Assignment: This assignment will demonstrate your ability to provide age-appropriate anticipatory guidance while recognizing the need to refer patients that are outside of the scope of practice of the family nurse practitioner. This will be demonstrated by completing a SOAP note based on a patient Angela Atwater seen in Unit 2 in the VR platform

Reason given by the patient for seeking medical care “in quotes”

Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors, pertinent positives and negatives, other related diseases, past illnesses, and surgeries or past diagnostic testing related to the present illness.

Medication Intolerances:

Chronic Illnesses/Major traumas

Hospitalizations/Surgeries

“Have you ever been told that you have  diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems, kidney problems, or psychiatric diagnosis?”

Does your mother, father, or siblings have any medical or psychiatric illnesses?  Is anyone diagnosed with: lung disease, heart disease, HTN, cancer, TB, DM, or kidney disease?

Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana.  Safety status

Weight change, fatigue, fever, chills, night sweats,  and energy level

Chest pain, palpitations, PND, orthopnea, and edema

Delayed healing, rashes, bruising, bleeding or skin discolorations, and any changes in lesions or moles

Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, and TB

Corrective lenses, blurring, and visual changes of any kind

Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, and black, tarry stools

Ear pain, hearing loss, ringing in ears, and discharge

Urgency, frequency burning, change in color of urine.

Contraception, sexual activity, STDs

   Female: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx

  Male: prostate, PSA, urinary complaints

Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, and throat pain

Back pain, joint swelling, stiffness or pain, fracture hx, and osteoporosis

SBE, lumps, bumps, or changes

Syncope, seizures, transient paralysis, weakness, paresthesias, and black-out spells

HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, and cold or heat intolerance

Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, and previous dx

Healthy-appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first and then brighter later.

Skin is brown, warm, dry, clean, and intact. No rashes or lesions noted.

Head is normocephalic, atraumatic, and without lesions; hair evenly distributed. Eyes:  PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly gray with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa, pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.

S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs. Capillary refills two seconds. Pulses 3+ throughout. No edema.

Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.

Abdomen obese; BS active in all the four quadrants. Abdomen soft, nontender. No hepatosplenomegaly.

Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin.

Bladder is nondistended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness.  No adnexal masses or tenderness. Ovaries are nonpalpable.

(Male:  Both testes are palpable, no masses or lesions, no hernia, and no uretheral discharge.)

(Rectal as appropriate:  No evidence of hemorrhoids, fissures, bleeding, or masses—Males: Prostrate is smooth, nontender, and free from nodules, is of normal size, and sphincter tone is firm).

Full ROM seen in all four extremities as the patient moved about the exam room.

Speech clear. Good tone. Posture erect. Balance stable; gait normal.

Alert and oriented. Dressed in clean slacks, shirt, and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.

Urinalysis—point of care test done today in the office- results positive for nitrites and blood, negative for leukocytes.

Urine culture collected in office—pending results, sent to lab

Wet prep collected in office—pending results, sent to lab

▪                      Provide rationale for each differential diagnosis

o        Final diagnosis

▪                      Pathophysiology of primary and rationale for choosing as final

o        Non-pharmacological recommendations

o        Diagnostic tests

o        Patient education

o        Culture considerations

o        Health promotion

o        Referrals

o        Follow up

Points: 8

Points: 6.4

Points: 4.8

●      Name, age, gender

●      Chief complaint

●      History of present illness (HPI) that follows OLD CARTS pneumonic

●      Medications

●      Allergies

●      Past medical history

●      Past surgical history

●      Pertinent family history

●      Social history

●      Review of Systems

Points: 8

Points: 6.4

Points: 4.8

0 Points

●      Vital signs

●      Body systems that are pertinent to specific case

Points: 4

Points: 3.2

Points: 2.4

0 Points

●      Primary diagnosis

●      Pathophysiology of primary diagnosis

●      Three differential diagnoses

●      Rationales for differential diagnoses

Points: 4

Points: 3.2

Points: 2.4

0 Points

●      Medications

●      Non-pharmacological recommendations

●      Diagnostic tests

●      Patient education

●      Cultural considerations

●      Health promotion

●      Referrals

●      Follow-Up

Points: 3

Points: 2.4

Points: 1.8

0 Points

●      Supports all opinions and ideas with relevant and credible reference sources of information.

●      Provides three or more peer-reviewed or evidence-based practice scholarly references sources.

●      All reference sources are within the past five years.

●     Supports many opinions and ideas with relevant and credible sources of information.

●     Provides two peer-reviewed or evidence-based practice scholarly references sources.

●     All reference sources are within the past five years.

●     Not all references utilized are relevant and/or credible sources of information.

●     Provides one peer-reviewed or evidence-based practice scholarly references source.

●     Reference sources are within the past five years.

Points: 3

Points: 2.4

Points: 1.8

● Correctly citing all reference sources. One or two formatting, in-text, or reference citation errors may occur.

● Quotation marks and citations make authorship clear.

● Correctly citing all reference sources. 3-4 formatting, in-text, or reference citation errors may occur.

● Quotation marks and citations generally, make authorship clear.

● Attempts to cite. 5-6 formatting, in-text, or reference citation errors may occur.

● Quotation marks and citations may be missing or incorrect.

● Authorship may be unclear in areas.

“I have been having headaches and feeling fatigued for the past three months. I also have periodic nosebleeds”

Angela Atwater, a 47-year-old Caucasian female, known hypertensive since 2018, on 100 mg/day Atenolol and 12.5 mg/day hydrochlorothiazide, and not adhering due to side effects, walks into the clinic complaining of headaches, fatigue, and occasional nosebleeds for three months. She describes the headache as gradual in onset, global, dull in character, with no identified aggravating factor, slightly relieved on Paracetamol 500mg PRN, has no specific timing, and has a severity rating of 6/10. She denies having had any convulsions, nausea or vomiting, head trauma, neck pain, stiffness, or limb weakness.

She also reports fatigue, which she says worsens when she takes Atenolol, which she blames for her noncompliance with her antihypertensive medications. She claims to have fainted twice in the last three weeks, the most recent while climbing the stairs. She now seeks the assistance of her son while climbing the stairs to avoid syncope and subsequent falling.

She reports having a periodic nosebleed that began three months ago. The nosebleed begins spontaneously without any finger trauma and occurs at least twice in one week, with her bedsheet frequently stained with blood when she wakes up in the morning. She reports bleeding from both nares but is unable to quantify the amount of blood lost. She denies any bleeding tendencies in the family. She denies any history of nasal trauma, infection, or foreign body. She also denies having used NSAIDS or being on anticoagulant therapy.

She also reports to have struggled with her weight since adolescence and to have tried several weight loss programs with little success. She has not changed her eating habits, and she claims to do sweat-inducing exercise only once a week. She also keeps smoking. She was diagnosed with hypertension in 2018 and has been managing it with the stated medications, which she has not been taking regularly. Despite the antihypertensive medication, her blood pressure remains elevated, ranging from 150 to 155/110 to 114 mm Hg. At her last visit with her primary care physician, she was diagnosed with obesity and hypertriglyceridemia, which she was advised to manage with lifestyle changes such as physical activity, avoiding junk food, and quitting smoking, which she ducked.

100 mg/day Atenolol

12.5 mg/day hydrochlorothiazide

1 gTDS Tylenol PRN

Medication Intolerances: Not tolerant of any medication

Chronic Illnesses/Major traumas: She is hypertensive since 2018. She is obese with the most recent BMI of 33.33kg/m². She also has hypertriglyceridemia

Hospitalizations/Surgeries: She has previously (17 years ago) been hospitalized for right breast surgery to remove a fibroadenoma. She has also undergone three cesarean operations for her three children.

Her mother was obese, hypertensive, and had chronic kidney disease. She succumbed to Covid19 in 2020.  Her father was diabetic and died in 2018 of a septic diabetic foot ulcer. She has three siblings, who have also struggled with being overweight since childhood.

She is married and has born three children. She has a Bachelor’s degree in computer science and runs an IT company. She smoked for the past 10 years, 15 cigarettes a day (7.5 Pack/year). She drinks alcohol occasionally, taking two bottles of beer in one sitting. She has medical insurance.

She has gained 9.2 kg in the past 6 months. Current weight 99kgs, height 1.75m, BMI 33.33Kg/m²

Reports fatigue and reduced energy level

She denies fever, chills, night sweats

Denies palpitations, chest pains, ND, orthopnea, and edema

Denies delayed healing, rashes, bruising, bleeding or skin discolorations, and any changes in lesions or moles

Denies cough, wheezing, hemoptysis, dyspnea, pneumonia, or TB history

Uses corrective lenses for short-sightedness

Denies blurry vision, and diplopia

Denies abdominal pain, nausea, vomiting, and diarrhea, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, and black, tarry stools

Denies ear pain, hearing loss, ringing in ears, and discharge

-Reports urgency, and frequency burning

Denies change in color of urine.

-Currently not on any contraceptive. Used Jadelle (5 years) during her reproductive years

-Sexually activity, no history of the treatment of STDs

-Last Pap smear 3 years ago

-History of fibroadenoma, 17 years ago

-Menarche at 15 years, menopause (last menses seen 13 months ago)

-Obstetric History: Para 3+0 nongravida with three living children. All her pregnancies were noneventful

Denies sinus problems, dysphagia, Reports nose bleeds

Denies dental disease, hoarseness, and throat pain

Denies back pain, joint swelling, stiffness or pain, fracture hx, and osteoporosis

Denies lumps, bumps, or changes on SBE

Reports two episodes of syncope, Denies seizures, transient paralysis, weakness, paresthesia, and black-out spells

HIV Negative as of June 3^rd, 2022

 Denies bruising, blood transfusion, night sweats, swollen glands, increase thirst, increase hunger, and cold or heat intolerance

Denies history of depression, anxiety, sleeping difficulties, suicidal ideation/attempts

BMI 33.33Kg/m²

Healthy-appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first and then brighter later.

Skin is brown, warm, dry, clean, and intact. No rashes or lesions were noted.

Head is normocephalic, atraumatic, and without lesions; hair evenly distributed. Eyes:  PERRLA. EOMs are intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly gray with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa, pink and moist. Pharynx is non-erythematous and without exudate. Teeth are in good repair.

S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs. Capillary refills two seconds. Pulses 3+ throughout. No edema.

Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.

Abdomen obese; BS active in all four quadrants. Abdomen soft, nontender. No hepatosplenomegaly.

Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin. Scar on the right breast due to excision of a fibroadenoma

Bladder is nondistended; no CVA tenderness. External genitalia reveal coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and multiparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness.  No adnexal masses or tenderness. Ovaries are nonpalpable.

Full ROM seen in all four extremities as the patient moved about the exam room.

Speech clear. Good tone. Posture erect. Balance stable; gait normal.

Alert and oriented. Dressed in clean slacks, shirt, and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.

Urinalysis—point of care test done today in the office- results positive for nitrites and blood, negative for leukocytes.

Urine culture collected in office—pending results, sent to lab

Wet prep collected in office—pending results, sent to lab

o        Stage 2 hypertension

o        Obesity

o        Epistaxis

o        Urinary tract infection

▪                      Provide rationale for each differential diagnosis

1. Stage 2 Hypertension: The blood pressure is elevated (166/101 mm Hg). The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) recommended the following BP classification for adults aged 18 and older:

o        Normal: systolic lower than 120 mm Hg, diastolic lower than 80 mm Hg

o        Prehypertension: Systolic 120-139 mm Hg, diastolic 80-89 mm Hg

o        Stage 1: Systolic 140-159 mm Hg, diastolic 90-99 mm Hg

o        Stage 2: Systolic 160 mm Hg or greater, diastolic 100 mm Hg or greater (Carey et al., 2018)

The patient’s BP falls in the stage 2 category.

2. Obesity: The World Health Organization, based on body mass index (BMI), classifies obesity as follows:

·         Grade 1 overweight (commonly and simply called overweight) – BMI of 25-29.9 kg/m²

·         Grade 2 overweight (commonly called obesity) – BMI of 30-39.9 kg/m²

·         Grade 3 overweight (commonly called severe or morbid obesity) – BMI ≥40 kg/m² (Weir & Jan, 2022)

The patient falls in the grade 2 category.

3. Epistaxis: the patient reports having an anterior nosebleed. Poorly controlled hypertension is one of the general causes of epistaxis

4. Urinary tract infection (UTI): The patient reports urgency and frequency burning. Furthermore, the presence of nitrites in urine may indicate a UTI.

o        Final diagnosis: Stage 2 Hypertension:

▪                      Pathophysiology of primary and rationale for choosing as final

Pathophysiology: Normal blood pressure is maintained by four mechanisms: (1) sympathetic nervous system (SNS) activities, vascular endothelial activities, renal system activities, and endocrine system activities. SNS has the net effect of increasing cardiac output and systemic vascular resistance, which raises blood pressure (Harrison et al., 2021). The vascular endothelium, on the other hand, produces vasoactive substances that are potent vasoconstrictors, raising blood pressure. The renal system produces ultimate vasoconstriction via the renin-angiotensin aldosterone system, whereas the endocrine system raises blood pressure via angiotensin and aldosterone (Harrison et al., 2021)

Rationale: Hypertension manifests with non-specific symptoms such as headaches, fatigue, and dizziness, just as evidenced in the patient. Severe hypertension may manifest as end-organ symptoms such as headaches (hypertensive encephalopathy) and epistaxis. The patients’ headaches and epistaxis are sequela symptoms of hypertension.

o        Reduce Atenolol dosage to 50 mg/day Atenolol

o        Continue with 12.5 mg/day hydrochlorothiazide

o        Add Atorvastatin 20 mg BD

o        Tylenol 1 g TDS when necessary

o        Non-pharmacological recommendations

o        Salt restriction to no more than 1500 mg/day (Ma et al., 2021).

o        Weight reduction

o        Physical exercise: sweat-inducing physical activity at least 30 minutes a day for at least five times a week (AHA, 2018)

o        Limiting/cessation of smoking and alcohol consumption

o        The Dietary Approaches to Stop Hypertension (DASH) dietary pattern

o        Diagnostic tests

o        Electrocardiogram

o        Urinalysis

o        Blood glucose,

o        Serum potassium, creatinine, or the corresponding estimated GFR, and calcium

o        Lipid profile

o        Nasal speculum and rhinoscopy

o        Patient education

Improve medication adherence. To improve adherence, the patient should have someone remind her of her medications daily, or use an alarm to remind her when to take them. The patient should regularly monitor her blood pressure at home and report it to her primary care physician.

o        Culture considerations

During festivals and celebrations, the patient’s family values smoking, alcohol consumption, and junk food. As a result, she may require much more assistance in quitting her health-risky behaviors.

o        Health promotion:

o        Observe dietary patterns

o        Cease smoking/alcohol

o        Physical exercise regularly

o        Weight loss

o        Home BP monitoring

o        Referrals:

o        If there is evidence of a suspected cerebrovascular accident, a referral can be made to a cardiologist/neurologist

o        Also, the epistaxis complaints require an ENT consultation

o        Follow up: After every 2 weeks to check for medication adherence