Clinical Decision Making

NU611 Clinical Decision Making
Unit 13 Discussion
Data Set Analysis
Instructions:
Review the ‘S’ and ‘O’ data sets accessed through this link.
Data Set SOAP NotePreview the document
Construct a discussion that includes the following:
An ‘Assessment’ (‘A’ of a SOAP note) section that is supported by the data sets reviewed.
Assignment of an ICD-10 Code for each diagnosis you included in your ‘A’
Identification of the subjective and objective data for each of the ‘Assessments’ (diagnoses) you included in the ‘A’.
Please be sure to validate your opinions and ideas with citations and references in APA format where appropriate.
The post and responses are valued at 20 points. Please review post and response expectations. Please review the rubric to ensure that your response meets criteria.
Estimated time to complete: 2 hours
Peer Response: Unit 13, Due Sunday by 11:59 pm CT
Data Set Analysis
Instructions:
Construct a response to at least 2 of your peers ideally one who determined the same list of diagnoses that you did and one who did not.
Include in your response discussion identification of the subjective and/or objective data OR absence of same that supports your agreement or disagreement with your course colleague.
Please be sure to validate your opinions and ideas with citations and references in APA format where appropriate.
Subjective:
CC: The patient complains of rash to the right shoulder.
HPI: The patient is a 74-year-old female with complaints of rash to the right shoulder. She reports onset of the rash was two days ago. The location of the rash is isolated to the back of the right upper shoulder. One day prior to the rash, she was having intermittent episodes of “stabbing” pain to the shoulder area. The occurrence has been progressive and worsening over the last two days. It is characterized as burning sensation and “itchy”. It is aggravated with touch and when she gets hot. Associated symptoms are fever of 100.8 and generalized fatigue.
The patient denies using any relieving treatments. She reports pain as a 4 out of 10. She denies any prior episode of rash, trauma, injury, illness exposure, or recent exposure to irritants. The patient reports history of chicken pox and denies receiving shingles vaccine. PMH: Diabetes Mellitus type two, hypertension, hyperlipidemia, GERD, osteoarthritis, cholecystectomy 1995, and hysterectomy 1999 for uterine fibroid. Allergies: NKDA
Medications: Metformin 1000mg PO BID, Lisinopril 20mg PO daily, Omeprazole 40mg PO BID, Calcium 500mg PO twice a day, Vitamin D 600 IU PO daily, Atorvastatin 40mg PO daily, Tylenol arthritis 2 tablets every 8 hours prn pain.
Social history: The patient is a widow and lives alone. She is a retired teacher with a college education, and she has three children who live out of state. The patient reports no history of smoking, drinking, drugs, HIV, stressors, and denies sexual activity. She consumes one cup of coffee a day. The patient states that she is Catholic and denies any cultural or spiritual preferences. She currently utilizes her teaching retirement for living expenses and Medicare plus
Medicare Part D for healthcare needs.
Family history: Mother had a stroke and died at 88 years old. Father had a heart attack and died at 80 years old. Sister had breast cancer. Daughter has depression and diabetes. Maternal grandmother had a heart attack. Health Maintenance/Promotion: Patient states she is up to date on immunizations but denies the shingles vaccine. She reports Pneumonia vaccine was in 2012 and influenza in 2018. Last colonoscopy was in 2012. Blood pressure monitoring is performed at home and medication controlled. The patient reports regular diet and watches carbohydrates for diabetes control. She denies routine exercise.
Review of Systems:
General: The patient has fatigue and febrile.
Skin: Reports painful, itchy rash to right shoulder, small scattered, brown moles to lower back.
HEENT:
Head: Denies headaches, head trauma, or light headedness.
Eyes: Reports wearing reading glasses for presbyopia. Denies burning, visual change,
redness, or watering.
Ears: Reports hard of hearing to right ear. Denies tinnitus, vertigo, discharge, and pain.
Nose: Denies nasal congestion or epistaxis.
Throat: Denies sore throat or difficulty with swallowing.
Neck: Denies pain, stiffness, or lumps.
CV: Denies chest pain, palpitations, edema, or dyspnea on exertion.
Lungs: Denies cough, shortness of breath, wheezing, or sputum production.
GI: Reports GERD and occasional constipation controlled with medication. Denies vomiting or
diarrhea. History of Cholecystectomy. Patient reports a good appetite.
GU: Reports stress incontinence with cough. Denies dysuria, hematuria, nocturia, urinary
frequency, or flank pain.
PV: Denies edema to upper and lower extremities. Denies skin ulcerations or pigmentation
changes.
MSK: Reports osteoarthritis of bilateral knees and hands. Denies leg cramps or muscle
weakness.
Neuro: Denies tremors, seizures, numbness, or fainting.
Endo: History of type 2 diabetes. Average morning glucose is 120. Denies appetite change, hot
or cold tolerance, or weight changes.
Psych: Denies depression or anxiety.
Objective:
Physical Examination:
VS: Temp 100.6, BP 140/88, pulse 76, respirations 20, SpO2 100%, Ht: 5’4”, Wt: 165lbs, BMI:
28.3
Gen: The patient is well nourished, well dressed, and no acute distress.
Skin: Unilateral erythematous, maculopapular rash with small areas with developing vesicles to right, posterior, upper shoulder with a dermatomal distribution. The rash is 4cm length by 2cm width. Multiple scattered 3mm seborrheic keratosis to lower back. No suspicious or irregular border moles. Skin is warm and dry. Skin tone is appropriate to ethnicity. Nailbeds are pink and are without clubbing.
HEENT:
Head: Atraumatic, normocephalic with no masses or lesions. Hair is gray with normal texture and thickness.
Eyes: Pupils are 3mm, equal, accommodating, and reactive to light. Sclera white and conjunctiva pink. No sclera edema or periorbital edema. Visual fields full by confrontation.
Ears: Bilateral tympanic membranes pearly gray and intact. Mild hearing deficit to whisper test on right ear. Left ear hearing intact.
Nose: Mucosa pink and septum midline. No nasal drainage or sinus tenderness.
Throat: Oral mucosa pink and moist. No ulcers or pharyngeal erythema. No signs of airway distress.
Neck: The neck has full range of motion and supple. No masses, thyromegaly, adenopathy, or enlarged lymph nodes. Trachea is midline.
CV: Heart sounds regular with normal S1 and S2. No murmurs and no S3 or S4 auscultated.
No JVD, carotid bruit, or pericardial rub. BP 140/88.
Lungs: Chest is symmetrical and no accessory muscles used for breathing. Lung sounds are
clear and resonant bilaterally. No crackles, wheezes, or pleural friction rub.
Abd: Abdomen is round with no abnormal pulsations, visible peristalsis, or paradoxical
movements. Abdomen soft, nontender, no rigidity, or masses. Bowel sounds normoactive in all
four quadrants.
PV: Bilateral upper and lower extremities pink and warm. Capillary refill less than 3 seconds.
Scattered spider veins to bilateral legs. No varicose veins, edema, stasis pigmentation, or ulcers.
MSK: Normal strength and tone. No laxity, instability, subluxation of joints, and normal
movements of all joints.
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Neuro: No facial drooping. Oriented to person, place, and time. She is able to answer
appropriately and intact judgement.
Psych: Calm, cooperative, and normal affect.
Diagnostic Tests: None