Description
I need a Soap note APA style and History and physical same clinical case with this condition: Chronic Atrial Afibriliation I place samples on attachments
Soap Note Grading Rubric
The following MUST be included in every write-up.
Identifying Data ( 5pts): The opening list of the note. It contains age, sex, race, marital status, and all other required fields. The patient complaint should be given in quotes. If the patient has more than one complaint, each complaint should be listed and numbered separately (1, 2, 3…) and each addressed in the subjective and under the appropriate number.
Subjective Data ( 30pts.): This is the historical part of the note. It contains the following:
Symptom analysis/HPI (Location, quality, quantity or severity, timing, setting, factors that make it better or worse, and associate manifestations. (10pts).
Review of systems of associated systems, reporting all pertinent positives and negatives (10pts).
Any PMH, family hx, social hx, allergies, medications related to the complaint/problem (10pts). If more than one chief complaint, each should be written in this manner.
Objective Data( 25pt.): Vital signs need to be present. Height and weight should be included where appropriate.
Appropriate systems are examined, listed in the note and consistent with those identified in 2b.(10pts).
Pertinent positives and negatives must be documented for each relevant system.
Any abnormalities must be fully described. Measure and record sizes of things (e.g., moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe things (5pts).
Assessment ( 10pts.): All diagnoses should be clearly listed and worded appropriately with ICD 10 codes. Rationale and Explanation must be evidence based and have 1-2 in text references to back up you’re reasoning for making your main diagnosis selection. Three differential diagnoses must be noted, rationale not required but encouraged.
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. Should not be generic information and should be tailored to your patient and their needs / specific diagnosis.
Subjective/ Objective, Assessment and Management and Consistent ( 10pts.): Does the note support the appropriate differential diagnosis process? Is there evidence thatyou 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.
Clarity of the Write-up(5pts.): Is it grammatically correct, clear, organized, and complete?
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Jonathan Perez
Miami Regional University
Date of Encounter: 01/18/2024
Soap Note # 2 DX: ANEMIA
Preceptor/Clinical Site: Yoandy Rodriguez Fuentes MD, West Gables Rehabilitation Hospital
Clinical Instructor: Kayla Azari DNP AGACNP BC
Main Diagnosis Anemia
Patient
Initials:
Age:
83
JR
years
Gender: male Allergies: none
Current Medications: Iron supplements Ferrous sulfate (325 mg) PO BID, Metformin
PMH:
Hyperlipidemia,
Immunizations:
he
Surgical
has
History:
received
ESRD,
all
vaccinations.
Colonoscopy/
Influenza
Anemia
this
current
EGD
season
12-27-2023
Family History: Diabetes Mellitus: Mother and Father
Social
History:
Lives
by
himself,
no
Subjective
pets.
Data:
Chief Complaint: Referred by PCP due low hemoglobin and missing dialysis
HPI: This is a 65 year old male with history of hyperlipidemia, Diabetes, ESRD, (HD M,W,F), Who
presented to the Emergency Department accompanied by family due low hemoglobin. Patient states he was
followed by his PCP and was told by his hemoglobin was 6.5. The patient was referred to the emergency
department for blood transfusion, but the patient decided to go home and comes today. Patient verbalized
he underwent EGD/ Colonoscopy on 12/27/2023 where they told him that polyps were removed.
Review of Systems:
General : Awake, Alert, Well-nourished in no acute distress, denies changes in weight, fatigue, or
weakness, fever.
HEENT: Head: Denies history of trauma or headaches.
Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earache.
Nose: Denies rhinorrhea prior to this episode. Denies stuffiness, sneezing, itching,
•
Lungs: Denies SOB
•
Cardiovascular: Patient reports no recent heart pain or chest discomfort.
•
GI Recent colonoscopy on 12-27-2023 verbalized removed polyps
•
GU: Oliguric
•
Neuro: Denies tremors, no gait imbalance, numbness in lower extremities, no visual disturbances
or speech problems, report dizziness.
•
Psychosocial: Denies anxiety or depression.
•
Derm: No rash or itching.
Physical Exam
•
BP 111/56 RR18 T36.6 HR 82 SP02 100%. Ht 167 Wt 74.1
General: Awake, Alert, well nourished, no acute distress
HEENT Normocephalic, normal hearing, ears/nose inspection non-revealing, moist oral mucosa
Neck: neck supple, non-tender without lymphadenopathy
Pulmonary: Normal respiratory effort, clear
Cardiovascular: Regular rate and rhythm, heart sounds of S1 and S2, no extra heart sounds, murmurs or
bruits noted, Left Arm AV fistula
Abdomen: Symmetric, no distended no visible masses. The skin is normal, no scars
Auscultation: Bowel sound active in all 4 quadrants. No bruits.
Musculoskeletal: Normal gait, no limited range of mobility (joints). Normal inspection, palpation, muscle
strength. Fingers, feet and toes are normal.
Derm: Clean, warm and dry without sores or bruises. No suspicious nevi, no bruises or ecchymoses
Assessment
(Differential Diagnoses)
1. Anemia unspecified D64.9
2. Iron deficiency anemia secondary to blood loss D 50.0
2. Kidney Failure N19
3. Elevated troponin R79.89
Main Diagnosis
Anemia: When your blood produces fewer healthy red blood cells than usual, it might lead to a condition
called anemia. Your body does not receive enough oxygen-rich blood if you have anemia. You may feel
weak or exhausted due to oxygen deprivation. In addition, headaches, dizziness, shortness of breath, and
irregular heartbeat are possible. Approximately 3 million Americans suffer from anemia, according to the
Centers for Disease Control and Prevention. Iron deficiency anemia is caused by insufficient iron in
the body, typically due to blood loss. For instance, in women, the predominant cause is
menstruation and during delivery when much blood is lost (Baradwan et al., 2018). Lastly, anemia
of chronic disease is related to chronic conditions like cancer, Kidney failure, autoimmune
inflammatory disorders like rheumatoid arthritis (Means & Quillen, 2018).
Differential
diagnosis
Iron deficiency anemia due blood loss: The illness known as iron deficiency anemia due to blood
loss occurs when the body is unable to synthesise hemoglobin, which is the protein found in red
blood cells that is responsible for carrying oxygen throughout the body. Iron deficiency anemia is
associated with loss of iron mainly through acute blood loss as a result of menstruation (Lopez et
al., 2016). When iron is lost from the body; there is a defective synthesis of red blood cells. Iron
is essential as it combines with the protein globin to firm hemoglobin (McLaren, Kleynberg &
Anderson, 2016). Gastrointestinal bleeding, peptic ulcers, colitis also lead to iron deficiency
anemia because of severe loss of blood (De Franceschi et al., 2017).
PLAN:
•
Patient admitted to medicine unit.
•
1 unit of PRBC to transfuse this patient hemoglobin is 6.5 Guidelines from ABBB advise to give
blood when Hg less than 7.0
•
Patient missed one dialysis section, nephrology would be consult for recommendations while
inpatient.
•
Medical Records request from the facility he had the colonoscopy done his hemoglobin drop could
be related to blood loss from procedures he had done.
•
Occult blood test ordered to rule out gastrointestinal bleeding.
Education
•
Patient educated on the causes, signs and symptoms of iron deficiency anemia.
•
Patient educated on importance of taking iron supplements
•
Importance about not missing dialysis treatment.
References
•
Barkley, T. W. & Myers, C.M. (2020). Practice Considerations for Adult-Gerontology
Acute Care Nurse Practitioners (3rd ed.) Barkley & Associates.
•
Carson JL, Stanworth SJ, Guyatt G, Valentine S, Dennis J, Bakhtary S, Cohn CS, Dubon
A, Grossman BJ, Gupta GK, Hess AS, Jacobson JL, Kaplan LJ, Lin Y, Metcalf RA,
Murphy CH, Pavenski K, Prochaska MT, Raval JS, Salazar E, Saifee NH, Tobian AAR,
So-Osman C, Waters J, Wood EM, Zantek ND, Pagano MB. Red Blood Cell Transfusion:
2023 AABB International Guidelines. JAMA. 2023 Nov 21;330(19):1892-1902. doi:
10.1001/jama.2023.12914. PMID: 37824153.
•
The Merck Manual, 20th Edition, Merck Publisher, April 2018, ISBN-13: 978-0911910421
ISBN-10: 9780911910421
History and Physical
Encounter date: 1-19-2024
Patient Initials: FR
Gender:
Male
Female__X_ Transgender ____
Age: 87
Chief Complaint: Family states patient was with AMS this morning with chest pain, vomiting once.
HPI: 87-year-old Hispanic female who comes to the emergency department with altered mental status.
Per the patient’s family, the patient is more lethargic than norma. Patient herself states that she is more
fatigued and feels some chest tightness, exacerbated by deep inspiration. The patient niece who is primary
caretaker at the bedside states that this has been happening with minimal exertion over the past several
days. Patient denies any cough, fever, congestion or chills. When prompted about urinary symptoms
patient stated that she does have burning with urination. in the ED, patient urinalysis shows leukocytosis
11.14 suggestive of infection.
Allergies (Drug/Other): NKDA
Current perception of Health:  Excellent
Good
Fair Poor
PMH:
Hypertension, Diabetes Mellitus, Pacemaker, Left Breast Cancer, Dementia
PSH: Left mastectomy 1994
Hospitalizations:
None recently
Current Meds: Amlodipine 2.5mg PO daily, Metformin 500mg PO BID, Metoprolol 50mg PO daily
Family Hx: Diabetes Mellitus: Mother Father: HTN
Social History: __Married _x_Widowed __Single Divorced __Cohabitating Partner
Lives: __Home __Alone __ Family x Caretaker
Smoke: Denies
__ACLF __ SNF ___Other:
ETOH Denies
Recreational Drug Use Denies
Review of Systems:
•
General: No weight loss, fever, chills, weakness, or fatigue.
•
HEENT: Eyes- Denies loss of vision. Denies scleral icterus. Denies purulent exudate.
Denies masses or lesions.
•
Ears- Denies masses, lesions, or trauma. Denies foreign object or obstruction. Denies
bulging or fluid noted.
•
Nose- Denies foreign object or obstruction. Denies septal deviation.
•
Throat- Denies exudate. Denies masses or lesions. Denies enlarged cervical lymph nodes.
•
RESPIRATORY: Denies cough, sputum. Fatigue while ambulating
•
GASTROINTESTINAL: Denies recent weight-loss or weight gain. Denies N/V/D.
Denies abdominal pain/tenderness. Denies changes in bowel habits. Denies food
allergies.
•
GENITOURINARY: Positive urinary frequency. Malodorous
•
NEUROLOGICAL: Denies HA, dizziness or syncope.
•
MUSCULOSKELETAL: No back pain, joint pain, muscle pain.
•
HEMATOLOGIC: Denies painful or enlarged lymph nodes. Denies splenectomy.
•
LYMPHATICS: Denies painful or enlarged lymph nodes.
•
PSYCHIATRIC: Denies depression or anxiety.
•
ENDOCRINOLOGIC: Denies polydypsia Denies intolerance to heat or cold.
•
ALLERGIES: No nasal allergies, itchy/red eyes
Physical Exam
GENERAL: Well developed. BP 122/70, HR 66, Temp 98.0 F, Resp 18, Pulse ox 98%
Head: Normocephalic. Atraumatic. Symmetrical. No abnormal hair loss. No masses or lesions.
No cervical pain or decreased ROM.
HEENT:
•
Eyes- Intact and symmetrical bilaterally. Pink and moist conjunctiva. No scleral icterus.
Bilateral lids w/o ptosis. Normal lash distribution. No purulent exudate. No masses or
lesions. PERRLA bilaterally.
•
Ears- Intact bilaterally. No masses, lesions, or trauma. No foreign object or obstruction.
Nose- Intact. Atraumatic. Bilateral nares patent. No foreign object or obstruction. No
septal deviation.
SKIN: Intact. hives. No eczema.
CARDIOVASCULAR: positive for chest discomfort. No edema.
RESPIRATORY: Symmetrical chest expansion. Clear to auscultation
GASTROINTESTINAL: BS normoactive x4. No masses or hernia. Abd soft and rounded. No
tenderness to palpitation. No anorexia, nausea, vomiting or diarrhea.
GENITOURINARY: Burning at urination and malodorous
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in
the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No history of splenectomy. No organomegaly. No splenomegaly. No lymph
node enlargement.
PSYCHIATRIC: No history of depression or anxiety. Patient with dementia not oriented to year
or location AAOX1, appropiate mood and affect
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance.
Assessment
(Differential Diagnoses)
1.
2.
3.
4.
Urinary Tract Infection N39.0
Acute Pyelonephritis N10
Bladder Cancer C67.9
Chest pain R07.9
Significant Data
Patient urinalysis has leukocytosis and positive nitrates suggesting UTI
Plan
1.
2.
3.
4.
5.
6.
Admit to observation
Rocephin 1gm IV daily, follow up UC result
D-dimer ordered if positive will order Chest CT to rule out PE
Elevated Troponin likely secondary to demand, cardiology consult
CBC – evaluation of hemoglobin
CMP- Evaluate variants and assessment of renal functioning
7. Urology consult if there is no improvement with conservative treatment
History and Physical
Encounter date: 1-19-2024
Patient Initials: FR
Gender:
Male
Female__X_ Transgender ____
Age: 87
Chief Complaint: Family states patient was with AMS this morning with chest pain, vomiting once.
HPI: 87-year-old Hispanic female who comes to the emergency department with altered mental status.
Per the patient’s family, the patient is more lethargic than norma. Patient herself states that she is more
fatigued and feels some chest tightness, exacerbated by deep inspiration. The patient niece who is primary
caretaker at the bedside states that this has been happening with minimal exertion over the past several
days. Patient denies any cough, fever, congestion or chills. When prompted about urinary symptoms
patient stated that she does have burning with urination. in the ED, patient urinalysis shows leukocytosis
11.14 suggestive of infection.
Allergies (Drug/Other): NKDA
Current perception of Health:  Excellent
Good
Fair Poor
PMH:
Hypertension, Diabetes Mellitus, Pacemaker, Left Breast Cancer, Dementia
PSH: Left mastectomy 1994
Hospitalizations:
None recently
Current Meds: Amlodipine 2.5mg PO daily, Metformin 500mg PO BID, Metoprolol 50mg PO daily
Family Hx: Diabetes Mellitus: Mother Father: HTN
Social History: __Married _x_Widowed __Single Divorced __Cohabitating Partner
Lives: __Home __Alone __ Family x Caretaker
Smoke: Denies
__ACLF __ SNF ___Other:
ETOH Denies
Recreational Drug Use Denies
Review of Systems:
•
General: No weight loss, fever, chills, weakness, or fatigue.
•
HEENT: Eyes- Denies loss of vision. Denies scleral icterus. Denies purulent exudate.
Denies masses or lesions.
•
Ears- Denies masses, lesions, or trauma. Denies foreign object or obstruction. Denies
bulging or fluid noted.
•
Nose- Denies foreign object or obstruction. Denies septal deviation.
•
Throat- Denies exudate. Denies masses or lesions. Denies enlarged cervical lymph nodes.
•
RESPIRATORY: Denies cough, sputum. Fatigue while ambulating
•
GASTROINTESTINAL: Denies recent weight-loss or weight gain. Denies N/V/D.
Denies abdominal pain/tenderness. Denies changes in bowel habits. Denies food
allergies.
•
GENITOURINARY: Positive urinary frequency. Malodorous
•
NEUROLOGICAL: Denies HA, dizziness or syncope.
•
MUSCULOSKELETAL: No back pain, joint pain, muscle pain.
•
HEMATOLOGIC: Denies painful or enlarged lymph nodes. Denies splenectomy.
•
LYMPHATICS: Denies painful or enlarged lymph nodes.
•
PSYCHIATRIC: Denies depression or anxiety.
•
ENDOCRINOLOGIC: Denies polydypsia Denies intolerance to heat or cold.
•
ALLERGIES: No nasal allergies, itchy/red eyes
Physical Exam
GENERAL: Well developed. BP 122/70, HR 66, Temp 98.0 F, Resp 18, Pulse ox 98%
Head: Normocephalic. Atraumatic. Symmetrical. No abnormal hair loss. No masses or lesions.
No cervical pain or decreased ROM.
HEENT:
•
Eyes- Intact and symmetrical bilaterally. Pink and moist conjunctiva. No scleral icterus.
Bilateral lids w/o ptosis. Normal lash distribution. No purulent exudate. No masses or
lesions. PERRLA bilaterally.
•
Ears- Intact bilaterally. No masses, lesions, or trauma. No foreign object or obstruction.
Nose- Intact. Atraumatic. Bilateral nares patent. No foreign object or obstruction. No
septal deviation.
SKIN: Intact. hives. No eczema.
CARDIOVASCULAR: positive for chest discomfort. No edema.
RESPIRATORY: Symmetrical chest expansion. Clear to auscultation
GASTROINTESTINAL: BS normoactive x4. No masses or hernia. Abd soft and rounded. No
tenderness to palpitation. No anorexia, nausea, vomiting or diarrhea.
GENITOURINARY: Burning at urination and malodorous
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in
the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No history of splenectomy. No organomegaly. No splenomegaly. No lymph
node enlargement.
PSYCHIATRIC: No history of depression or anxiety. Patient with dementia not oriented to year
or location AAOX1, appropiate mood and affect
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance.
Assessment
(Differential Diagnoses)
1.
2.
3.
4.
Urinary Tract Infection N39.0
Acute Pyelonephritis N10
Bladder Cancer C67.9
Chest pain R07.9
Significant Data
Patient urinalysis has leukocytosis and positive nitrates suggesting UTI
Plan
1.
2.
3.
4.
5.
6.
Admit to observation
Rocephin 1gm IV daily, follow up UC result
D-dimer ordered if positive will order Chest CT to rule out PE
Elevated Troponin likely secondary to demand, cardiology consult
CBC – evaluation of hemoglobin
CMP- Evaluate variants and assessment of renal functioning
7. Urology consult if there is no improvement with conservative treatment
Jonathan Perez
Miami Regional University
Date of Encounter: 01/19/2024
Soap Note # 2 DX: Urinary Tract Infection
Preceptor/Clinical Site: Yoandy Rodriguez Fuentes MD, West Gables Rehabilitation Hospital
Clinical Instructor: Kayla Azari DNP AGACNP BC
Main Diagnosis Urinary Tract Infection
Patient Initials: FR
Age:
87
years
Gender: Female Allergies: none
Current Medications: Amlodipine 2.5mg PO daily, Metformin 500mg PO BID, Metoprolol 50mg PO daily
Left mastectomy 1994
Immunizations:
he
has
received
all
vaccinations.
Influenza
this
current
season
no
pets.
Surgical History: Left mastectomy 1994
Family Hx: Diabetes Mellitus: Mother Father: HTN
Social
History:
Lives
by
himself,
Subjective
Data:
Chief Complaint: Family states patient was with AMS this morning with chest pain, vomiting once.
HPI: 87-year-old Hispanic female who comes to the emergency department with altered mental status. Per
the patient’s family, the patient is more lethargic than norma. Patient herself states that she is more fatigued
and feels some chest tightness, exacerbated by deep inspiration. The patient niece who is primary caretaker
at the bedside states that this has been happening with minimal exertion over the past several days. Patient
denies any cough, fever, congestion or chills. When prompted about urinary symptoms patient stated that
she does have burning with urination. in the ED, patient urinalysis shows leukocytosis 11.14 suggestive of
infection.
Review of Systems:
•
General: No weight loss, fever, chills, weakness, or fatigue.
•
HEENT: Eyes- Denies loss of vision. Denies scleral icterus. Denies purulent exudate.
Denies masses or lesions.
•
Ears- Denies masses, lesions, or trauma. Denies foreign object or obstruction. Denies
bulging or fluid noted.
•
Nose- Denies foreign object or obstruction. Denies septal deviation.
•
Throat- Denies exudate. Denies masses or lesions. Denies enlarged cervical lymph nodes.
•
RESPIRATORY: Denies cough, sputum. Fatigue while ambulating
•
GASTROINTESTINAL: Denies recent weight-loss or weight gain. Denies N/V/D. Denies
abdominal pain/tenderness. Denies changes in bowel habits. Denies food allergies.
•
GENITOURINARY: Positive urinary frequency. Malodorous
•
NEUROLOGICAL: Denies HA, dizziness or syncope.
•
MUSCULOSKELETAL: No back pain, joint pain, muscle pain.
•
HEMATOLOGIC: Denies painful or enlarged lymph nodes. Denies splenectomy.
•
LYMPHATICS: Denies painful or enlarged lymph nodes.
•
PSYCHIATRIC: Denies depression or anxiety.
•
ENDOCRINOLOGIC: Denies polydypsia Denies intolerance to heat or cold.
•
ALLERGIES: No nasal allergies, itchy/red eyes
Physical Exam
GENERAL: Well developed. BP 122/70, HR 66, Temp 98.0 F, Resp 18, Pulse ox 98%
Head: Normocephalic. Atraumatic. Symmetrical. No abnormal hair loss. No masses or lesions. No cervical
pain or decreased ROM.
HEENT:
•
Eyes- Intact and symmetrical bilaterally. Pink and moist conjunctiva. No scleral icterus. Bilateral
lids w/o ptosis. Normal lash distribution. No purulent exudate. No masses or lesions. PERRLA
bilaterally.
•
Ears- Intact bilaterally. No masses, lesions, or trauma. No foreign object or obstruction. NoseIntact. Atraumatic. Bilateral nares patent. No foreign object or obstruction. No septal deviation.
SKIN: Intact. hives. No eczema.
CARDIOVASCULAR: positive for chest discomfort. No edema.
RESPIRATORY: Symmetrical chest expansion. Clear to auscultation
GASTROINTESTINAL: BS normoactive x4. No masses or hernia. Abd soft and rounded. No tenderness
to palpitation. No anorexia, nausea, vomiting or diarrhea.
GENITOURINARY: Burning at urination and malodorous
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the
extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No history of splenectomy. No organomegaly. No splenomegaly. No lymph node
enlargement.
PSYCHIATRIC: No history of depression or anxiety. Patient with dementia not oriented to year or location
AAOX1, appropriate mood and affect
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance.
Differential diagnoses:
Urinary Tract Infection-It is an infection of the urinary system which can include the urethra, kidneys, or
bladder (Kennedy-Malone, Plank, & Duffy, 2019). The findings from the laboratory showed increased
WBCs in the urine and positive nitrites in urinalysis. The presence of WBCs and nitrites in urine is an
indication of bacterial infection in the urinary tract. An infection in the urinary tract causes blood in urine
(hematuria). Nitrites in urinalysis are more sensitive and specific than other urinalysis components for UTI
in geriatrics (Shian & Larson, 2018)
Pyelonephritis- It is a bacterial infection of the kidney parenchyma. The bacteria ascend from the lower
urinary tract and may reach the kidney through the bloodstream (Fulop, 2021; Jackson & Cruz, 2018). It
presents with gross hematuria, fever, nausea and vomiting, burning sensation with urination, increased
frequency, and urgency.
Bladder Cancer-It is prevalent in older adults. The most common symptoms of this diagnosis is blood in
urine, frequent urination, and dark urine (Kennedy-Malone, Plank, & Duffy, 2019).
Plan
1. Admit to observation
2. Rocephin 1gm IV daily, follow up UC result
3. D-dimer ordered if positive will order Chest CT to rule out PE
4. Elevated Troponin likely secondary to demand, cardiology consult
5. CBC – evaluation of hemoglobin
6. CMP- Evaluate variants and assessment of renal functioning
7. Urology consult if there is no improvement with conservative treatment
References
•
Barkley, T. W. & Myers, C.M. (2020). Practice Considerations for Adult-Gerontology
Acute Care Nurse Practitioners (3rd ed.) Barkley & Associates.
•
Fulop, T. (2021, July 1). Acute Pyelonephritis. Retrieved from Medscape:
https://emedicine.medscape.com/article/245559-overview
•
Kennedy-Malone, L., Plank, L. M., & Duffy, E. G. (2019). Advanced practice nursing in
the care of older adults. Philadelphia: Davis Company.
•
The Merck Manual, 20th Edition, Merck Publisher, April 2018, ISBN-13: 978-0911910421
ISBN-10: 9780911910421
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