Maria Alvarez, a 45-year-old Hispanic female who is a new patient, presents today for a medication refill.

Maria Alvarez, a 45-year-old Hispanic female who is a new patient, presents today for a medication refill.
She relocated to Arizona from Texas 6 months ago due to a job transfer and needs a refill on her blood pressure medication.
Early in the visit, Maria mentions for the past year she has been having episodes of pain in her abdomen under her right rib cage, especially after she eats greasy foods. As of late, the episodes have been happening more frequently, and she feels bloated and nauseated at times. It seems the episodes are triggered with any kind of food now. Not eating seems to ease the pain a little. Maria had an ultrasound a couple of weeks ago at a local urgent care and was told she has gallstones and needs to have her gallbladder removed. She hand-carried that report today and would like to know which surgeon you recommend she visit. Maria indicates she is having a flare of pain today in her right upper abdomen and took some acetaminophen this morning for it, which helped a little. Her current level of pain is 5/10.
Maria had an appendectomy at age 10. She works as a call center manager, is married, and has 2 kids. Her mother is age 82 and has high blood pressure, high cholesterol, diabetes, and arthritis. Her father is deceased from a heart attack at age 63 and was a heavy smoker. Her sister is age 53 with diabetes, high blood pressure, and breast cancer; her brother is 50 and doesn’t speak to her; her maternal grandmother died of a stroke and had diabetes; her paternal grandmother died of lung cancer; her paternal grandfather died of natural causes at an elderly age. She very rarely drinks alcohol and does not smoke.
Meds: losartan 50mg daily, multivitamin daily. Drug allergies: none known.
BP P R T HT WT BMI
128/78 78 16 98.8 5’4” 180 30.9
The abdominal u/s report’s impression she brought with her is “gallbladder wall thickening with sludge and numerous stones noted in the gallbladder.”
Diagnosis:
· Hypertension
· Cholelithiasis w/cholecystitis

View Transcript

For this assignment, you will conduct an advanced health assessment of Maria Alvarez, who is coming in for a well-woman visit. You will complete a comprehensive SOAP note and then write a reflection about the assessment, including evidence-based practices related to the diagnoses. Make sure you use the appropriate codes for the patient’s age and type of visit.

Read the Maria Álvarez Scenario.

Assessment Deliverable 
Part 1: SOAP Note
Use the SOAP Note Template and the SOAP Note Structure Guide to develop the documentation needed to complete your SOAP note.

The assessment and plan sections will not be graded, but should be completed to ensure documentation of a complete SOAP note. You will also use this information to complete your E/M coding for the visit. Make sure to:
• Document all relevant information using appropriate terminology.
• List the appropriate ICD-10 codes and E/M codes using the diagnoses provided.

Part 2: Reflection
This reflection is your opportunity to review what you learned about the patient, the process, and the outcomes in preparation for future patient encounters. The reflection must include a discussion about an evidence-based practice to improve the quality of care the patient receives.

Write a 525- to 700-word reflection providing rationale for your completed SOAP note in which you:
• Discuss which E/M codes are appropriate for this case and why.
• Locate and summarize a current evidence-based article about evidence-based guidelines or new research relating to each diagnosis.
• Identify a minimum of 2 barriers to quality health care the patient can potentially experience based on the information you obtained in the interview (e.g., cultural, linguistic, economic, previous conditions).
• Explain how an NP can address these barriers to improve the quality of care the patient receives. Use a minimum of 2 peer-reviewed articles to support your answers.

Note: Consider the interview information provided in the patient scenario when writing your reflection.

Cite the references used to support your assignment according to APA guidelines.

Submit your assessment.

Assessment Support
• Review the grading rubric for guidance on deliverable expectations.
• Review the following resources for writing guidelines and APA information:
• Center for Writing Excellence
• Reference and Citation Generator
• Grammar Assistance
• Use the following resources to research evidence-based care for any disease, disorder, or condition:
• Medscape
• UpToDate

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