To prepare:<\/p>\n
Review this week\u2019s Learning Resources, including the Focused SOAP Note Template.
\nSelect a patient who you saw at your practicum site during the last 3 weeks. With this patient in mind, consider the following:
\nSubjective: What details did the patient provide regarding his or her personal and medical history?
\nObjective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities and psychosocial issues.
\nAssessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 code for the diagnosis. What was your primary diagnosis and why?
\nPlan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
\nReflection notes: What was your \u201caha\u201d moment? What would you do differently in a similar patient evaluation? Patient to use 67 years black male with High blood pressure, Diabetes Type 2 on insulin. Live alone and has home health<\/p>\n
Weight 258 Height 5\u20194
\nDiagnosis :
\nType 2 diabetes mellitus with diabetic polyneuropathy
\nHypertensive heart disease with heart failure<\/p>\n
Chronic diastolic (congestive) heart failure<\/p>\n
Bilateral primary osteoarthritis of knee<\/p>\n
Type 2 diabetes mellitus with hyperglycemia<\/p>\n
Type 2 diabetes mellitus with other specified complication<\/p>\n
Other hyperlipidemia<\/p>\n
Morbid (severe) obesity due to excess calories<\/p>\n
Body mass index [BMI] 45.0-49.9, adult<\/p>\n
Long term (current) use of insulin<\/p>\n
Long term (current) use of aspirin<\/p>\n
Medications
\nTresiba FlexTouch Subcutaneous 100 UNIT\/ML 40u Tresiba FlexTouch Subcutaneous 100 UNIT\/ML 40 units
\ndaily. Take AM subcutaneous(SQ)if > 200mg\/dl consistently,
\nIf you have a piece of Chess Pie with a meal give patient 15 units of Novolog (C)
\nNovoLOG FlexPen Subcutaneous 100 UNIT\/ML 15 units Decrease Novolog (orange pen) to 15 units before
\nmeals…If you are having a small meal take only 10 units daily. (C)
\nMeloxicam Oral 7.5 MG 1 Tab(s) Daily\/By mouth
\nFarxiga Oral 10 MG 1 Tab(s) Daily\/By mouth
\nOzempic (0.25 or 0.5 MG\/DOSE) Subcutaneous 2 MG\/1.5ML 2 once weekly till sample pen completed then
\nstart ozempic 1mg sub q weekly
\nCholecalciferol Oral 1.25 MG (50000 UT) 1 Tab(s) Daily\/By mouth
\namLODIPine Besylate Oral 10 MG 1 Tab(s) Daily By mouth
\nAspirin Oral 81 MG 1 Tab(s) Daily By mouth
\nCarvedilol Oral 12.5 MG 1 Tab(s) Twice daily. By mouth
\nFurosemide Oral 40 MG 1 Tab(s) Twice daily. By mouth
\nLosartan Potassium-HCTZ Oral 100-25 MG 1 Tab(s) Daily By mouth
\nPotassium 20MG\/By mouth\/1(tab) Twice daily
\nCelecoxib Oral 200 MG 1 Cap(s) Daily By mouth<\/p>\n
________________________<\/p>\n
Subjective<\/p>\n
The patient is a 67-year-old black male with a chief complaint of fatigue and shortness of breath.
\nHe has a history of type 2 diabetes mellitus, hypertension, and heart failure.
\nHe is currently taking insulin, lisinopril, hydrochlorothiazide, and carvedilol.
\nHe is a retired construction worker and lives alone.
\nHe has no significant family history.
\nObjective<\/p>\n
Vital signs: BP 140\/90 mmHg, HR 80 beats\/min, RR 20 breaths\/min, SpO2 95% on room air
\nWeight: 258 lbs, Height: 5’4″
\nBMI: 47.5
\nGeneral: Well-developed, well-nourished male in no acute distress
\nHEENT: Pupils equal, round, and reactive to light; Sclerae anicteric; Neck veins flat
\nLungs: Clear to auscultation bilaterally
\nHeart: Regular rate and rhythm, no murmurs, rubs, or gallops
\nAbdomen: Soft, non-tender, non-distended
\nExtremities: No edema
\nAssessment<\/p>\n
Type 2 diabetes mellitus with diabetic polyneuropathy
\nHypertension with heart failure
\nBilateral primary osteoarthritis of the knee
\nHyperlipidemia
\nObesity
\nLong-term use of insulin
\nLong-term use of aspirin
\nPlan<\/p>\n
Continue current medications
\nStart metformin 500 mg twice daily
\nStart lifestyle modification program (diet, exercise, weight loss)
\nRefer to cardiologist for evaluation of heart failure
\nRefer to physical therapist for evaluation of osteoarthritis
\nMonitor blood pressure, blood sugar, and lipid levels
\nSchedule follow-up appointment in 1 month
\nReflection notes<\/p>\n
My \u201caha\u201d moment was when I realized that the patient\u2019s fatigue and shortness of breath were likely due to his underlying medical conditions.
\nI would do differently in a similar patient evaluation by spending more time discussing the patient\u2019s lifestyle and risk factors. I would also make sure to refer the patient to a dietitian and a physical therapist.<\/p>\n","protected":false},"excerpt":{"rendered":"
To prepare: Review this week\u2019s Learning Resources, including the Focused SOAP Note Template. Select a patient who you saw at your practicum site during the last 3 weeks. With this patient in mind, consider the following: Subjective: What details did the patient provide regarding his or her personal and medical history? Objective: What observations did […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[210,215,212,220,219,209,222,213,211,214,45,218,216,221,208,217],"tags":[232,229,230,224,228,236,233,235,226,234,225,227,223,231],"class_list":["post-766","post","type-post","status-publish","format-standard","hentry","category-1-assignment-help-online-service-for-students-in-the-usa","category-ai-plagiarism-free-essay-writing-tool","category-australian-best-tutors","category-best-trans-tutors","category-buy-essay-uk","category-can-someone-write-my-assignment-for-me","category-cheap-dissertation-writer","category-do-my-essay-assignment","category-help-me-write-my-dissertation","category-help-with-writing-an-essay","category-homework-for-you","category-help-write-my-paper-ai-free","category-online-essay-writers","category-phd-essays","category-write-my-assignment-help-for-college-students","category-write-my-essay-for-me","tag-apa-citation-format-assignment","tag-assignment-help-by-uks-no-1-writing-service","tag-assignment-writers-australia-college-student","tag-assignment-writers-canada-university-cost","tag-assignment-writers-china-english-free-ai","tag-buy-essay-usa","tag-help-write-a-page-assignment","tag-i-need-someone-to-do-my-assignment-within-hours","tag-in-page-paper-write-an-essay","tag-need-to-write-an-essay","tag-professional-assignment-writers-usa","tag-uae-1-cheap-assignment-writing-service","tag-write-a-word-essay","tag-write-pages"],"_links":{"self":[{"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/posts\/766","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/comments?post=766"}],"version-history":[{"count":0,"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/posts\/766\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/media?parent=766"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/categories?post=766"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/tags?post=766"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}