unit 5 Soap

Name:

James Hanson

 Pt. Encounter Number:

Date: 8/29/2022

Age: 47

Sex: M

SUBJECTIVE

CC: 

“pain in the left great toe for 3 days”

HPI: 

47 yo male presents to the office c/o pain in the left great toe with associated redness and swelling. He reports that the pain started 3 days ago when it woke him from sleep during the night. He reports he had “a few too many beers with the boys” prior to the onset of the pain. Pain is located in the left great toe joint and has been constant. He describes the pain as severe, throbbing, and pulsating. He reports that the bed sheet, socks or shoes make it worse and he is unable to stand, bear weight or wear a shoe.. Position changes, elevation, rest and aspirin have been ineffective. He did get minimal relief from ice to the area. Rates the pain a 10 on a 1-10 pain scale. Denies trauma to area. He reports he has had some periodic pain mild pain in the joint previously but he has not received care for this condition previously.

Medications:
HCTZ 25mg daily for HTN x 10 years

Allergies:
NKDA

Medication Intolerances: N/A

Past Medical History:
HTN, overweight

Chronic Illnesses/Major traumas:
History of clavicle fracture after a fall while intoxicated

Hospitalizations/Surgeries:
denies

Preventive/Immunizations
: Pt reports he is UTD on all immunizations. TDaP 2018, Flu 2019, Covid # 4/2021, Covid #2 4/2021. Screened and negative for all STD and HIV 3 months ago.

Family History

Both mother and father have history of HTN. Father treated for gouty arthritis in multiple joints. Maternal and paternal grandparents with history of CVD and diabetes. 

Social History

Preferred pPt is employed as a lawyer, attended law school in Boston. Never married, lives alone and has no children. Sexually active, interested in women. Lifetime partners 20. Reports condom use 100% of the time. Denies tobacco use. Reports he drinks aprox 7-10 drinks a week, sometimes more. Uses marijuana on the weekends. CAGE score=0.

ROS

General

Denies recent change in weight but reports needing to lose some weight. Denies fever, chills, night sweats, fatigue. 

Cardiovascular

Denies chest pain, palpitations, dizziness, syncope.

Skin

Denies rashes or bruising. Reports redness and swelling of left great toe with peeling skin.

Respiratory

Denies cough, SOB

Eyes

Denies any problems with eyes, no change in vision.

Gastrointestinal

Denies abdominal pain, nausea, vomiting, constipation.

Ears

Denies ear pain or difficulty hearing.

Genitourinary/Gynecological

Denies dysuria and frequency.

Reports he is sexually active, women only. Uses condoms 100% of the time. Screened for HIV and STD’s 3 months ago, all negative.

Head/Nose/Mouth/Throat

Denies trauma to head. Denies congestion, sore throat.

Musculoskeletal

Denies muscle or joint pain with the exception of the left great toe redness, swelling and pain. ROM intact all joints with the exception of left great toe which is limited due to pain. Denies trauma to area. Denies difficulty ambulating.

Breast

N/A

Neurological

Denies syncope, dizziness. Denies numbness or tingling. Denies difficulty with speech, coordination or sensation.

Heme/Lymph/Endo

Denies swollen glands or lymph nodes. Denies bruising or bleeding. Denies being immunocompromised.

Psychiatric

Denies depression/SI. Reports some trouble sleeping especially when using alcohol.

OBJECTIVE

Weight      200lbs   BMI 28.7

Temp 98.5

BP 129/84 left, 128/82 right

Height 5’10”

Pulse 86

Resp 18
O2 sat 99%

General Appearance

Healthy appearing, appropriately dressed, adult male. Alert and oriented; answers questions appropriately.

Skin

Redness and desquamation around left first metatarsophalangeal joint.

HEENT

Head is normocephalic, atraumatic, and without tenderness, visible or palpable masses, depressions or scarring. Hair evenly distributed. Eyes:  PERRLA. Visual acuity intact. EOMs intact. Ears: Canals patent. Bilateral TMs pearly gray with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. No mass, trachea midline. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa, pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.

Cardiovascular

Chest normal in appearance, no lifts, heaves, or thrills. S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs. Capillary refills two seconds. Pedal pulses 3+ bilaterally. No edema.

Respiratory

Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.

Gastrointestinal

BS active in all the four quadrants. Abdomen soft, nontender. No hepatosplenomegaly. 

Breast

Deferred

Genitourinary

Deferred.

Musculoskeletal

Limping on left foot noted on ambulation, otherwise full ROM seen in all four extremities.

Neurological

Alert and oriented x4, speech clear. No motor deficit noted. Muscles strength 5/5 bilaterally. Sensantion intact bilaterally. Balance stable.

Psychiatric

Pt does not appear depressed or anxious. Maintains eye contact.

Lab Tests

6 Panel Drug Screen

–

·
Amphetamines-negative

·
Barbituates-negative

·
Cocaine metabolites-negative

·
THC-negative

·
Opiates-negative

·
PCP-negative

Ethanol, blood

– <5mg.dL

CBC

·
RBC 4

·
HGB 12

·
HCT 36

·
WBC 7

·
Plt 157

CMP

·
Glucose 99mg/dL

·
Calcium 9.8mg/dL

·
Sodium 138 mEq/L

·
Chloride 100mEq/L

·
BUN 19mg/dL

·
Creatinine 0.9mg/dL

·
Albumin 4.5g/dL

·
Total Protein 7.5g/dL

·
Alk Phos 40 U/L

·
ALT 20 U/L

·
AST 15 U/L

·
Bilirubin 0.5mg/dL

ESR

-5mm/hr

CRP

-0.5

ANA

< or = 1:4

RF

Negative

Serum Uric Acid

8.4mg/dL

Synovial Fluid Analysis

– positive for uric acid crystals but negative gram stain

Imaging

Left Foot Xray

Normal, no radiologic evidence of fracture or bony lesions.

Assessment

· Include at least three differential diagnoses

· Provide rationale for each differential diagnosis

· Final diagnosis

· Pathophysiology of primary and rationale for choosing as final

Plan

· Medications

· Non-pharmacological recommendations

· Diagnostic tests

· Patient education

· Culture considerations

· Health promotion

· Referrals

· Follow up

Assignment Criteria

Level III

Level II

Level I

Not Present

Criteria

1

Level III

Points: 8

0

Level II

Points: 64

Level I

Points: 48

Not Present

0 Points

Total Score

· Within Exam Mode, obtains 65 to 80 points of the required total components for virtual reality patient scenario

· Within Exam Mode, obtains between 49 to 64.9 points of the required total components for virtual reality patient scenario

· Within Exam Mode, obtains between 33 to 48.9 points of the required total components for virtual reality patient scenario

· Does not attempt in Exam Mode

· Does not meet the criteria

Criteria 1

Level III Max Points

Points: 8

Level II Max Points

Points: 6.4

Level I Max Points

Points: 4.8

Content Quality- Subjective Data

Subjective data displays complete understanding of all critical concepts of virtual reality patient case including:

· Name, age, gender

· Chief complaint

· History of present illness (HPI) that follows OLD CARTS pneumonic

· Medications

· Allergies

· Past medical history

· Past surgical history

· Pertinent family history

· Social history

· Review of Systems

· Subjective data displays understanding of critical concepts of chosen virtual reality patient case; there may be 1-2 critical concepts with errors/omissions or lack of details.

· Subjective data displays understanding of critical concepts of chosen virtual reality patient case; there may be 3-4 critical concepts with errors/omissions or lack of details.

· Does not meet criteria

Criteria 2

Not Present

0 Points

Content Quality- Objective Data

Objective data displays complete understanding of all critical concepts of chosen virtual reality patient case including:

· Vital signs

· Body systems that are pertinent to specific case

· Objective data displays understanding of critical concepts of chosen virtual reality patient case; there may be 1-2 critical concepts with errors/omissions or lack of details.

· Objective data displays understanding of critical concepts of chosen virtual reality patient case; there may be 3-4 critical concepts with errors/omissions or lack of details

Criteria 3

Level III Max Points

Points: 4

Level II Max Points

Points: 3.2

Level I Max Points

Points: 2.4

Content Quality- Assessment

Assessment displays complete understanding of all critical concepts of chosen virtual reality patient case including:

· Primary diagnosis

· Pathophysiology of primary diagnosis

· Three differential diagnoses

· Rationales for differential diagnoses

· Assessment displays understanding of critical concepts of chosen virtual reality patient case; there may be 1 critical concept with errors/omissions or lack of details.

· Assessment displays understanding of critical concepts of chosen virtual reality patient case; there may be 2 critical concepts with errors/omissions or lack of details.

Criteria 4

Content Quality- Plan of Care

Plan displays complete understanding of all critical concepts of chosen virtual reality patient case including:

· Medications

· Non-pharmacological recommendations

· Diagnostic tests

· Patient education

· Cultural considerations

· Health promotion

· Referrals

· Follow-Up

· Plan displays understanding of critical concepts of chosen virtual reality patient case; there may be 1 critical concept with errors/omissions or lack of details.

· Plan displays understanding of critical concepts of chosen virtual reality patient case; there may be 3-4 critical concepts with errors/omissions or lack of details.

Criteria 5

Level III Max Points

Points: 3

Level II Max Points

Points: 2.4

Level I Max Points

Points: 1.8

Collegiate-level academic writing

· Includes no more than three grammatical, spelling, or punctuation errors that do not interfere with the readability.

· Supports all opinions and ideas with relevant and credible reference sources of information.

· Provides three or more peer-reviewed or evidence-based practice scholarly references sources.

· All reference sources are within the past five years.

· Includes no more than four grammatical, spelling, or punctuation errors that do not interfere with the readability.

· Supports many opinions and ideas with relevant and credible sources of information.

· Provides two peer-reviewed or evidence-based practice scholarly references sources.

· All reference sources are within the past five years.

· Includes five or more grammatical, spelling, and punctuation errors that makes understanding parts of assignment difficult, but does not interfere with readability.

· Not all references utilized are relevant and/or credible sources of information.

· Provides one peer-reviewed or evidence-based practice scholarly references source.

· Reference sources are within the past five years.

Criteria 6

Citations and Formatting

● The overall order of information is clear and contributes to the meaning of the assignment. There may be 1-2 sentences, or one paragraph that is out of order, or other minor organization issues.

● Correctly citing all reference sources. One or two formatting, in-text, or reference citation errors may occur.

● Quotation marks and citations make authorship clear.

● The overall order of information is confusing in places due to 3-4 sentences, or two paragraphs that may be out of order, or other organization issues that interfere with the meaning or intent of the paper.

● Correctly citing all reference sources. 3-4 formatting, in-text, or reference citation errors may occur.

● Quotation marks and citations generally, make authorship clear.

● The overall order of information is confusing in places due to 5-6 sentences or three paragraphs that may be out of place, or other organization issues that interfere with the meaning or intent of the paper.

● Attempts to cite. 5-6 formatting, in-text, or reference citation errors may occur.

● Quotation marks and citations may be missing or incorrect.

● Authorship may be unclear in areas.

Maximum Total Points

30

24

18

Minimum Total Points

25

19

Level III Max Points

Points: 15

Level II Max Points

Points: 12

Level I Max Points

Points:9

Presentation of subjective data displays complete understanding of all critical concepts of chosen virtual reality patient case including:

· Name, age, gender
· Chief complaint
· History of present illness (HPI) that follows OLD CARTS pneumonic
· Medications
· Allergies
· Past medical history
· Past surgical history
· Pertinent family history
· Social history
· Review of Systems

· Presentation of subjective data displays understanding of all critical concepts of chosen virtual reality patient case; there may be 1-2 critical concepts with errors/omissions or lack of details.

· Presentation of subjective data displays understanding of all critical concepts of chosen virtual reality patient case; there may be 3-4 critical concepts with errors/omissions or lack of details.

Presentation of objective data displays complete understanding of all critical concepts of chosen virtual reality patient case including:

· Vital signs
· Body systems that are pertinent to specific case

· Presentation of objective data displays understanding of all critical concepts of chosen virtual reality patient case; there may be 1-2 critical concepts with errors/omissions or lack of details.

· Presentation of objective data displays understanding of all critical concepts of chosen virtual reality patient case; there may be 3-4 critical concepts with errors/omissions or lack of details.

Presentation of assessment displays complete understanding of all critical concepts of chosen virtual reality patient case including:

· Primary diagnosis
· Pathophysiology of primary diagnosis
· Three differential diagnoses
· Rationales for differential diagnoses

· Presentation of assessment displays understanding of all critical concepts of chosen virtual reality patient case; there may be one critical concept with errors/omissions or lack of details.

· Presentation of assessment displays understanding of all critical concepts of chosen virtual reality patient case; there may be two critical concepts with errors/omissions or lack of details.

Presentation of plan displays complete understanding of all critical concepts of chosen virtual reality patient case including:

· Medications

· Non-pharmacological management

· Diagnostic tests
· Patient education
· Cultural considerations
· Health promotion
· Referrals
· Follow-Up

· Presentation of plan displays understanding of all critical concepts of chosen virtual reality patient case; there may be one critical concept with errors/omissions or lack of details.

· Presentation of plan displays understanding of all critical concepts of chosen virtual reality patient case; there may be 3-4 critical concepts with errors/omissions or lack of details.s

Quality of Oral Presentation

· Presentation demonstrated thorough organization and delivery.

· All ideas were stated in a clear and logical manner.

· Presentation was on topic and relevant.

· Presentation time no longer than 5 minutes

· Presentation was organized and well spoken.

· All ideas were stated in a clear and logical manner.
· Presentation was on topic and relevant.

· Presentation >5 minutes

· Presentation needed more details or content inconclusive.

· Presentation >5 minutes

75

60

45

61

46