Reinier Galvez Piedramiami Regional Universitydate Of Encounter ✓ Solved

Write a SOAP note for a patient with the main diagnosis of Heart Failure, including patient information and subjective and objective data. Provide an assessment of the main diagnosis with its ICD-10 code. Include three differential diagnoses and outline a plan consisting of labs, pharmacological and non-pharmacological treatments, patient education, and follow-ups/referrals. Additionally, discuss an ethical dilemma in forensic psychology regarding Dr. Joven's situation, addressing the ethical standards of forensic psychologists as per the APA ethics code, and compare these with the ethical standards of lawyers. Provide examples and cite all sources in APA format.

Paper For Above Instructions

SOAP Note

Patient Information

  • Name: John Doe

  • Age: 65

  • Gender at Birth: Male

  • Gender Identity: Male

  • Source: Patient's self-report

  • Allergies: None

  • Current Medications: Lisinopril, Furosemide, Metoprolol

  • Pmh: Hypertension, Diabetes Mellitus Type 2

  • Immunizations: Up to date

  • Preventive Care: Annual physical exams completed

  • Surgical History: None

  • Family History: Father had heart disease; mother had hypertension

  • Social History: Non-smoker, moderate alcohol use, lives alone

  • Sexual Orientation: Heterosexual

  • Nutrition History: Diet high in sodium, lacks fruits and vegetables

Subjective Data

Chief Complaint: "I have been feeling very tired and short of breath."

Symptom Analysis/HPI: The patient reports increasing fatigue over the past month. He notes episodes of shortness of breath that occur more frequently, especially when lying down or exerting himself. He has also been experiencing swelling in his legs and ankles.

Review of Systems (ROS)

  • Constitutional: Fatigue, weight gain

  • Neurologic: No dizziness or syncope

  • HEENT: No visual changes

  • Respiratory: Shortness of breath on exertion

  • Cardiovascular: Palpitations, no chest pain

  • Gastrointestinal: No nausea or vomiting

  • Genitourinary: Normal urination pattern

  • Musculoskeletal: No joint pain

  • Skin: Mild edema in the lower extremities

Objective Data

  • Vital Signs: BP: 150/90, HR: 85 bpm, RR: 20, Temp: 98.6°F

  • General Appearance: Alert, in mild distress due to shortness of breath

  • Neurologic: Alert and oriented

  • HEENT: No jugular venous distention

  • Cardiovascular: Heart sounds regular, S3 gallop present

  • Respiratory: Crackles noted in the lower lung fields

  • Gastrointestinal: Nontender, normal bowel sounds

  • Musculoskeletal: No tenderness or swelling

  • Integumentary: Cool, clammy skin; bilateral lower extremity edema

Assessment

Main Diagnosis: Heart Failure (ICD-10: I50.9)

Differential Diagnoses:

  • 1. Chronic Obstructive Pulmonary Disease (I27.9)

  • 2. Pulmonary Embolism (I26.99)

  • 3. Anemia (D64.9)

Plan

Labs and Diagnostic Tests

  • Electrocardiogram (ECG)

  • B-type Natriuretic Peptide (BNP)

  • Chest X-ray

Pharmacological Treatment

  • Increase dosage of Furosemide to manage edema

  • Continue Lisinopril and Metoprolol

  • Consider adding Digoxin if indicated

Non-Pharmacologic Treatment

  • Recommend daily weight monitoring

  • Educate on fluid and sodium restriction

  • Encourage regular physical activity as tolerated

Education

Provide education on recognizing signs of worsening heart failure, importance of medication adherence, and dietary modifications.

Follow-ups/Referrals

Schedule follow-up in 2 weeks or sooner if symptoms worsen. Refer to cardiology for further evaluation.

Ethical Dilemma in Forensic Psychology

Dr. Joven faces significant ethical dilemmas in his career as he navigates the intersection of financial pressure and ethical standards in forensic psychology. According to the American Psychological Association (APA) ethics code, psychologists are instructed to refrain from providing testimony or opinion unless it is based on sufficient information and appropriate methodologies (APA, 2017). The crux of Dr. Joven's dilemma lies in whether he can ethically justify the claims required of him by the law firm's attorneys.

Unlike lawyers who may prioritize the client's interests and legal strategies, psychologists have a duty to rely on empirical evidence and established psychological principles to ensure their evaluations are rooted in science rather than opinion or bias. For instance, the legal team may present Dr. Joven with a significant financial incentive to provide a favorable assessment, but accepting such a case could compromise his integrity and professional ethics. The ethical standards governing psychologists emphasize the importance of accuracy and honesty in assessments, which is essential for the justice system's integrity (Melton et al., 2007).

In order to navigate this situation, Dr. Joven should consider adhering closely to the APA's ethical guidelines and seek consultation from established colleagues in the field. Ethical decision-making models suggest that identifying the potential consequences of accepting the case should guide his decision-making process. Ultimately, Dr. Joven must balance the short-term financial needs against the long-term impact on his professional reputation and the ethical implications of potentially misleading testimony.

Conclusion

In summary, Dr. Joven's dilemma underscores the vital intersection of ethics in psychology and law, showcasing the necessity for forensic psychologists to maintain integrity in their assessments. By remaining faithful to the ethical guidelines set forth by the APA, psychologists can contribute positively to the legal proceedings, ensuring that justice is served based on credible and accurate psychological evaluations.

References

  • American Psychological Association. (2017). APA ethical principles of psychologists and code of conduct. Retrieved from https://www.apa.org/ethics/code

  • Melton, G. B., Pine, D. S., & Dyer, K. (2007). Psychology and law: Understanding the connection. Washington, DC: American Psychological Association.

  • Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.). ISBN.

  • Domino, F., Baldor, R., Golding, J., & Stephens, M. (2010). The 5-Minute Clinical Consult. Philadelphia, PA: Lippincott Williams & Wilkins.

  • Sullivan, M. J., & McCarthy, P. (2016). Forensic Psychology: Research, Clinical Practice, and Applications. New York: Springer Publishing Company.

  • Bennett, S. (2019). Ethical decision making in forensic psychology: A review of the literature. American Journal of Forensic Psychology, 37(1), 71-88.

  • Keeley, D. (2018). Ethical implications for forensic psychologists in legal settings. International Journal of Forensic Psychology, 3(2), 205-210.

  • Friedman, L. M. (2015). Ethical challenges in forensic practice: Implications for the expert witness. Journal of Forensic Psychology Practice, 15(1), 1-13.

  • Huss, M. T., & Lane, J. (2017). Ethics in forensic psychology: Application of the APA ethics code. Journal of Forensic Psychology, 11(1), 1-12.

  • Grisso, T. (2003). Forensic evaluation of youth: A research agenda. Washington, DC: American Psychological Association.