. Read the following SOAP note about “J.G.” He has been having diarrhea now for over a week, and he is desperate for some relief!

2. Answer the questions on a separate Word document. Use the Documentation Guide for Acute Conditions as a guide.

3. Submit your work on Sakai under “Assignment #2”.

Objectives:

1. Identify components of system-based physical examinations.

2. Critique SOAP notes for missing history elements.

3. Identify the pathophysiology of an identified disease process and its relationship to assessment findings for individual patients.

4. Differentiate pertinent findings in a patient’s health history and physical examination.

5. Identify sources for clinical decision-making for use in the assessment of patients.

SOAP Note:

Date

09/21/17

Pt Identity

J.G., 56 y/o male, seems reliable. Prior medical records reviewed.

Chief Concern

“I’ve had diarrhea for about a week or so.”

History of Present Illness

Having 5-10 soft unformed light-brown stools per day (including overnight), which started suddenly 7 days ago. He has not had diarrhea this bad before. Has not identified a relationship between diarrhea and food or fluid intake. Some relief from Imodium and Pepto-Bismol. Also reports a 3-day history of increased hemorrhoidal bleeding during defecation w/ perianal burning and itching for about 20 minutes after each BM. Denies direct contact with anyone experiencing similar symptoms, recent travel, and dietary changes. Started taking metformin 500 mg BID 2 weeks ago. Has h/o irritable bowel syndrome, previously well-controlled on Bentyl.

Past Medical History

Adult Illnesses

HTN for “around 15 years” – controlled on lisinopril/HCTZ

Irritable bowel syndrome “since I was a teenager” – Bentyl

T2DM, diagnosed 2 weeks ago – BG stable on metformin

Sinus tachycardia for “about a year” – controlled on metoprolol

Denies CA, CAD, CVA, and HLD.

Health Maintenance

Colonoscopy was ordered last year, but not done d/t to fear of bowel prep causing incontinence.

Vaccines “up to date” per patient. Has not had hepatitis B vaccine.

Childhood Illnesses

IBS, as noted above.

Surgical History

None reported.

Family History

Uncle died at age 47, from colon cancer. Otherwise noncontributory.

Accidents/Injuries

Denies.

Hospitalizations

Denies.

Psychosocial History

Married, 3 grown children. Works as a high school science teacher w/ intermittently high stress, but has not noticed an increase recently. Denies h/o military service.

Denies smoking, alcohol, and recreational drug use.

Monogamous sexual partner denies current or prior receptive anal intercourse or rectal-oral sexual practices.

Denies recent domestic or international travel, camping/hiking, and fishing/hunting. Denies owning pets.

Allergies

NKDA. Denies environmental and food allergies.

Current Medications

Lisinopril/HCTZ 20/12.5 daily. The last dose was this morning.

Dicyclomine (Bentyl) 40 mg q6h. The last dose was this morning.

Metformin 500 mg BID. The last dose was this morning.

Metoprolol 50 mg BID. The last dose was this morning.

Acetaminophen 1000 mg PRN for “aches and pains”. Last dose 2 days ago.

Review of Systems

General: Denies weight change, fever, chills, night sweats, fatigue, weakness, and changes in appetite.

Skin: Denies rashes, ulcerations, dryness, flaking, and excessive sweating.

Pulmonary: Denies cough, dyspnea, increased sputum production, hemoptysis, snoring, and wheezing.

Cardiovascular: Denies chest pain, palpitations, orthopnea, PND, known heart murmurs, edema, intermittent claudication, leg cramps, and varicose veins.

GI: Reports diarrhea, perianal burning and itching, and bright-red blood on toilet paper, as described above. Reports history of hemorrhoids. Denies N/V, indigestion, abdominal pain or cramping, excessive flatulence, bloating, fecal incontinence, constipation, anal trauma, and dark tarry stools. The last BM was 15 minutes before the appointment, light brown, soft, and unformed.

Psych: Denies feeling depressed, nervous, or anxious.

PHYSICAL EXAM

Constitutional: Appears well-groomed, well-nourished, and well-developed. Sitting comfortably in an exam room chair. T 98.1F (oral), HR 114, RR 16, BP 118/99 (right). BMI 28.4.

Skin: Exposed skin is smooth and free of lesions, bruising, tattoos, and piercings.

Lungs/Thorax: Rate regular and unlabored. No accessory muscle use. Lung sounds clear and equal bilat. Resonant in all lung fields. Nail beds pink w/o clubbing.

Cardiovascular: Regular rate/rhythm w/o clicks, gallops, rubs, S3, S4, or murmurs. Pedal pulses 2+ bilat. Skin warm, dry. No edema.

Abdomen: Round, soft, symmetrical, w/o masses, lesions, or hernia. Bowel sounds hyperactive x4 quadrants. Resonant w/ gastric tympany. No tenderness or rigidity on light and deep palpation. No renal/aortic/iliac bruits.

Psych: Affect bright and appropriate.

1. Based on the documented health history, identify 2 “provoking factors” for diarrhea that we can rule out (e.g., sick contacts). Identify 2 “provoking factors” for diarrhea that should still be considered for J.G.

2. His medication list is incomplete. Which 2 medications are missing, and what information (besides their names) is important to document about them?

3. Based on his history and physical exam, create your patient’s problem list.  you should include at least 5 problems. Remember this should include anything “abnormal” about your patient – not just a list of medical diagnoses.

4. There is at least 1 system missing from the Physical Exam that is relevant for this acute visit. Which system is missing, and what problem(s) are you specifically looking for?

neuromuscular exam for assessment of muscle weakness due to electrolyte imbalance

5. What do you think is causing his acute diarrhea? Explain your answer. Include at least 1 peer-reviewed source.

The rise of the electric car: One of the most notable social trends affecting consumer behavior is the idea of going green. As climate change and environmental concerns increase in their seriousness and impact, consumers seek to buy green products that might help mitigate or combat the problem. In response, many companies are developing new green products—including electric cars. The first electric car actually was built in 1891, but it lost popularity when Henry Ford introduced the gas-powered Model T. Electric cars regained consumers’ interest as Toyota developed its Prius in the late 1990s. The original Prius actually was a hybrid, powered by both gas and electricity; its success prompted other companies such as Honda, General Motors (GM), Ford, and Chevrolet to innovate their own hybrid models, as well as some all-electric versions. By the early 2000s, though, all the major automakers had terminated their all-electric programs. It was not until 2006, when Tesla Motors revealed its Roadster, that a modern version of the all-electric car became a distinct and appealing possibility.

Tesla remains the gold standard for electric cars. The Model S all-electric sedan is the top-ranked ultra-luxury vehicle. Yet its high price has kept the brand from being a very widely purchased car. For example, a new Tesla Model S 75D starts at $75,700, and models with longer ranges without recharging start at $98,700.71 Even if more customers might want to purchase an all-electric car, few of them can afford a Tesla. In response, Tesla innovated a less expensive entry model, the Model 3, that starts at around $35,000.72 In parallel, other companies have released their more economical all-electric options: the Chevrolet Bolt starts at around $37,000 and offers a battery life comparable to that of the Tesla Model S.73 General Motors also recently decided to compete with Tesla directly. One of Tesla’s greatest advantages has been its over-the-air software, which automatically and regularly updates the cars’ software when they are plugged in overnight. Recognizing that it already installs OnStar Page 170 as a safety service standard on any GM vehicle, GM has found a large fleet of connected cars at its disposal already. Therefore, it plans to use OnStar as a means to compete directly with Tesla’s software.

Furthermore, GM’s latest all-electric car seeks to do more than address just the problem of climate change; it wants to help drivers overcome the problem of congestion in cities. Its all-electric E100 will cost only $14,000 before incentives; with the incentives, the paid price drops to close to $5,000.75 But it is being launched only in China, under the company’s Baojun brand. The Chinese car market is the largest in the world, and the electric car segment is the largest growing segment in China, due in part to the subsidies and incentives offered by the national and local governments. Accordingly, China already makes up 40 percent of the worldwide electric car market. The E100 has been designed specifically to meet the needs of consumers living in Chinese cities, in that it is compact, seating only two adults, and easy to maneuver in the heavily populated streets. Furthermore, its top speed is 62 miles per hour, and its battery can last for about 96 miles, and then takes only about 7.5 hours to charge. It might not be an ideal option for someone living in a rural area who needs to travel long distances, but it is perfect for a city dweller. Finally, although the car does not cost much to own, the E100 still provides some key luxuries: the interior features a digital dashboard, a seven-inch touchscreen center console, and Wi-Fi capabilities.

Launched in China by General Motors, the inexpensive Baojun electric car is designed to overcome the problems of congestion in cities. ©Imaginechina via AP Images Within the week of its announcement, more than 5,000 people had registered to buy the first 200 models of the E100, spurring the company to make another 500 cars available quickly. Although the E100 will be available only in the Guangxi region of China in the immediate term, GM plans to expand its availability throughout the country as soon as possible.

1. Discuss how specific environmental issues examined in this chapter impact the development and sale of electric cars.

2. Which market do you believe will be more successful, Tesla in the United States or GM’s E100 in China?

3. Defend your answer.

In the past, leaders could communicate and interact with employees in face-to-face settings to share their vision for the organization. This allowed them to read facial expressions and body language, respond to questions, and get a sense of how and if their messages were being received. Today, more and more organizations have staff that is working remotely and the opportunity to interact in person is not as available as it once was. Imagining that you are the leader within your organization (and perhaps you are), what communication strategies would you employ to share your vision with the staff in a work environment where everyone works remotely?

Explore some common beliefs about culture and communication while demonstrating the concepts you’ve learned about communication competence.  Consider a time someone in your circle of friends and relatives posted a remark on social media or said something to you in person that you felt was culturally insensitive. Alternately, consider a time when a celebrity you admire said something you felt was culturally insensitive.

Assuming you choose to address this, how should you communicate with this person about what they posted? What are the advantages and disadvantages of each choice? Is it possible for the original communication to be undone? Why is it important to be culturally aware and sensitive?