Academic Clinical SOAP Note Academic clinical SOAP notes provide a unique opportunity to practice and demonstrate advanced practice documentation skills, to develop and demonstrate critic

Academic Clinical SOAP Note

Academic clinical SOAP notes provide a unique opportunity to practice and demonstrate advanced practice documentation skills, to develop and demonstrate critical thinking and clinical reasoning skills, and to practice identifying acute and chronic problems and formulating evidence-based plans of care.

Develop a hospital follow-up progress SOAP note based on a clinical patient from your practicum setting. In your assessment, provide the following:

· A one-sentence description of the primary working diagnosis, pending differential diagnoses, and the context or service in which the patient is being seen.( Acute Care Hospital)

· A one-to-two paragraph description of the current illness or hospital stay, including pertinent diagnostic findings or procedures. Include how many days the patient has been hospitalized, if applicable.

· List of at least five systems affected by the working diagnosis. Provide two positive or negative effects that the working diagnosis has on each system.

· List of at least five systems examined within the last 24 hours. Provide at least two pertinent positive or negative findings relevant to each system examined and include a full set of vital signs.

· List of all admission diagnostics conducted for this visit or conducted within the last 24 hours.( (CPT codes)

· List of all pertinent acute and chronic diagnoses in order of priority using ICD-10. Identify any differential diagnoses being eliminated.

· Treatment plan that corresponds with the diagnosis. Provide information on admission type, types of diagnostics, any prescribed medications and dosages, and any relevant consults or follow-up procedures needed.

· Discussion of any relevant ethical, legal, or geriatric-specific considerations.

Incorporate at least 3-5 peer-reviewed articles in the assessment or plan. (Minimum 1200 words).

Don’t Forget to include all coding including ICD-10, CPT and all others.

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to LopesWrite. Refer to the LopesWrite Technical Support articles for assistance.

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Academic Clinical Soap Note

SUBJECTIVE

Chief Complaint:

Patient is in clinic today for second peptide receptor radionuclide treatment (PRRT) with Lutathera treatment.

Background:

This is a pleasant 47-year-old female with a history of metastatic pancreatic neuroendocrine tumor. She was initially diagnosed in October 2016 presenting with pneumonia with an incidental lung nodule noted. Biopsy demonstrated low-grade neuroendocrine of 1%. She then was noted to have metastatic disease in the right breast biopsy proven in February 2017. Somatostatin analog therapy was initiated then. When the patient progressed in September 2017 she was transitioned to Afinitor. A right thyroid nodule was noted and biopsied in December 2018 with benign findings. That due to Tait scan in January 2019 showed progression of disease. She was transitioned to Capoten for one cycle with recurrence of pancreatitis as well as development of splenic vein thrombus in February 2019. She had persistent pancreatitis in March 2019 on CT imaging. After, GI tumor board review at Stony Brook University Hospital she was found to be metastatic low-grade neuroendocrine tumor more likely pancreatic origin. Because of persistent abdominal pain she underwent celiac plexus block in May 2019. She was subsequently referred for peptide receptor radionuclide therapy/ Lutathera and received first dose on 7/17/2019. She has recently moved to Florida 3 weeks ago and presents to reestablish for continuation of Lutathera treatment at Moffitt Cancer Center.

Family History:

Father died of prostate cancer in 1998. Mother had diabetes, heart disease, and hypertension, she passed in 2010. Patient state she had several uncles that died from cancer, but she does not recall which cancer they had.

Medication:

· Insulin (Lantus) glargine 20 unit(s), SubQ, DAILY.

· fluticasone nasal (Flonase 50 mcg/inh nasal spray) 2 spray(s), NASAL, DAILY.

· pancrelipase 6000 units oral delayed release capsule, PO, QID.

· Simvastatin 10 mg, 1 tab(s), PO, Bedtime

· Metoprolol 50 mg, 1 tab(s), PO, Daily

· NIFEdipine 30 mg, 1 tab(s), PO, Daily

· Losartan (losartan 100 mg oral tablet) 100 mg, 1 tab(s), PO, AS NEEDED.

· Multivitamin (Multi Vitamin+) PO, DAILY

· Vitamin C lozenge 500 mg, 1 tab(s), PO, Daily

· Multivitamin with iron (Iron 100 Plus) PO, DAILY.

· Multivitamin (Vitamin B Complex oral capsule) 1 cap(s), PO, Daily

· Biotin (biotin 5000 mcg oral tablet, disintegrating) PO, DAILY

Review of Systems:

Constitutional: She has a long-term history of fatigue. Weight loss of 30lb since beginning of 2019. No fever, no chills, no weakness, no decrease activity.

Eye: No recent visual problem, No double vision.

Ear/Nose/Mouth/Throat: No dry mouth, No nasal congestion, No mouth sores, No mucositis.

Respiratory: No shortness of breath, No cough, No sputum production.

Cardiovascular: No palpitations, No bradycardia, No tachycardia.

Breast: No nipple discharge.

Gastrointestinal: Occasionally nausea with no vomiting. She has constipation alternating with diarrhea. Stomach pain 4 on scale 0-10. Last bowel movement today.

Genitourinary: No dysuria, No hematuria.

Gynecologic: Negative.

Hematological/Lymphatics: No bruising tendency, No bleeding tendency.

Endocrine: No cold intolerance, No heat intolerance.

Immunologic: No recurrent fevers, No recurrent infections.

Musculoskeletal: No claudication.

Integumentary: No rash.

Neurologic: Alert and oriented X4.

Psychiatric: Not delusional, No hallucinations.

OBJECTIVE

Vital Signs:

Temperature: 98.65 Heart Rate: 74, Blood Pressure: 112/74, Respiratory Rate: 14, SpO2: 100%, Weight: 57.3kg, Height: 5 ft 6 in and BMI: 21.1

Physical Examination:

General: Compared weight chart and noted a 30lb weight loss. Alert and oriented, No acute distress.

HEENT: Oropharynx clear, Normocephalic, Oral mucosa is moist.

Cardiovascular: Normal rate, Good pulses equal in all extremities.

Respiratory: Lungs are clear to auscultation, Symmetrical chest wall expansion.

Gastrointestinal: Pain elected on lite palpation soft. Non-tender, Non-distended. Hematological/Lymphatics: Lymphatic exam: Right, Submandibular, 10 mm ( By 10 mm ). Extremities: Normal range of motion, No deformity, Normal gait.

Integumentary: Warm, Intact.

Neurologic: Normal sensory, No focal defects.

Cognition and Speech: Speech clear and coherent, Functional cognition intact.

Psychiatric: Cooperative, Appropriate mood & affect

Labs/Imaging/ Diagnostic Test Result:

Abnormal Labs: Glucose- 219 H: Mean Cell Volume: 94.2 H: RDW: 52.7 H:

Diagnostic Data: Detailed review of the PET/CT: demonstrates numerous metastatic avid lesions within the soft tissues and osseous structures involving bilateral breasts, liver, pancreas, metastatic lesion in the left peritoneum and irregular mass in the left pelvis and persistent multiple osseous metastasis.

ASSESSMENT/CLINICAL IMPRESSIONS

Health Problems:

1. Neuroendocrine Tumor D3A.8

2. Pancreatitis K85

3. Diabetes E23.2

4. Hyperlipidemia E78.49

Differential Diagnosis:

ICD-10 K29: Zollinger-Ellison Syndrome– is characterized by gastric acid hypersecretion resulting in severe acid-related peptic disease and diarrhea. The tumors are thought to emerge from the delta cells that are found in the pancreas and it was founded to account for about 25% to 40% of gastrinomas. The rest of the endocrine tumors to include the 50- 70% of abnormal cells were found in the small digestive tract, while about 5% emerge from other intra-stomach area. “Gastric not only directly stimulates parietal cell secretion but also causes expansion of the mass of parietal cells. The increase in parietal cells results in an increase in basal acid output and maximal acid output. This substantial secretion of acid results in gastroesophageal reflux disease (GERD) symptoms and damage to the mucosal lining of the GI tract, causing peptic ulcers. In addition, the acid inactivates pancreatic enzymes, which contributes to the diarrhea, steatorrhea, and malabsorption of lipid-soluble nutrients (www.epocrate.com.2019).”

ICD-10 E34.0: Carcinoid Syndrome- progress in some people with carcinoid tumors and is identified by cutaneous flushing, abdominal cramps, and diarrhea. There are a number of symptoms relevant to CS that healthcare work looks for such as the abnormal labs are the first to investigate then there are the physical manifestations. Carcinoid syndrome is seen in individuals who have an underlying carcinoid tumor that has spread to the liver. Carcinoid syndrome is a rare condition that effect about 10% of the population. “Carcinoid syndrome may be more prevalent than suspected because diagnosis is difficult and sometimes overlooked; some patients may not exhibit all three of the hallmark symptoms of flushing, wheezing, and diarrhea (www.raredisease.org. 2019).”

ICD-10 D35.00: Pheochromocytoma- Is the type of “tumor arising from catecholamine-producing chromaffin cells of the adrenal medulla that classically presents with headaches, diaphoresis, and palpitations in the setting of paroxysmal hypertension (www.epocrate.com 2019).” This disease secrete adrenaline in an uncontrolled manner and can cause severe medical issues including heart disease, stroke, and ultimate this can lead to death.

PLAN COMPONENT MANAGEMENT:

Research has shown that there are few neuroendocrine tumors that may not have a clear primary tumor site and these tumors will be treated based on the histology. Many neuroendocrine tumors tend to poorly differentiated and may grow and spread rapidly. In order to get a better understanding of the tumor dynamic imaging studies a long with scopes to see the internal area of the tumor body will be utilized by the provider. EUS and biopsy may be done to confirm the cell type. The initially diagnostic test can start with the CT of the chest, abdomen, and/ or pelvis, MRI, FDG_PET/ CT scan, and biochemical testing. The patient that has a poorly differential neuroendocrine tumor the treatment option ideally utilizes a combination of options. The doctor will decide which treatment will work best, for the patient at that time; “one treatment option is the surgical option this will include resection + adjuvant chemotherapy +/- radiation therapy. There is locoregional surgical option that involves radiation therapy and chemotherapy given at the same time or one treatment after the other or just chemotherapy only. If the neuroendocrine tumor is metastatic than the treatment option is chemotherapy and every three months the patient will come into the clinic and have his/ her lab drawn and CT or MRI completed to check the progression of the treatment and at the time the provider and patient will decide based on the diagnostic report how to proceed (www.nccn.org. 2019).”

Providers at the Moffitt cancer center have used peptide receptor radionuclide therapy (PRRT) with great success. “The FDA approval of Lutathera, a peptide receptor radionuclide therapy (PRRT), on January 26, 2018, for a new era in treatment options for the neuroendocrine tumor (www.newRx.org. 2016).” When PRRT is use it was found to manifest long term effectiveness to the treatment of neuroendocrine tumor while also allowing the patient to maintain a high-quality lifestyle. The patient can use PRRT repeatedly with very little side effects and rarely these patients were dialysis dependent.

“All PRRT candidates must first be seen by an Oncologist in order to be evaluated for treatment. The requests for PRRT treatment should be for a GI oncology consult (De Visser, M., 2008).” Cost associated with the PRRT can be costly but patient who do not have insurance, Medicare/ Medicaid there are programs that can help with getting qualified for therapy. The PRRT drug can be offered free to the patient that do not have insurance but there will be costs for medications to help with the side effect of PRRT such as nausea and vomiting, and there will be costs to the institution and medical personnel providing the service.

Disposition/ Discharge Plan:

“Peptide Receptor Radionuclide Therapy uses radiation to kill cancer cells, this mean that this medication works differently than other cancer drugs. PRRT is given in a hospital setting and have two components to the therapy (Thang. S. P., et.al 2018).” There is the tumor targeted part that finds the cancer cell with a receptor called somatostatin. Then there is the radioactive component that actually kills the cancer cell. This cancer infusion is given up to four times and eight weeks apart from each infusion. Once the infusion has completed the patient will be given an injection of long acting octreotide to decrease the cancer from growing or spreading. The patient will be given anti-nausea medication, amino acid hydration solution medication, and then 45 minutes later the patient will receive the PRRT treatment.

The nurse will explain during the discharge planning that it is imperative that the patient must drink a lot of fluids/ water and urinate frequently before, during and after treatment because this will help the radiation to leave the body. Patient should also limit close contact with pregnant women, children, and immune compromised patient for the first two weeks after therapy to prevent exposure and the patient must practice good hand hygiene with soap and water often. Expected outcome of PRRT is to “reduce the risk of cancer spreading, growing, or getting worse by 79% compared to a larger than normal dose of long-acting octreotide (www.carcinoid.org. 2019).”

Health Education/ Promotion and Disease Prevention:

Patient education/ health promotion include “minimize radiation exposure during and after treatment with PRRT-consistent with institutional good radiation safety practices and patient management procedures, monitor blood cell counts because of myelosuppression; treatment may be placed on hold, dose educed, or permanently discontinue PRRT treatment based on negative reaction to treatment, hepatotoxicity can cause a decrease in blood levers therefore monitor transaminases, bilirubin and albumin. Due to neuroendocrine hormonal crisis patient must be monitored for flushing, diarrhea, hypotension, bronchoconstriction or other signs and symptoms, embryo-fetal toxicity can occur with PRRT in which the fetal harm can come about. Advise females and males of reproductive potential of the potential risk to a fetus and to use effective contraception and PRRT can cause infertility (www.carcinoid.org. 2019).” Patient are also instructed to make sure they continue to update their medication list to prevent adverse reaction. Disease prevention focus is on consuming half the patient body weight in water daily, eating a healthy diet that consist of fresh fruit and vegetable, avoid white pasta and rice, organic meats, fruits, and vegetables is considered a better choice (think rainbow colors when it comes to healthy eating). Maintaining a healthy weight and BMI. Patient are instructed to work out 150 minutes per week about 3 to 4 times in that week, stress reduction is another prevention option, and finally getting enough rest so that the body can fight off the cancer cell that is circulating in the body.

References

Carcinoid Syndrome. (2019). Retrieved from https://rarediseases.org/rare-diseases/carcinoid-syndrome/

de Visser, M., Verwijnen, S. M., & de Jong, M. (2008). Update: Improvement strategies for peptide receptor scintigraphy and radionuclide therapy. Cancer Biotherapy & Radiopharmaceuticals, 23(2), 137-57. doi:http://dx.doi.org.lopes.idm.oclc.org/10.1089/cbr.2007.0435

Neuroendocrine cancer; long-term experience supports efficacy and safety of PRRT for treating neuroendocrine tumors. (2016, Nov 06). NewsRx Health Retrieved from https://lopes.idm.oclc.org/login?url=https://search-proquest-com.lopes.idm.oclc.org/docview/1832797816?accountid=7374

Pheochromocytoma. (2019). Retrieved from https://online.epocrates.com/diseases/16332/Pheochromocytoma/Risk-Factors

Thang, S. P., Mei, S. L., Kong, G., Hofman, M. S., Callahan, J., Michael, M., & Hicks, R. J. (2018). Peptide receptor radionuclide therapy (PRRT) in european neuroendocrine tumour society (ENETS) grade 3 (G3) neuroendocrine neoplasia (NEN) – a single-institution retrospective analysis. European Journal of Nuclear Medicine and Molecular Imaging, 45(2), 262-277. doi:http://dx.doi.org.lopes.idm.oclc.org/10.1007/s00259-017-3821-2

Treatment Guideline: Neuroendocrine Tumors. (2019). Retrieved from https://www.nccn.org/patients/guidelines/neuroendocrine/88/

What is LUTATHERA®? (2019). Retrieved from https://www.carcinoid.org/wp-content/uploads/2018/07/AAA_Lu177_US_0058_LUTATHERA_lutetitum_Lu177_dotatate_Patient_Fact-Sheet_Final-July-2018.pdf

Zollinger-Ellison syndrome. (2019). Retrieved from https://online.epocrates.com/diseases/40824/Zollinger-Ellison-syndrome/Etiology27, 2018, from https://www.atsjournals.org/doi/citedby/10.1513/pats.200604-099SS

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