(Student Name)

Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor:

Soap Note # Main Diagnosis Diabetes Mellitus type 2

PATIENT INFORMATION

Name: Mr. ET

Age: 56-year-old

Gender at Birth: Female

Gender Identity: Female

Source: Patient

Allergies: Penicillins

Current Medications:

· Multi-Vitamin Centrum Silver

· Lisinopril 10 mg daily

· PMH: HTN

Diabetes mellitus type 2

Immunizations:

Preventive Care: Coloscopy 3 years ago (Negative)

Surgical History: laparoscopic cholecystectomy

Family History: Father alive

Mother-alive, 90 years old, Diabetes Mellitus, HTN

Daughter-alive, 21 years old, healthy

Social History: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, she lives alone.

Sexual Orientation: Straight

Nutrition History: Diets off and on

Subjective Data:

Chief Complaint: “I cannot stop to drink water and to pee, I need to see my labs”

Symptom analysis/HPI:

The patient is 56 years old female who complaining of she cannot stop to drink water and to pee. Patient noticed the problem started 1 month ago and sometimes it is accompanied by anxious for eat. She states that she has been under stress because her daughter for the last month. Patient denies pain, or another symptom. She makes some labs and coming to see the results.

Review of Systems (ROS)

CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures.

HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.

RESPIRATORY: Patient denies shortness of breath, cough or hemoptysis.

CARDIOVASCULAR: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal

dyspnea.

GASTROINTESTINAL: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or diarrhea.

GENITOURINARY: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.

MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound.

SKIN: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.

Objective Data:

VITAL SIGNS and Lab valuesTemperature: 97.5 °F, Pulse: 84, BP: 142/82 mmhg, RR 20, PO2-98% on room air, Ht- fill, Wt fill lb, BMI 37.2. No report pain 0/10.

HbA1C 9.5 %.

Serum creatinine 1.2 mg/dl, add more

GENERAL APPREARANCE: The patient is alert and oriented x 3. No acute distress noted. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5.

HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without lesions,. Lids non-remarkable and appropriate for race.

Neck: supple without cervical lymphadenopathy, no jugular vein distention, no thyroid swelling or masses.

CARDIOVASCULAR: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary refill < 2 sec.

RESPIRATORY: No dyspnea or use of accessory muscles observed. No egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on auscultation.

GASTROINTESTINAL: No mass or hernia observed. Upon auscultation, bowel sounds present in all four quadrants, no bruits over renal and aorta arteries. Abdomen soft non-tender, no guarding, no rebound no distention or organomegaly noted on palpation

MUSKULOSKELETAL: No pain to palpation. Active and passive ROM within normal limits, no stiffness.

INTEGUMENTARY: intact, no lesions or rashes, no cyanosis or jaundice.

ASSESSMENT:

Main Diagnosis: Diabetes mellitus type 2 explain why

Obesity, HTN

Differential diagnosis: Put 3 and explain

PLAN: Metformin 500 mg one tablet daily in addition to daily style modifications. This dose can be increased to twice daily as needed or as tolerated every 1 o 2 weeks, until a maximum of 2 grams daily.

Hydrochlorothiazide (thiazide diuretic) 1 tablet daily added to the treatment for HTN to better control.

Labs and Diagnostic Test to be ordered:

· CMP

· Complete blood count (CBC)

· Lipid profile

· Liver function test (because the metformin requires routine monitoring)

· Serum creatinine

· Potassium because the ACE inhibitors requires monitoring of electrolytes

· Urinalysis with Micro

· Electrocardiogram (EKG 12 lead)

· Urine to monitor ketone and glucose

Pharmacological treatment:

· Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily.

· Lisinopril 10mg PO Daily

· Metformin tab 500 mg one tablet daily.

Non-Pharmacologic treatment:

· Weight changes must be done to manage better the Diabetes

· Healthy diet (DASH dietary pattern): Diet rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced content of saturated and trans l fat

· Reduced intake of dietary sodium: <1,500 mg/d is optimal goal but at least 1,000 mg/d reduction in most adults

· Enhanced intake of dietary potassium

· Exercises must be done at least 3 times per week like: walking, swimming or running

· Measures to release stress and effective coping mechanisms.

Education

· Provide with nutrition/dietary information.

· To avoid GI side effects, take the Metformin with foods.

· Instruction about medication intake compliance.

· Avoid drinking alcohol: Alcohol has a negative interaction with Metformin and contribute to hyperglycemia.

· Education of possible complications of Diabetes such as stroke, heart attack, and other problems.

· Educate to the importance to foot examination and to choose diabetes footwear.

Follow-ups/Referrals

· Follow up appointment 1 weeks for managing blood sugars: It is important to target levels of A1C less than 7 %, so labs will be every 3 months.

· Follow up nutritionist to…..

References(acerca de la enfermedad y el tratamiento, en alfabetico orden, en APA

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I nee full 3 pages and abstract. then you will need to fill up the forms and include them at the end of the paper. I uploaded an example to take a look at
For more complete assignment details, read the attached instructions and the rubric  
Prior to  starting this project, read the section on performance appraisals,  especially the 360 feedback, so you have the context necessary to  complete the project.        Whereas  most performance appraisal ratings traditionally come from one person  — the boss — 360-degree feedback is obtained from four sources: the  boss, subordinates, peers and coworkers, and the employees themselves.  For this assignment, you will:   

obtain 360-feedback from 4-5 individuals whom you interact with on a regular basis and who can attest to your behavior.
select  a ‘Feedback Facilitator’.  This person will collect the feedback from  your identified 4-5 individuals and provide their input to you in a  confidential, anonymous manner.
interpret the feedback received, identifying goals and an action plan for what you will do with this information.

 

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Left Sided Heart Failure Concept Map

Number of Pages: 2 (Double Spaced)

Pathophysiology template
Disease: Ischaemic stroke affecting the dominant left cerebral hemisphere

Definition : An ischaemic stroke is death of brain tissue resulting from an occluded artery caused either by an atherosclerotic obstruction or embolus that interrupts blood supply to the area of the brain supplied by the occluded artery. The sudden loss of blood circulation results in a corresponding loss of neurologic function (Jauch, 2014).

AETIOLOGY:

A depletion of blood flow in a cerebral artery resulting from a:

· Thrombus –atherosclerotic plaque that has ruptured in a cerebral artery

· Embolus

· from heart e.g. left atrial thrombus, left ventricular thrombus, atrial fibrillation

· from carotid artery (Craft &Gordon,2011)

PATHOGENESIS:

· Interruption of blood flow to cerebral tissue initiates a biochemical ischaemic cascade.

· Mitochondrial production of ATP ceases depolarisation  influx of sodium and calcium and efflux of potassium. Passive inflow of water into cells causes cytotoxic oedema and destruction of cells in infarct core.

· Membrane depolarization also stimulates the release of neurotransmitters. Glutamate release excessive calcium influx into nearby neurons (exocitotoxicity) destruction of cells by lipolysis, proteolysis and free radicals.

· Mitochondria break down releasing toxins and apoptotic factors.

· Injured brain tissue triggers inflammatory response release of inflammatory mediators cell death and oedema

destruction of cells in infarct core necrosis

ischaemic penumbra around core has diminished blood flow but preserved cellular metabolism.

Areas of necrotic tissue are not able to conduct nerve impulses so functions such as initiating and conveying motor impulses, receiving and interpreting sensory information and speech control will be interrupted.

(Bautista, 2014; Craft & Gordon, 2011; Maas & Safdieh,2009).

CLINICAL MANIFESTATIONS:

Just superior to the medullary junction, 90% of axons in the left pyramid cross to the right right motor dysfunction.

The middle cerebral artery supplies the frontal, temporal and parietal lobes as well as the basal ganglia and internal capsule. (Tocco,2011).

Therefore specific clinical manifestations include:

· Hemiplegia and weakness on right side of body

· Sensory loss on right side

· Inability to see the right visual field of each eye

· Aphasia

· Apraxia

· Dysarthria

· Impaired reasoning

· Behavioural changes

· Problems with memory

(Bautista, 2014; Craft & Gordon, 2011).

DIAGNOSIS

· Complete history

· Physical and neurological examination

· Brain MRI or CT scan – Essential in differentiating cerebral haemorrhage from ischaemic stroke. MRI is superior as cerebral ischaemia can be identified within minutes and can identify small areas of stroke.

· Other tests for vascular imaging can be used e.g. CT angiography, magnetic resonance angiography

(Silverman & Rymer, 2009).

TREATMENT

The emphasis of ischaemic stroke treatment is placed on salvaging potentially reversible ischemic penumbra brain tissue, preventing secondary stroke and minimising longterm disability. (Jaunch, 2014).

· Reperfusion

· thrombolytic agent (e.g.tPA)

· intra-arterial technique

· Neuroprotection

-antithrombotic therapy (e.g. aspirin)

· Nursing management

Acute phase

· frequent evaluation of neurological status

· frequent evaluation of vital signs

· Monitor oxygen saturation – administer oxygen if required

· Screen for swallowing deficits and manage appropriate hydration and nutrition strategies

· Manage activities of daily living

· Screen for communication deficits and address appropriate communication strategies

· Prevent complications e,g pressure areas, contractures, DVT

· Assess urinary and faecal continence and address appropriately

Rehabilitation

· begin as early as possible by preventing complications, passive and active movement and mobilizing as early as possible.

· Support and encourage activities provided by physiotherapists, occupational therapists and speech therapists

· Education – e.g. lifestyle modification, adherence to medications

(National Stroke Foundation, 2010).

COURSE OF DISEASE

· With reperfusion – blood is restored to the area and signs and symptoms gradually resolve

· Without treatment – Course is determined by severity of stroke. Ischaemia will extend to penumbra as stroke evolves, signs and symptoms worsen. As cerebral oedema resolves, and with structural and functional reorganisation recovery may continue for 6 months to a year. (peak recovery in about 3 months). Requires rehabilitation to optimise function.

(Teasell & Hussein, 2014).

· Complications

Contractures

Fatigue

Incontinence

Mood disturbances

Falls

Dysarthria and aphasia

PROGNOSIS

· Stroke prognosis is influenced by factors such as age and stroke severity.

· One in five likely to die within one month of suffering ischaemic stroke.

· Of those who recover about 90% will experience some impairment

(Dashe,2014)

PREVENTION

Eliminating modifiable risk factors will prevent an ischaemic stroke.

· Don’t smoke

· Diet high in fruit and vegetables, low in fats and salt

· 30 minutes of moderate-intensity physical activity on most days of the week

· Maintain healthy BMI

· Limit alcohol to no more than two standard drinks per day

(National Stroke Foundation, 2010)

If a history of atrial fibrillation – ensure adherence to anticoagulation therapy.

References

Bautista, C. (2014). Disorders of Brain Function. In S. Grossman & C. Porth (Eds),

Porth’s pathophysiology: Concepts of altered health states (9th ed.). (pp489-

524). Philadelphia: Lippincott Williams & Wilkins.

Craft, J. & Gordon, C. (2011), Alterations of Neurological Function across the

Lifespan. In J.Craft, C.Gordon & A. Tiziani (Eds). Understanding

Pathophysiology (pp 188-226). Sydney, Australia:Elsevier Australia.

Dashe, J. F. (2014). Stroke prognosis in adults. UpToDate. Retrieved from:

http://www.uptodate.com/contents/stroke-prognosis-in-adults

Jaunch, E.C. (2014). Ischemic stroke treatment and management, Retrieved from:

http://emedicine.medscape.com/article/1916852-overview

Maas, E.B. & Rymer, M.M. (2009). Ischaemic stroke: Pathophysiology and Principles

of Localization. Neurology 13 .Retrieved from:

http://www.turner-white.com/pdf/brm_Neur_V13P1.pdf

National Stroke Foundation (2010). Clinical guidelines for stroke management

2010. Melbourne Australia.

Silverman, I.E. & Rymer, M.M. (2009). An atlas of investigation and treatment.

Ischaemic stroke. Clinical publishing:Oxford,U.K.

Teasell, R.& Hussein, N. (2014)Brain reorganization, recovery and organizecare.

In Stroke rehabilitation clinician handbook 2014. Retrieved from:

http://www.ebrsr.com/sites/default/files/Chapter%202_Brain%20Reorganization,%20Recovery%20and%20Organized%20Care_June%2018%202014.pdf

Tocco, S. (2011). Identify the vessel recognize the stroke. American Nurse Today

9 (6).Assessment 1 – Concept map and guided questions.

Information 1 – Getting started.

Your first assessment is generating a concept map for left heart failure and answering three questions related to a case study about a patient who has an acute exacerbation of heart failure. When preparing your assignment refer to the criteria and standards in the Learning Guide.

You can begin this assessment now by finding readings about heart failure and summarising the information under the headings of the pathophysiology template. This information can then be used for your concept map.

Some readings that you may find helpful to start your assignment are:

Your textbook:

Craft,J.A., Gordon,C.J., Huether,S.E., McCance, K.L., Brashers, V.L. & Rote,N.E.

(2015). Understanding pathophysiology – ANZ adaptation (2nd ed.).

Chatswood, NSW: Elsevier Australia. Chapter 23.

Also:

Aitken, L., Marshall,A. & Chaboyer, W. (2015). ACCCN’s critical care nursing

(3rd ed.). Chatswood, NSW: Elsevier Australia. Chapter 10.

Wagner, K.D. (2014). High acuity nursing (6th ed.). Upper Saddler River, New

Jersey: Pearson. Chapter13.

(These books are available online from the Western Sydney University library).

This is just to begin. You will then find more readings to add to your information.

Remember that the information in your concept map and answers to the questions must correlate with the references that you cite so keep an accurate record when preparing your assignment. The marker of your assessment will check your citations.

An example of a pathophysiology template for a left-sided ischaemic stroke and a concept map using this information has been attached to start you thinking about how you will approach your assignment. The concept map has been generated using Word. However, if you wish, you may prefer to use a concept map template that you may find on the web.
Number of sources: 4

Writing Style: APA

Type of document: Case Study

Academic Level:Undergraduate

Category: Nursing

Dear Writer

More details attached.
influences

Aetiology

Depletion of blood flow in a cerebral artery resulting from a thrombus or embolus. (1)

Pathogenesis

Occlusion of cerebral artery production of ATP failure of energy pumps influx of sodium and calcium ions and efflux of potassium passive inflow of water cytotoxic oedema destruction of cells in infarct core.

Membrane depolarisation release of glutamate excessive calcium influx into neurons destruction of cells by lipolysis, proteolysis and free radicals.

infarct core and ischaemic penumbra

necrotic tissue not able to conduct impulses interrupting normal function such as motor and sensory transmission and speech.

Risk factors

· Obesity

· Smoking

· Sedentary lifestyle

· Age 1.

· ageg

Clinical features

· Right-sided hemiplegia and weakness

· Sensory loss on right side

· Inability to see the right visual field of each eye

· Aphasia

· Apraxia

· Dysarthria

· Impaired reasoning

· Behavioural changes

· Problems with memory

Diagnosis

· Complete history

· Physical and neurological examination

· Brain MRI or CT scan –differentiate cerebral haemorrhage from ischaemic stroke

· Other tests for vascular imaging – CT angiography, magnetic resonance angiography

Primary prevention

· Don’t smoke

· Diet high in fruit and vegetables

· Diet low in fats and salt

· 30 minutes of exercise daily

· Limit alcohol

1,7

Treatment

Medical

· Reperfusion Thrombolytic (tPA )

Nursing acute phase

· Frequent evaluation of neurological status and vital signs

· Oxygen saturations – administer oxygen if required

· Screen for swallowing – manage hydration and nutrition

· Manage activities of daily living

· Address appropriate communication strategies

· Prevent complications

Rehabilitation

· Passive and active movement

· Encourage activities provided by physiotherapists, speech and occupational therapists e.g. mobility, speech, ADL

· Education-

Secondary prevention

· Neuroprotection – e.g, aspirin

Course of disease

With reperfusion – blood restored to area, many symptoms gradually resolve

Without treatment – ischaemia extends to penumbra –symptoms worsen. Recovery may continue 6 months to a year but left with disability. Requires rehabilitation to optimise function 8

Complications

· Contractures

· Incontinence

· Falls

· Mood disturbances

· Dysarthria and aphasia

·

·

Death of brain tissue resulting from an occluded cerebral artery in the left side of the brain.. 6.

Prognosis

One in five likely to die within one month.

Of those who recover about 90% will experience some impairment. 9

causes

Atherosclerosis

Prevents formation of

4,7

6,7

5

1,2,4

1,2,3

Leads to need for immediate

diagnoses

Diagnosed by

Results in

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December 2, 2021

 

Objectives

The objective of assignment 2 is to have students act as financial managers in order to make critical management decisions, including performance measurement, valuation, and financing. Students will employ several key learnings from the course in a practical setting.

Description & Case Questions

Vitality Vancouver Inc. (VVI) has recently raised debt capital through long-term financing. The bond indenture includes issuing 8% coupon bonds on the market that are selling at $989, pay interest semi-annually, and mature in fifteen years. The company would like to issue additional $1 million in new fifteen-year bonds. VVI has another bond issue outstanding that pays a 7.5% coupon and matures in 14 years. The bond has a par value of $1,000 and a market price of $942.90. Interest is paid semiannually.

The company evaluates the potential of issuing a third bond that pays an annual coupon of $35, has a face value of $1,000, matures in seven years, and has a yield to maturity of 8%. As a result of the recent financing, the CFO of the company is concerned about protective covenants that could hamper the future risk-taking ability of the firm. In particular, the bondholders reserve the right to force the repayment of the bonds prior to the maturity. VVI is also experiencing rapid growth. Dividends are expected to grow at 20% per year during the next three years, 10% over the following year, and then 4% per year indefinitely. The required return on this stock is 10%.

The company is also considering the prospect to issue some preferred stock to alter the capital structure of the firm. It is however unsure about the main characteristics of the preferred stock which could cause some dilution to the existing capital structure due to similarity with another instrument. The CFO is also preparing for a meeting with the Board of Directors next week. While giving the final touches to the quarterly results, he realizes the board is likely to focus on the potential of dividend distribution to various classes of shareholders. The CFO has additionally prepared some notes regarding the voting structure of those classes of stocks. The company plans to improve the profitability and stock price related ratios because of the recent changes in the capital structure. 

1. What coupon rate should be applied to the new bonds if VVI wants to sell them at par? (Use values in the dollar)
2. What is the yield to maturity on a 14-year bond? 
3. What should be the price of the third bond being considered for an issue?
4. What is the projected stock price for the coming year, if VVI just paid a $2 dividend? 
5. Assuming VVI’s stock is currently selling for $51, the expected dividend one year from now is $1.50 and the required return is 10, what is the firm’s dividend growth rate?
6. How would issuing the preferred stock affect the capital structure of the firm in comparison to the common stock?
7. Why is the dividend distribution and voting structure a matter of interest to the Vitality’s board?
8. What recommendations would you make in improving the financial prospect of the company especially with respect to the relevant ratios? 

Evaluation and Feedback 

Question

Weight

Question 1

5 marks

Question 2

5 marks

Question 3

5 marks

Question 4

2 marks

Question 5

2 marks

Question 6

2 marks

Question 7

5 marks

Question 8

10 marks

Integration of relevant financial concepts

2 marks

Spelling, grammar and citation

2 marks

TOTAL

40 Marks

 

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