using estrogen
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