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NU611 Clinical Decision Making
Unit 4 Discussion
Social Determinants of Health
Instructions:
Review the SOAP note accessed through the link below.
Social Determinants SOAP NotePreview the document
Initial Post
Consider the knowledge you have gained from this week’s lecture.
Use your lecture materials to determine three priority Social Determinants of Health (SDH) to assess for in the patient represented in the SOAP note. NOTE:  Priority may refer to a strength in a SDH category necessary for the individual to attain/maintain health OR the priority may be a challenge in a SDH category identified as needing support or intervention for the individual to attain/maintain health. 
In paragraph form construct a discussion that identifies those priority SDHs using data from the objective and subjective data sets where appropriate to support your discussion.
Please be sure to validate your opinions and ideas with citations and references in APA format where appropriate.
The post and responses are valued at 20 points. Please review post and response expectations. Please review the rubric to ensure that your response meets criteria.
Estimated time to complete: 2 hours
Peer Response: Unit 4, Due Sunday by 11:59 pm CT
Social Determinants of Health
Instructions:
Construct a response to at least 2 of your peers commenting – ideally one who identified the same 3 priority SDHs that you did and one who did not.
Please be sure to validate your opinions and ideas with citations and references in APA format where appropriate.
Subjective:
CC: “I don’t go to doctors and have been having headaches and need to start taking care of myself. I bought a blood pressure cuff and have numbers but do not know what to do now.”
HPI: Two months ago, patient noticed she was getting “pounding headaches”. She went to the ER and was given Fioricet for migraines but states it has not been helping. Was told she needs to have a PCP to “further investigate and treat” these symptoms. At the time of being seen in the ER, her BP was noted to be 170/92, and she was given a onetime dose of clonidine and discharged when her symptoms subsided. Since then she has tried ibuprofen and her Fioricet to treat her headaches, but they have offered only mild relief. After seeing high blood pressure listed on her paperwork from the ED, she bought a BP cuff and started monitoring it at home. Patients log lists BP readings in the 140-160s systolic and 80-96s diastolic for the last three weeks.PMH: Headaches and recent weight gain. Denies recent illness, trauma, hospitalizations, or surgical history.
Allergies: Augmentin causes generalized rash
Medications: Fioricet 50/300/40 mg PO 1-2 caps q 4h as needed
Ibuprofen 200 mg PO as needed
Social history: Recently divorced mother of two who works at a retail store. Smokes a half a pack of cigarettes a day(1PPD X 13 years). Social drinks 1-2 times a week beer or wine; denies illicit drugs; is not sexually active. Motivated to improve her health for her children who are 10 and 15.
STAGE II HYPERTENSION 3
Family history: Mother 74, overweight, HTN, breast cancer, and DM II; father 78 had CABG in 2010, HTN, DM II; brother 40, overweight, HTN; maternal grandparents: grandmother breast cancer deceased in her 60s, grandfather Parkinson’s disease; Paternal grandparents: grandmother with DM II, grandfather deceased unknow causes.
Health Maintenance/Promotion: Smoking cessation counseling 6/4/2019; last dental exam 9 months ago, eye exam in 2010. Immunizations: states up to date, unknown years (will provide paperwork next visit). Cervical cancer screening: overdue 9/2015; Colorectal Cancer screening: 10/2035; High Blood Pressure screening: done today 6/04/2019; BRCA screening: + family history of cancer will recommend; Mammography: due to increased risk will recommend screening referral now (Monticciolo, Newell, Moy, Niell, Monsees, & Sickles, 2018). PHQ-9 depression screening: 6/4/2019. Orders placed today for genetics counselor referral and mammography referral.
ROS:
General: Denies any fever, weakness, or night sweats
Skin: Denies changes in moles, lumps or rash, changes in hair or nails.
HEENT: Headaches daily, denies dizziness, eye pain, blurriness, earaches, nasal
stuffiness, discharge, bleeding gums, sore tongue or hoarseness.
Neck: Denies swollen glands or stiffness in neck.
CV: High blood pressure, denies heart murmurs, palpitations, shortness of breath, swelling, or difficulty sleeping flat.
Lungs: Denies cough, wheezing, asthma
STAGE II HYPERTENSION 4
GI: Denies trouble swallowing, heartburn, nausea. Last BM “normal” 6/3/19 brown, not hard.
PV: Swelling to both ankles and feet after standing all day. Denies leg cramps, prior clots in veins, changes to color of fingers or toes in cold weather.
MSK: Denies muscle or joint pain, arthritis, gout, backache, or limitations to movement.
Neuro: Denies changes in mood, attention, or speech, headache, tingling, or seizures.
Psych: States some depression recently, denies SI, HI or past psychiatric diagnosis.
Objective:
PE:
Gen: 34-year-old Caucasian female, looks stated age and presently not in distress. Well groomed, clothing appears appropriate for weather and clean.
VS: T. 98.9 (oral), HR 88, R 18, BP 152/88, 5’3”, 142 pounds BMI 25
Skin: warm, dry, no open lesions visible, normal distribution of hair on scalp, nails without clubbing and pink.
HEENT: normocephalic, PERRLA, sclera white with no lesions or redness. No papilledema, retinal hemorrhages, or arterial narrowing noted. Ears equal in size bilaterally, no discharge. Buccal mucosa pink, moist, and without exudates. Gums pink without redness or swelling. Teeth intact, soft palate smooth and pink, tonsillar pillars pink +1 and symmetric. Nose inferior and middle turbinates pink, moist, no drainage noted. Frontal and maxillary sinuses nontender to palpation.
Neck: midline trachea, lobes palpable but not enlarged, thyroid isthmus midline.
CV: RRR, crisp S1 and S2, S1 noted louder at the apex than S2. No murmurs or extra sounds noted. No bruits auscultated over carotids. Carotid pulse equal bilaterally, 2+,  STAGE II HYPERTENSION 5 elastic, jugular venous pulsation disappears when upright. Apical pulse – 86 beats/minute. BP rechecked and 142/84.
Lungs: CTA, no retraction of interspaces, tactile fremitus symmetric. No adventitious sounds present.
GI: soft, non-tender, positive bowel sounds noted in all 4 quadrants. No abdominal bruits auscultated. Umbilicus is midline and recessed with no bulging. Abdomen is rounded, no guarding noted, no truncal obesity noted. PV: Extremities are warm with trace edema of lower legs bilaterally. No varicosities or stasis changes noted. No abdominal bruits. Radial, dorsalis pedis pulses are 2+ and symmetric. Capillary refill time less than 3 seconds.
MSK: Gait smooth, with equal stride. Upper and lower extremities symmetric without lesions, deformities, or swelling.
Neuro: A & O X 4, clear speech, thought process organized and appropriate.
Diagnostic Tests: Depression screening PHQ-9 score of 4 (minimal)
Assessment: 1. Stage II Hypertension (AHA, 2019)
2. Nicotine abuse
3. Headache
Plan:
1. Diagnostics: (to be done today) CBC, CMP, lipid panel, A1C, UA, ECG
Therapeutic: chlorthalidone 12.5mg PO daily, benazepril 5 mg PO daily. Take BP readings once a day and keep log, bring back on 1 month follow up. Educational: Smoking cessation, maintaining alcohol consumption to 1 drink per day when drinking, watching salt and fats in diet while increasing fruits and  STAGE II HYPERTENSION 6 vegetables, exercise 150 minutes or more/week. How to measure BP accurately and information on complications of HTN and ways to manage it at home (i.e. meditation to help reduce stress). Community resource guides on nutrition classes and exercise groups were also provided.
Consultation/Collaboration: Cardiology, ophthalmologist (Hollier, 2018)
2. Diagnostics: NA (no signs or symptoms to prompt diagnostics at this time)
Therapeutic: Declined at this time
Educational: Smoking cessation and options to help
Consultation/Collaboration: Pamphlet given for smoking cessation support group
3. Diagnostics: NA (imaging was done in the ER)
Therapeutic: Continue using Fioricet 50/300/40 mg PO 1-2 caps q 4h as needed
Educational: Stress reduction techniques
Consultation/Collaboration: none at this time, will reconsider if headaches do not
subside when blood pressure is controlled. May consider referral to neurology
(Hollier, 2018).

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