What are three objectives that could be focused on from the SOAP note below?
Question Answered step-by-step What are three objectives that could be focused on from the SOAP note below?Focused SOAP Note TemplatePatient Information: GH, 82, Male, CaucasianS CC: Son reports he found the patient lying on the floor beside the bed HPI: The patient is an 82 y/o male relocated from California, who was found beside his bed by his son. The patient had been lying beside his bed for an unknown amount of time. The patient was taken to his primary care physician and recommended to come to ER for evaluation. The patient was initially taken to a local ER and was hypotensive with a B/P of 68/48, HR 68. The initial patient workup showed elevated Troponin of 121, CK of 4140, BUN of 25, and Creatinine of 2.15. The patient was also found to have elevated AST of 274, ALT of 48, Total bilirubin 2.6, WBC of 29, and Lactic acid of 3.6. His UA was consistent with a UTI, and EKG showed no ST changes. CT of the head was negative. The patient was transported from the local ER to our facility as a direct admit for close monitoring and Critical care. Current Medications: 1) Melatonin 3 mg 1-tab PO at bedtime for Insomnia2) Oxybutynin 5 mg 1-tab PO bid for overactive bladder.3) Gabapentin 300mg 1 cap PO at bedtime Neuropathy4) Aspirin 81mg 1-tab PO daily blood thinner5) Protonix 40 mg 1-tab PO daily GERD6) Docusate Sodium 100 mg as needed PRN Stool softener7) MiraLAX 17 gm 1 cap daily as needed for constipation.8) Magnesium hydroxide 30 ml PO as needed for constipation.9) Tylenol 1000 mg Q 6 hours as needed for pain and fever. Allergies: Penicillin (Breaks out in a rash, itching)PMHx: 1) Hypertension 2) Dyslipidemia 3) GERD 4) BPH 5) Severe aortic stenosisImmunization status: Reports receiving both doses of Covid vaccine (Moderna), PNA vaccination up to date, Tetanus shot Unknow status, Flu vaccination not in season at this time.Soc and Substance Hx: The patient is retired and has just relocated from California to be close to his grandchildren. He is currently married and was living in a single-story home prior. The patient wife has currently admitted inpatient at the rehab center across the street. He has a son that lives next door and a daughter that lives out of state. Son is the most vital support system at this time. He denies alcohol, tobacco, or illicit drug use. Fam Hx: Father died at 72 of a heart attack, and Mother died at 84 from natural causes. No other health concerns were noted.Surgical Hx: 1) Left Cataract removal2) IOL implant3) Right cataract/IOL implant4) Colectomy secondary to traumatic perforation of the bowel5) Colostomy reversal6) Pyloromyotomy7) Right knee surgery8) Eyebrow lift Mental Hx: The patient per family is currently emotional at this moment. Reports that the patient’s wife is at the rehab dying. Before his wife’s admission to the hospital, he had no history of anxiety or depression. No suicidal or homicidal ideationViolence Hx: Family reports that patient was safely staying at home with wife before his hospitalization and was safe at home prior. Reproductive Hx: Unknown if sexually activeROS:· GENERAL: Reports no recent fever or chills. Denies any weight gain or loss. Patient lethargic· HEENT: No recent sinus tenderness or sore throat. No hearing loss. He wears glasses, reports blurred vision on occasion.· SKIN: There is no recent skin rash or skin breakdown. The patient with fragile skin· CARDIOVASCULAR: Denies chest pain or palpitations.· RESPIRATORY: Denies SOB, no coughing, no hemoptysis. · GASTROINTESTINAL: No nausea, no vomiting, no diarrhea· GENITOURINARY: Denies any dysuria or hematuria. · NEUROLOGICAL: There is no headache. One report syncope spell by the family found lying by the bed. Mild dizziness. No changes to bowel or bladder control· MUSCULOSKELETAL: Complaining of generalized weakness and joint aches.· HEMATOLOGIC: Reports bruises to BUE, no anemia, or any other active forms of bleeding· LYMPHATICS: No enlarged lymph nodes. No surgical history of splenectomy· PSYCHOLOGICAL: The patient has been emotional per family. The family states the patient wife is at the rehab dying.· ENDOCRNOLOGIC: No cold intolerance or heat intolerance. · REPRODUCTIVE: Sexually active status unknown currently· ALLERGIES: Denies asthma, eczema, or hives. .O VITAL SIGNS: 69/40, 94% RA, 86bpm, 22 RR, T 99.1, 198lbs, Ht. 5’10 inches, BMI 28.4GENERAL APPEARANCE: 82-year-old Caucasian male. The patient is lethargic, lying in bed. Son is present at the bedside to assist with answering questions. HEENT: Normocephalic and atraumatic. Pupils are equal, round, and reactive to light. Extraocular muscles are intact. No significant sinuses tenderness or mouth lesions were noted. NECK: There is no elevated jugular vein distention. No thyromegaly.CARDIOVASCULAR: S1 and S2 heard. Capillary refill delayed to upper and lower extremities. RESPIRATORY: Diminished and coarse on auscultation with no accessory muscle use.ABDOMEN: nontender, bowel sounds normal active x 4 quadrants. GENITOURINARY: Foley inserted on arrival, dark yellow urine present in the catheter bagEXTREMITIES: There is no clubbing, no cyanosis. There is a trace of bilateral lower extremity edema. MUSCULOSKELETAL: No calf pain or joint deformity, weakness depressedNEUROLOGICAL/CNS: Lethargic, decreased orientation at this time, goes in and out. Normal tone. Normal sensory system SKIN: Scattered bruising to BUE, no skin breakdown present PSYCHIATRY: Not homicidal or suicidal ideations. No hallucinations or deliriums. The wife is currently, per patient’s son, inpatient at rehab with health declining. Diagnostic results:Labs: Troponin: 121, CK- 4140, BUN 25, CR 2.15, Elevated AST 274, ALT 48, Bilirubin 2.6, WBC 29, Lactic acid 3.6, EGFR 60, PLT 122,000Blood cultures- pending.UA- Loaded with WBC, large leukocyte esterase. Positive for nitrates with 10-20 RBCsEKG- showed nonspecific ST changes.Diagnostics/Imaging Results:CT HEAD- NormalCXR- NormalECHO Impression: Shows an Ejection fraction of 40-45 % with mild concentric left ventricular hypertrophy. A (assessment)Differential diagnoses: 1) Septic Shock:. Severe sepsis is described as sepsis plus infection-induced organ dysfunction or infection-induced acute tissue hypoperfusion (Kleinpell et al., 2018). Organ dysfunctions associated with sepsis include acute lung injury, acute kidney injury, coagulopathy, liver dysfunction, and cardiovascular abnormality (Antonelli et al., 2016). In this case, the patient has visible hypoperfusion abnormalities, including hypotension, elevated lactate, oliguria, and altered mental status. There is some overlap between tissue hypoperfusion abnormalities and organ dysfunction associated with the cardiovascular system (Kleinpell et al., 2018). The patient blood pressure, in this case, would not respond to a bolus solution of Normal Saline, but There must be indications of severe sepsis to be diagnosed with septic shock, which includes a remarkably low blood pressure that doesn’t sufficiently respond to fluid replacement alone. Vasopressors will be initiated. Indicators: B/P 69/48, WBC 29.6, and Lactic acid is 3.6 2) Sepsis Induced Cardiomyopathy (SICM): is typically characterized by left ventricular dilatation and depressed ejection fraction (Jardin et al., 2016). Elevated Trop, CK levels mean myocardial damage.Indicators: 1.) Evidence of ongoing infection: urinalysis shows the patient has UTI; WBC of 29 highly suggests a bacterial infection. 2.) Hypotension is a sign of sepsis.3.) Decreased ejection fraction in the ECHO (for SICM to be considered ，EF should be <50%)The patient possibly has preexisting heart failure as seen in symptoms such as leg edema; decreased breath sounds in the lungs may mean fluid congestion.3) Acute Coronary Syndrome- Non-ST Elevation Myocardial Infarction; Generally characterized as Non-ST Elevation Indicators1.) Elevated cardiac markers 2) The patient has risk factors such as hypertension, dyslipidemia & severe aortic stenosis, predisposing him to such complications.3) The absence of chest pain cannot rule out M.I because this patient has an existing neuropathy that can impair pain sensation. 4) Family history of heart attack 5) EKG has non-specific ST changes. 6) Can present with hypotension.4) Urinary Tract Infection- The presence of leukocytosis or nitrates in the urine specimen indicates urinary tract infection (Foxman, 2018). Indicators:1) Urinalysis shows the patient has UTI; WBC of 29 highly suggests a bacterial infection.2) UA Loaded with WBC, large leukocyte esterase3) Positive for nitratesP lan of Treatment Serum lactate level obtained upon presentation to local ER. Lactic Acid 3.6, obtained within 3 hours. Blood cultures were obtained and pending before empirical antibiotics were started. The patient started on Vancomycin 1 G intravenous pharmacy to dose until blood cultures results come back. Even though O 2 levels is 94 % on RA, supplemental oxygen was administered to support the patient's respiratory system. 2. Normal Saline 0.9 % initiated at 100 ml/hr intravenous for adequate fluid replacement, to assist in correcting hypotension, and to restore tissue hypoperfusion that assists in the management of Sepsis. 3. Levophed (Norepinephrine) drip will be initiated per ICU protocol once a central line is placed to help manage hypotension and to achieve a MAP of 65 mmHg or higher. 4. Broad-spectrum antibiotics are started until C&S from UA are received. Cefepime 1G intravenous initiated Q 8 hours. 5. Acute Kidney Injury-BUN of 25, and Creatinine of 2.15. Continue fluid replacement. 6. Non-ST elevation myocardial infarction. Troponin 121, CK-MB 132,8. EKG showed nonspecific St changes. ECHO shows an ejection fraction of 40-45% with mild left trace mitral regurgitation. Cardiology consulted and will treat. Continue continuous telemetry. 7. Dyslipidemia- will continue atorvastatin 40 mg a bedtime. 8. Hypertension, the patient, comes in hypotensive will be cautioned with high blood pressure management. 9. BPH- will resume home medication oxybutynin 5 mg bid 10. GERD- Protonix 40 mg ordered IV push. 11. Deep vein thrombosis - Cardiology consulted and ordered heparin drip. Sequential compression devices ordered. Reflection: The patient arrived at the facility in critical condition to the ER and was transferred for continuous monitoring in the ICU setting. The patient arrived with altered mental status, but the family was present at the bedside to answer questions. The patient was immediately started on IV resuscitation fluids for hypotension and to correct tissue hypoperfusion. I have found that discharge planning and education are usually initiated upon admission, and it is imperative to include the patient's family when possible and if applicable. As healthcare professionals, I have found it essential to treat the patient, address all systems, and initiate these in the patient's plan of care for the most optimal care. From my preceptor, I have learned that it is best to assess each patient by addressing each diagnosis, each co-morbidity, each abnormal lab value, and each medication the patient is on so that the most efficient treatment plan will be optimized for each patient. In this case, the patient was found to have septic shock most likely, and the patient and the family were educated on identifying factors that could have been involved. The patient and family were educated on the treatment of emergency administration of medications, IV therapy, expected hospitalization that would be most beneficial for the patient and after the patient is discharged. The family was encouraged to constantly support the patient to keep the patient on his medication regimen post-discharge. However, the family informed that the patient might be cared for in a long-term care facility or rehabilitation setting after hospital discharge because of the physical toll associated with recovery from shock. Alternatively, a referral may be made for home or community based. The transitional patient care and the patient's physical status and recovery will be monitored closely to determine the best treatment route for the patient to guide in recovery. 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