Additional scenario In activity 1, you as a support worker

2 Subjective CC: “I’m having trouble sleeping, I need something to help me sleep”. HPI: Onset- It has been going on for years but lately it’s getting worse Duration- I can only sleep 2 to 3 hours a night and it’s affecting my work Characteristics – My mind races, I can’t stop thinking and even when I fall asleep, I can’t stay asleep, I keep waking up every hour. Associated/Aggravating- “I’m not sure”. Relieving- “I drink beer to help me get tired and fall asleep. But I still wake up in the middle of the night” Treatment- “I drink beer so that I can get tired”. Summary- 42-year-old male complaining of Insomnia for years but worse the past few years, the patient has not tried anything over the counter but drinks 2-3 beers a night to fall asleep. However, patient reports waking up several times a night and waking up fatigued in the morning. The patient reports the lack of sleep is affecting his work and family life. PMH: Obesity-2000 Hypertension- 2011 Hyperlipidemia-2011 Allergies: NKDA 3 Medications: Amlodipine 10mg daily Atorvastatin 40mg daily Social history: Educational level/literacy- College. Smoking – Denies use of tobacco or cigarettes. Alcohol- Drinks 2-3 beers a day. Drugs- Denies illicit drug use Sexual Health-Currently sexually active with female spouse. Cultural and spiritual beliefs that impact health and illness- Patient denies. Financial resources – Patient is gainfully employed and denies financial need. Family history: Father: Deceased (2000)- Heart attack Mother: Alive and Well-Hypertension, Diabetes, Depression. Maternal Grandmother: Deceased age 75- Cancer. Maternal Grandfather: Deceased age 90- Natural causes. Paternal Grandmother: Deceased age 80’s- Stroke. Paternal Grandfather: Deceased Age 65- Heart attack. Health Maintenance/Promotion: Immunizations: Up to date 4 Screening: Nutritional counselling – Due Review of Systems (ROS) General: Reports fatigue, denies pain. Skin: Denies itching or lesions. HEENT: Reports ability to see well without glasses. Denies hearing difficulties. CV: Denies chest pain or discomfort. Lungs: Denies cough or shortness of breath. GI: Reports good appetite. Regular bowel movement, daily. Denies nausea or vomiting. GU: Denies pain with urination, denies frequency or urgency. PV: Denies calf pain or swelling. MSK: Reports ability to walk with no assistive devices. Neuro: Reports occasional headaches. Denies forgetfulness or dizziness. Endocrine: Reports fatigue. Denies extreme thirst. Psych: Reports frequent feelings of anxiety. Denies thoughts of suicide or self-harm. Objective: Physical Examination (PE): Vital Signs: Blood Pressure 138/82, Pulse- 89, Respirations- 18, Temperature- 97.8(Oral), Oxygen Saturation-96% room air. Height 175.2cm, weight 280lbs, BMI- 41.34 General: Appears well groomed. Skin: Warm, dry and intact. 5 HEENT: Eye lids in normal position. PERRLA. Extraocular movements smooth and symmetric. Ears equal in size bilaterally. No discharge. Lips pink and moist, no lesions. Neck: Symmetric with no noted masses. Full range of motion. No jugular vein distention. CV: Heart beat regular, Apical rate is 84 beats per minute, S1, S2, S3 sounds auscultated. Lungs: Respirations even and unlabored. No pain or tenderness on palpation. Tactile fremitus symmetric, diminished breath sounds to posterior lower lobe bases bilaterally. Non-productive cough. GI: Abdomen round and soft. No tenderness. Active bowel sounds x 4 quadrants. Umbilicus midline. Abdominal striae noted. PV: No edema. No clubbing of fingertips. Bilateral extremities warm to touch. Strong pedal and popliteal pulses. MSK: Normal flexion and extension. Able to overcome gravity. Normal spine curvature. Neuro: Alert and oriented. No tremors or unilateral weakness. Sensation intact bilaterally. No Babinski reflexes intact at 2+. Diagnostic Tests: Complete blood count with differential, Complete Metabolic Panel, Thyroid panel. Assessment: Diagnosis/Diagnoses: 1. Insomnia 2. Obesity 3. Hypertension – Stable with current medication. 4. Hyperlipidemia – Stable with current medication. Post a discussion constructed as the ‘P’ (treatment plan) that completes the partial SOAP note accessed through the link above. Include in the discussion: Your treatment “Plan” for the first two diagnoses (see note below on how to structure the ‘P’) Citations for each of the evidence-based practice (EBP) interventions included in your Plan For each article you cited in support of an element of the Plan provide your thoughts about the strength of the evidence presented in the article(s) Plan (P): These are the interventions that relate to each individual, numbered diagnosis. Document individual plans directly after each corresponding assessment (Ex. Assessment­ Plan). Address the following aspects (they should be separated out as listed below): Diagnostics: labs, diagnostics testing – tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your work up for the patient’s chief complaint Therapeutic: changes in meds, skin care, counseling, include full prescribing information for any pharmacologic interventions including quantity and number of refills for any new or refilled medications. Educational: information clients need in order to address their health problems. Include follow­ up care. Anticipatory guidance and counseling. Consultation/Collaboration: referrals or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning. NOTE: please input N/A where appropriate for the above 4 categories, do not assume that your clinical faculty person will know it was not applicable.

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