Chronic Conditions : Acute Kidney Injury (AKI)

Chronic Conditions : Acute Kidney Injury (AKI)

Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)
Follow the MRU Soap Note Rubric as a guide

Turn it in Score must be less than 15% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 15%. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement

Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)  Follow the MRU Soap Note Rubric as a guide

Turn it in Score must be less than 20% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement

 

 

Student______________________________________

This sheet is to help you understand what we are looking for, and what our margin remarks might be about on your write ups of patients. Since at all of the white-ups that you hand in are uniform, this represents what MUST be included in every write-up.

Important information for writing discussion questions and participation

Welcome to class

Hello class and welcome to the class and I will be your instructor for this course. This is a -week course and requires a lot of time commitment, organization, and a high level of dedication. Please use the class syllabus to guide you through all the assignments required for the course. I have also attached the classroom policies to this announcement to know your expectations for this course. Please review this document carefully and ask me any questions if you do. You could email me at any time or send me a message via the “message” icon in halo if you need to contact me. I check my email regularly, so you should get a response within 24 hours. If you have not heard from me within 24 hours and need to contact me urgently, please send a follow up text to

I strongly encourage that you do not wait until the very last minute to complete your assignments. Your assignments in weeks 4 and 5 require early planning as you would need to present a teaching plan and interview a community health provider. I advise you look at the requirements for these assignments at the beginning of the course and plan accordingly. I have posted the YouTube link that explains all the class assignments in detail. It is required that you watch this 32-minute video as the assignments from week 3 through 5 require that you follow the instructions to the letter to succeed. Failure to complete these assignments according to instructions might lead to a zero. After watching the video, please schedule a one-on-one with me to discuss your topic for your project by the second week of class. Use this link to schedule a 15-minute session. Please, call me at the time of your appointment on my number. Please note that I will NOT call you.

Please, be advised I do NOT accept any assignments by email. If you are having technical issues with uploading an assignment, contact the technical department and inform me of the issue. If you have any issues that would prevent you from getting your assignments to me by the deadline, please inform me to request a possible extension. Note that working fulltime or overtime is no excuse for late assignments. There is a 5%-point deduction for every day your assignment is late. This only applies to approved extensions. Late assignments will not be accepted.

If you think you would be needing accommodations due to any reasons, please contact the appropriate department to request accommodations.

Plagiarism is highly prohibited. Please ensure you are citing your sources correctly using APA 7th edition. All assignments including discussion posts should be formatted in APA with the appropriate spacing, font, margin, and indents. Any papers not well formatted would be returned back to you, hence, I advise you review APA formatting style. I have attached a sample paper in APA format and will also post sample discussion responses in subsequent announcements.

Your initial discussion post should be a minimum of 200 words and response posts should be a minimum of 150 words. Be advised that I grade based on quality and not necessarily the number of words you post. A minimum of TWO references should be used for your initial post. For your response post, you do not need references as personal experiences would count as response posts. If you however cite anything from the literature for your response post, it is required that you cite your reference. You should include a minimum of THREE references for papers in this course. Please note that references should be no more than 5 years old except recommended as a resource for the class. Furthermore, for each discussion board question, you need ONE initial substantive response and TWO substantive responses to either your classmates or your instructor for a total of THREE responses. There are TWO discussion questions each week, hence, you need a total minimum of SIX discussion posts for each week. I usually post a discussion question each week. You could also respond to these as it would count towards your required SIX discussion posts for the week.

I understand this is a lot of information to cover in 5 weeks, however, the Bible says in Philippians 4:13 that we can do all things through Christ that strengthens us. Even in times like this, we are encouraged by God’s word that we have that ability in us to succeed with His strength. I pray that each and every one of you receives strength for this course and life generally as we navigate through this pandemic that is shaking our world today. Relax and enjoy the course!

Hi Class,

Please read through the following information on writing a Discussion question response and participation posts.

Contact me if you have any questions.

Important information on Writing a Discussion Question

• Your response needs to be a minimum of 150 words (not including your list of references)
• There needs to be at least TWO references with ONE being a peer reviewed professional journal article.
• Include in-text citations in your response
• Do not include quotes—instead summarize and paraphrase the information
• Follow APA-7th edition
• Points will be deducted if the above is not followed

Participation –replies to your classmates or instructor

• A minimum of 6 responses per week, on at least 3 days of the week.
• Each response needs at least ONE reference with citations—best if it is a peer reviewed journal article
• Each response needs to be at least 75 words in length (does not include your list of references)
• Responses need to be substantive by bringing information to the discussion or further enhance the discussion. Responses of “I agree” or “great post” does not count for the word count.
• Follow APA 7th edition
• Points will be deducted if the above is not followed

• Remember to use and follow APA-7th edition for all weekly assignments, discussion questions, and participation points.
• Here are some helpful links
• The is a great resource

 

 

 

1)      Identifying Data (___5pts): The opening list of the note. It contains age, sex, race, marital status, etc. The patient complaint should be given in quotes. If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number.

 

2)      Subjective Data (___30pts.): This is the historical part of the note. It contains the following:

 

a) Symptom analysis/HPI(Location, quality , quantity or severity, timing, setting, factors that make it better or worse, and associate manifestations.(10pts).

b) Review of systems of associated systems, reporting all pertinent positives and negatives (10pts).

c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem (10pts). If more than one chief complaint, each should be written u in this manner.

 

3)      Objective Data(__25pt.): Vital signs need to be present. Height and Weight should be included where appropriate.

 

a)      Appropriate systems are examined, listed in the note and consistent with those identified in 2b.(10pts).

b)      Pertinent positives and negatives must be documented for each relevant system.

c)        Any abnormalities must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe things. (5pts).

 

4)      Assessment (___10pts.): Diagnoses should be clearly listed and worded appropriately.

 

5)      Plan (___15pts.): Be sure to include any teaching, health maintenance and counseling along with the pharmacological and non-pharmacological measures. If you have more than one diagnosis, it is helpful to have this section divided into separate numbered sections.

 

6)      Subjective/ Objective, Assessment and Management and Consistent (___10pts.): Does the note support the appropriate differential diagnosis process? Is there evidence that you know what systems and what symptoms go with which complaints? The assessment/diagnoses should be consistent with the subjective section and then the assessment and plan. The management should be consistent with the assessment/ diagnoses identified.

 

7)      Clarity of the Write-up(___5pts.): Is it literate, organized and complete?

Chronic Conditions : Acute Kidney Injury (AKI)

 

Example:

(sent me in word for edit, and not copy pasted pleased, thank you )

 

 

PATIENT INFORMATION

Name: Mr. W.S.

Age: 65-year-old

Sex: Male

Source: Patient

Allergies: None

Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime

PMH: Hypercholesterolemia

Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.

Surgical History: Appendectomy 47 years ago.

Family History: Father- died 81 does not report information

Mother-alive, 88 years old, Diabetes Mellitus, HTN

Daughter-alive, 34 years old, healthy

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

SUBJECTIVE:

Chief complain: “headaches” that started two weeks ago

Symptom analysis/HPI:

The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month.

Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.

 

ROS:

CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizzeness 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

CONSTITUTIONAL: Vital signs: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 0/10.

General appearance: 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

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

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

 

Assessment

Essential (Primary) Hypertension (ICD10 I10): Given the symptoms and high blood pressure (156/92 mmhg), classified as stage 2. Once the organic cause of hypertension has been ruled out, such as renal, adrenal or thyroid, this diagnosis is confirmed.

Differential diagnosis:

1.  (ICD10 I70.1)

1. Chronic kidney disease (ICD10 I12.9)

1. Hyperthyroidism (ICD10 E05.90)

Plan

Diagnosis is based on the clinical evaluation through history, physical examination, and routine laboratory tests to assess risk factors, reveal identifiable causes and detect target-organ damage, including evidence of cardiovascular disease.

Chronic Conditions : Acute Kidney Injury (AKI)

These basic laboratory tests are:

1. CMP

1. Complete blood count

1. Lipid profile

1. Thyroid-stimulating hormone

1. Urinalysis

1. Electrocardiogram

1. Pharmacological treatment:

The treatment of choice in this case would be:

Thiazide-like diuretic and/or a CCB

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

 

1. Non-Pharmacologic treatment:

1. Weight loss

1. 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

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

1. Enhanced intake of dietary potassium

1. Regular physical activity (Aerobic): 90–150 min/wk

1. Tobacco cessation

1. Measures to release stress and effective coping mechanisms.

Education

1. Provide with nutrition/dietary information.

1. Daily blood pressure monitoring at home twice a day for 7 days, keep a record, bring the record on the next visit with her PCP

1. Instruction about medication intake compliance.

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

1. Patient was educated on course of hypertension, as well as warning signs and symptoms, which could indicate the need to attend the E.R/U.C. Answered all pt. questions/concerns. Pt verbalizes understanding to all

 

Follow-ups/Referrals

1. Evaluation with PCP in 1 weeks for managing blood pressure and to evaluate current hypotensive therapy. Urgent Care visit prn.