- 2 days ago
create a SOAP note with information below
Create – objectives to understand assessment and treatment of COPD
Add 3 APA style sources no older than 5 years
Chief Complaint Pt states gastric acid is getting into his lungs, making it hard to breathe and coughing with flems History of Present Illness 50-year-old male with a past medical history of GERD, COPD presented to ED with complaints of worsening cough and shortness of breath for the last 3 days. Patient reports he started feeling heart burn about 2 months ago and soon after developed a cough that worsened within the last 3 days. Associated with nasal congestion, sore throat, chest pain and yellow mucus that is hard to expectorate. He reported taking Tagamet for acid reflux. Reported allergy to PPIs. Denied history of asthma, sick contact or smoking. Patient stated he had GERD surgery about 20 years ago. Reported being a supervised and doing office work. Patient exercises 4 -5 times a week however he had to stop due to symptoms. Reported exposure to second hand smoke as a child. At time of evaluation patient was sitting on stretcher, alert and oriented. Speaks in short sentences. He is currently on room air, sat 92%. He denies fevers, HA, chest pain, abdominal pain, nausea, vomiting, diarrhea or dysuria. Patient is admitted to telemetry for further management of acute bronchitis. Plan of care was discussed with patient, he verbalized understanding. VS on arrival to ED: BP 140/83, HR 68, RR 17, O2 sat 92% on room air. Patient afebrile. BMI 34.6. Labs on admission: CBC remarkable for neutrophils of 70.1%. BMP remarkable for chloride of 109 and creatinine of 1.36. Troponin x1 negative. Lipid panel remarkable for HDL of 69. COVID-19 negative. EKG shows sinus rhythm with sinus arrhythmia. Chest x-ray: Hyperinflation no consolidation. Review of Systems Constitutional: No unexplained weight gain or loss, fevers, chills, fatigue Eye: No recent visual problems ENMT: No ear pain, nasal congestion, sore throat Respiratory: + shortness of breath, +cough Cardiovascular: N+ chest pain, no palpitations, leg edema Gastrointestinal: No nausea, vomiting, diarrhea,+ heartburn Genitourinary: No dysuria, hematuria Hema/Lymph: Negative for bruising tendency, swollen lymph glands Endocrine: Negative for excessive thirst or urination, heat or cold intolerance Musculoskeletal: No back pain, joint pain, muscle pain Integumentary: No rash, itching, abrasions Neurologic: No history of fainting, memory loss,numbness Psychiatric: No anxiety, depression Allergic/Immun: No nasal allergies, itchy/red eyes, enlarged lymph nodes Physical Exam
Vitals & Measurements T: 36.7 °C (Oral) HR: 68 (Peripheral) HR: 99 (Monitored) RR: 20 BP: 132/98 SpO2: 96% WT: 67 kg (Measured) BMI: 26.17 General: Alert, well nourished, speaks in short sentences Eye: Pupils equal, EOMI, normal conjunctiva, no scleral icterus ENMT : Normocephalic, normal hearing, moist oral mucosa. Neck: Supple, non-tender, trachea midline, no JVD Respiratory : Normal respiratory effort, regular rate, bilateral wheezing to auscultation, O2 sat 92% on RA Cardiovascular: Regular rate and rhythm, no murmur or pedal edema Gastrointestinal: Soft, non-tender, non-distended, normal bowel sounds, no rebound or guarding. Genitourinary: No costovertebral angle tenderness to palpation Musculoskeletal: MAE, No digital clubbing or cyanosis. Negative Homans sign. Skin: Skin is warm, no rashes or lesions. Neurologic: AAOx3, MAE, Sensation to touch intact Psychiatric: Good judgment and insight, appropriate mood and affect Assessment/Plan
1. Acute bronchitis COPD exacerbation. Patient presented to ED with complaints of worsening cough and shortness of breath for the last 3 days. Patient reports he started feeling heart burn about 2 months ago and soon after developed a cough that worsened within the last 3 days. Associated with nasal congestion, sore throat and yellow mucus that is hard to expectorate. He reported taking Tagamet for acid reflux. Reported allergy to PPIs. Denied history of asthma, sick contact or smoking. Patient stated he had GERD surgery about 20 years ago. Reported being a supervised and doing office work. Patient exercises 4 -5 times a week however he had to stop due to symptoms. Reported exposure to second hand smoke as a child. -No leukocytosis, patient afebrile. Chest x-ray: Hyperinflation no consolidation. COVID-19 negative. plan: Started on Rocephin and Zithromax, respiratory treatments, systemic and inhaled steroids, supplemental oxygen as needed, follow RPP, check mycoplasma, strep pneumonia and Legionella
2. Acute renal injury (N17.9: Acute kidney failure, unspecified) creatinine of 1.36. plan: IVF, avoid nephrotoxins, adjust medications per creatinine clearance, BMP in a.m.
3. Chest pain (R07.9: Chest pain, unspecified) Denies at this time. Likely atypical. Patient reports chest pain associated with coughing. Troponin x1 negative. Lipid panel remarkable for HDL of 69. EKG shows sinus rhythm with sinus arrhythmia. Chest x-ray: Hyperinflation no consolidation. Plan: Telemetry, trend troponin, cardiology consult, check A1c, follow echocardiogram
4. GERD (gastroesophageal reflux disease) (K21.9: Gastro-esophageal reflux disease without esophagitis) History of GERD surgery. Reports heart burn. Takes Tagamet. Plan: Started on Pepcid and sucralfate, GI consulted VTE prophylaxis: Lovenox GI prophylaxis: Pepcid Case and plan of care discussed with admitting physician.
Medical Necessity Needs cardiology and GI evaluation, IVF, IV antibiotics, systemic and inhaled steroids. Pending troponins and echocardiogram. Problem List/Past Medical History Ongoing GERD (gastroesophageal reflux disease) Procedure/Surgical History
Home Medications Home Medications (3) Active albuterol 90 mcg/inh inhalation aerosol 1 puffs, PRN, Inhale, Every 6 hrs Carafate 1 g oral tablet 1 g = 1 tabs, Oral, BID metoclopramide 5 mg/5 mL oral syrup 5 mg = 5 mL, Oral, BID Allergies Prevacid Social
albuterol 2.5 mg/0.5 mL (0.5%) inhalation solution, 2.5 mg= 0.5 mL, Nebulized Inhalation, Every 2 hrs, PRN
Antivert, 25 mg= 1 tab(s), Oral, Every 6 hrs, PRN
Artificial Tears, 2 drops, Eye-Both, Every 2 hrs, PRN
Ayr Saline 0.65% nasal solution, 1 sprays, Nasal, 6 times per day, PRN
bisacodyl, 10 mg= 1 supp, Rectal, Daily, PRN
budesonide 0.5 mg/2 mL inhalation suspension, 0.5 mg= 2 mL, Inhale, BID
Carafate, 1 g= 1 tab(s), Oral, QID
famotidine, 20 mg= 2 mL, IV Push, BID
guaiFENesin-dextromethorphan 100 mg-10 mg/5 mL oral liquid, 5 mL, Oral, Every 4 hrs, PRN
ipratropium-albuterol 0.5 mg-2.5 mg/3 mL inhalation solution, 3 mL, Nebulized Inhalation, Every 6 hr
labetalol, 10 mg= 2 mL, IV Push, Every 4 hr, PRN
Lovenox, 40 mg= 0.4 mL, SubCutaneous, Daily
LR 1,000 mL, 1000 mL, IV Continuous
melatonin, 5 mg, Oral, Daily at bedtime, PRN
methylPREDNISolone sodium succinate, 40 mg, IV Push, Every 8 hrs
metoclopramide, 5 mg= 5 mL, Oral, BID before meals
Metoprolol Tartrate, 2.5 mg= 2.5 mL, IV Push, Once, PRN
ondansetron, 4 mg= 2 mL, IV Push, Every 4 hrs, PRN
simethicone, 80 mg= 1 tab(s), Oral, QID, PRN
Tessalon Perles, 100 mg= 1 cap(s), Oral, TID, PRN
Tylenol, 650 mg= 2 tab(s), Oral, Every 6 hrs, PRN
Zithromax IV, 500 mg= 1 tab(s), Oral, Every 24 hr
Current user, Occasional Use
Tobacco Use: Never (less than 100 in lifetime). Exposure to Secondhand Smoke: Yes. Family History Arthritis: Mother. MI: Father. Stroke: Father.
Lab Results (Most Recent 36 hrs) Hemoglobin: 15.6 g/dL (09/13/23 08:25:00) Hematocrit: 45.7 % (09/13/23 08:25:00) WBC: 10.56 K/uL (09/13/23 08:25:00) Platelet Count: 237 K/uL (09/13/23 08:25:00) Sodium on Blood: 141 mmol/L (09/13/23 08:25:00) Potassium on Blood: 3.6 mmol/L (09/13/23 08:25:00) Chloride on Blood: 109 mmol/L High (09/13/23 08:25:00) CO2 on Blood: 26 mmol/L (09/13/23 08:25:00) Anion Gap: 6 mmol/L (09/13/23 08:25:00) Glucose on Blood: 96 mg/dL (09/13/23 08:25:00) Creatinine on Blood: 1.36 mg/dL High (09/13/23 08:25:00) BUN on Blood: 11 mg/dL (09/13/23 08:25:00) Calcium (Total): 9.1 mg/dL (09/13/23 08:25:00) TSH: 1.67 uIU/mL (09/13/23 08:25:00) Hemoglobin A1C (Glycosylated): 5.5 % (09/13/23 08:25:00) Cholesterol Level: 186 mg/dL (09/13/23 08:25:00) Triglycerides: 92 mg/dL (09/13/23 08:25:00) HDL Cholesterol: 61 mg/dL High (09/13/23 08:25:00) Cholesterol/HDL Ratio: 3 ratio (09/13/23 08:25:00) LDL: 107 mg/dL (09/13/23 08:25:00) Diagnostics Results (Last 48 hrs) Chest Single View XR 09/13/23 09:03:00 IMPRESSION: Hyperinflation no consolidation. - 039321 - 9/13/2023 9:08 AM
· Based on this patient case, and using the focused SOAP note as a reference, develop a case study presentation that includes the history of present illness (HPI), appropriate positive and negative physical exam findings, past medical and surgical history, diagnostic results, diagnosis including differentials that were ruled out, and treatment plan.
· Your presentation should also include objectives for your audience (see the resource on Bloom’s Taxonomy), at least three possible discussion questions/prompts for your classmates to respond to, and at least five scholarly resources to support your diagnostic reasoning and treatment plan.
· Add 3 APA style citations no older than 5 years
Using Bloom’s Taxonomy to Write Effective Learning Outcomes
Bloom’s Taxonomy is a classification of the different objectives and skills that educators set for their students (learning outcomes).
What is Bloom’s Taxonomy
Bloom’s Taxonomy is a classification of the different outcomes and skills that educators set for their students (learning outcomes). The taxonomy was proposed in 1956 by Benjamin Bloom, an educational psychologist at the University of Chicago. The terminology has been recently updated to include the following six levels of learning. These 6 levels can be used to structure the learning outcomes, lessons, and assessments of your course. :
1. Remembering: Retrieving, recognizing, and recalling relevant knowledge from long‐term memory.
2. Understanding: Constructing meaning from oral, written, and graphic messages through interpreting, exemplifying, classifying, summarizing, inferring, comparing, and explaining.
3. Applying: Carrying out or using a procedure for executing, or implementing.
4. Analyzing: Breaking material into constituent parts, determining how the parts relate to one another and to an overall structure or purpose through differentiating, organizing, and attributing.
5. Evaluating: Making judgments based on criteria and standards through checking and critiquing.
6. Creating: Putting elements together to form a coherent or functional whole; reorganizing elements into a new pattern or structure through generating, planning, or producing.
Like other taxonomies, Bloom’s is hierarchical, meaning that learning at the higher levels is dependent on having attained prerequisite knowledge and skills at lower levels. You will see Bloom’s Taxonomy often displayed as a pyramid graphic to help demonstrate this hierarchy. We have updated this pyramid into a “cake-style” hierarchy to emphasize that each level is built on a foundation of the previous levels.
You may use this graphic for educational or non-profit use if you include a credit for Jessica Shabatura and citation back to this website.
How Bloom’s can aid in course design
Bloom’s taxonomy is a powerful tool to help develop learning outcomes because it explains the process of learning:
· Before you can understand a concept, you must remember it.
· To apply a concept you must first understand it.
· In order to evaluate a process, you must have analyzed it.
· To create an accurate conclusion, you must have completed a thorough evaluation .
However, we don’t always start with lower order skills and step all the way through the entire taxonomy for each concept you present in your course. That approach would become tedious–for both you and your students! Instead, start by considering the level of learners in your course:
1. Are lots of your students freshman? Is this an “Introduction to…” course? If so, many your learning outcomes may target the lower order Bloom’s skills, because your students are building foundational knowledge. However, even in this situation we would strive to move a few of your outcomes into the applying and analyzing level, but getting too far up in the taxonomy could create frustration and unachievable goals.
2. Are most of your students juniors and seniors? Graduate students? Do your students have a solid foundation in much of the terminology and processes you will be working on your course? If so, then you should not have many remembering and understanding level outcomes. You may need a few, for any radically new concepts specific to your course. However, these advanced students should be able to master higher-order learning objectives. Too many lower level outcomes might cause boredom or apathy.
How Bloom’s works with learning outcomes
Fortunately, there are “verb tables” to help identify which action verbs align with each level in Bloom’s Taxonomy.
You may notice that some of these verbs on the table are associated with multiple Bloom’s Taxonomy levels. These “multilevel-verbs” are actions that could apply to different activities. For example, you could have an outcome that states “At the end of this lesson, students will be able to explain the difference between H2O and OH-.” This would be an understanding level outcome. However, if you wanted the students to be able to “… explain the shift in the chemical structure of water throughout its various phases.” This would be an analyzing level verb.
Adding to this confusion, you can locate Bloom’s verb charts that will list verbs at levels different from what we list below. Just keep in mind that it is the skill, action or activity you will teach using that verb that determines the Bloom’s Taxonomy level.
Key Verbs (keywords)
Example Learning Outcome
design, formulate, build, invent, create, compose, generate, derive, modify, develop.
By the end of this lesson, the student will be able to design an original homework problem dealing with the principle of conservation of energy.
choose, support, relate, determine, defend, judge, grade, compare, contrast, argue, justify, support, convince, select, evaluate.
By the end of this lesson, the student will be able to determine whether using conservation of energy or conservation of momentum would be more appropriate for solving a dynamics problem.
classify, break down, categorize, analyze, diagram, illustrate, criticize, simplify, associate.
By the end of this lesson, the student will be able to differentiate between potential and kinetic energy.
calculate, predict, apply, solve, illustrate, use, demonstrate, determine, model, perform, present.
By the end of this lesson, the student will be able to calculate the kinetic energy of a projectile.
describe, explain, paraphrase, restate, give original examples of, summarize, contrast, interpret, discuss.
By the end of this lesson, the student will be able to describe Newton’s three laws of motion to in her/his own words
list, recite, outline, define, name, match, quote, recall, identify, label, recognize.
By the end of this lesson, the student will be able to recite Newton’s three laws of motion.
Learning outcome examples adapted from, Nelson Baker at Georgia Tech: [email protected]
How Bloom’s works with Quality Matters
For a course to meet the Quality Matters standards it must have learning outcomes that are measurable. Using a verb table like the one above will help you avoid verbs that cannot be quantified, like: understand, learn, appreciate, or enjoy. Quality Matters also requires that your course assessments (activities, projects, and exams) align with your learning outcomes. For example, if your learning outcome has an application level verb, such as “present”, then you cannot demonstrate that your students have mastered that learning outcome by simply having a multiple choice quiz.
Course level and lesson level outcomes
The biggest difference between course and lesson level outcomes is that we don’t directly assess course level outcomes. Course level outcomes are just too broad. Instead, we use several lesson level outcomes to demonstrate mastery of one course level outcome. To create good course level outcomes, we need to ask ourselves: “what do I want the students to have mastery of at the end of the course?” Then, after we finalize our course level outcomes, we have to make sure that mastery of all of the lesson level outcomes underneath confirm that a student has mastery of the course level outcome–in other words, if your students can prove (through assessment) that they can do each and every one of the lesson level outcomes in that section, then you as an instructor agree they have mastery of the course level outcome.
How Bloom’s works with course level and lesson level outcomes:
· Course level outcomes are broad. You may only have 3-5 course level outcomes. They would be difficult to measure directly because they overarch the topics of your entire course.
· Lesson level outcomes are what we use to demonstrate that a student has mastery of the course level outcomes. We do this by building lesson level outcomes that build toward the course level outcome. For example, a student might need to demonstrate mastery of 8 lesson level outcomes in order to demonstrate mastery of one course level outcome.
· Because the lesson level outcomes directly support the course level outcomes, they need to build up the Bloom’s taxonomy to help your students reach mastery of the course level outcomes. Use Bloom’s Taxonomy to make sure that the verbs you choose for your lesson level outcomes build up to the level of the verb that is in the course level outcome. The lesson level verbs can be below or equal to the course level verb, but they CANNOT be higher in level. For example, your course level verb might be an Applying level verb, “illustrate.” Your lesson level verbs can be from any Bloom’s level that is equal or below this level (applying, understanding, or remembering).
Steps towards writing effective learning outcomes:
1. Make sure there is one measurable verb in each objective.
2. Each outcome needs one verb. Either a student can master the outcome , or they fail to master it. If an outcome has two verbs (say, define and apply), what happens if a student can define, but not apply? Are they demonstrating mastery?
3. Ensure that the verbs in the course level outcome are at least at the highest Bloom’s Taxonomy as the highest lesson level outcomes that support it. (Because we can’t verify they can evaluate if our lessons only taught them (and assessed) to define.)
4. Strive to keep all your learning outcomes measurable, clear and concise.
When you are ready to write, it can be helpful to list the level of Bloom’s next to the verb you choose in parentheses. For example:
Course level outcome 1. (apply) Demonstrate how transportation is a critical link in the supply chain.
1.1. (understand) Discuss the changing global landscape for businesses and other organizations that are driving change in the global environment.
1.2. (apply) Demonstrate the special nature of transportation demand and the influence of transportation on companies and their supply chains operating in a global economy.
This trick will help you quickly see what level verbs you have. It will also let you check that the course level outcome is at least as high of a Bloom’s level as any of the lesson level outcomes underneath.
- ECO 365 Week 4 Discussion Question 2
- Group Motivation Inventory Paper
- COMM 315 Week 3 Individual Assignment Personal Action Plan
- ECET 330 Week 4 Lab Devry
- here is the Second one this is worth 160 points
- Assignment 2: Discussion—Using Business Analytics
- QNT351 Week 5 Paper
- Bus 308 – Week 4 Quiz
- MAT 540 Week 8 - Linear Programming - Continued