Assignment Prompt & Instructions
SEE ATTACHED DOCUMENTS FOR TEMPLATE AND INSTRUCTIONS
– 2 years ago
**files (2)**
– ## CASEANDINSTRUCTIONS.pdf
– ## FNUSOAPSTEMPLATE.docx
**## CASEANDINSTRUCTIONS.pdf**
Read the case scenario presented below and create a plan of
care using the SOAP Note Template.
Case Scenario:
A.B. is a retired 69-year-old man with a 5-year history of type 2
diabetes. Although he was diagnosed in 1997, he had symptoms
indicating hyperglycemia for 2 years before diagnosis. He had
fasting blood glucose records indicating values of 118–127 mg/dl,
which were described to him as indicative of “borderline diabetes.”
He also remembered past episodes of nocturia associated with
large pasta meals and Italian pastries. At the time of initial
diagnosis, he was advised to lose weight (“at least 10 lb.”), but no
further action was taken.
Referred by his family physician to the diabetes specialty clinic,
A.B. presents with recent weight gain, suboptimal diabetes
control, and foot pain. He has been trying to lose weight and
increase his exercise for the past 6 months without success. He
had been started on glyburide (Diabeta), 2.5 mg every morning,
but had stopped taking it because of dizziness, often
accompanied by sweating and a feeling of mild agitation, in the
late afternoon. A.B. also takes atorvastatin (Lipitor), 10 mg daily,
for hypercholesterolemia (elevated LDL cholesterol, low HDL
cholesterol, and elevated triglycerides). He has tolerated this
medication and adheres to the daily schedule.
During the past 6 months, he has also taken chromium picolinate,
gymnema sylvestre, and a “pancreas elixir” to improve his
diabetes control. He stopped these supplements when he did not
see any positive results. He does not test his blood glucose levels
at home and expresses doubt that this procedure would help him
improve his diabetes control. “What would knowing the numbers
do for me?” he asks. “The doctor already knows the sugars are
high.”
A.B. states that he has “never been sick a day in my life.” He
recently sold his business and has become very active in a variety
of volunteer organizations. He lives with his wife of 48 years and
has two married children. Although both his mother and father had
type 2 diabetes, A.B. has limited knowledge regarding diabetes
self-care management and states that he does not understand
why he has diabetes since he never eats sugar. In the past, his
wife has encouraged him to treat his diabetes with herbal
remedies and weight-loss supplements, and she frequently scans
the Internet for the latest diabetes remedies. During the past year,
A.B. has gained 22 lb. Since retiring, he has been more physically
active, playing golf once a week and gardening, but he has been
unable to lose more than 2–3 lb. He has never seen a dietitian
and has not been instructed in self-monitoring of blood glucose
(SMBG).
A.B.’s diet history reveals excessive carbohydrate intake in the
form of bread and pasta. His normal dinners consist of 2 cups of
cooked pasta with homemade sauce and three to four slices of
Italian bread. During the day, he often has “a slice or two” of
bread with butter or olive oil. He also eats eight to ten pieces of
fresh fruit per day at meals and as snacks. He prefers chicken
and fish, but it is usually served with a tomato or cream sauce
accompanied by pasta. His wife has offered to make him plain
grilled meats, but he finds them “tasteless.” He drinks 8 oz. of red
wine with dinner each evening. He stopped smoking more than 10
years ago, he reports, “when the cost of cigarettes topped a buck-
fifty.” The medical documents that A.B. brings to this appointment
indicate that his hemoglobin A1c (A1C) has never been <8%. His
blood pressure has been measured at 150/70, 148/92, and
166/88 mmHg on separate occasions during the past year at the
local senior center screening clinic. Although he was told that his
blood pressure was “up a little,” he was not aware of the need to
keep his blood pressure ≤130/80 mmHg for both cardiovascular
and renal health. A.B. has never had a foot exam as part of his
primary care exams, nor has he been instructed in preventive foot
care. However, his medical records also indicate that he has had
no surgeries or hospitalizations, his immunizations are up to date,
and, in general, he has been remarkably healthy for many years.
Physical Exam
A physical examination reveals the following:
• Weight: 178 lb;
height: 5'2"; b
Body mass index (BMI): 32.6 kg/m2
• Fasting capillary glucose: 166 mg/dl
• Blood pressure: lying, right arm 154/96 mmHg; sitting, right arm
140/90 mmHg
• Pulse: 88 bpm;
respirations 20 per minute
• Eyes: corrective lenses, pupils equal and reactive to light and
accommodation, Fundi-clear, no arteriovenous nicking, no
retinopathy
• Thyroid: nonpalpable
• Lungs: clear to auscultation
• Heart: Rate and rhythm regular, no murmurs or gallops
• Vascular assessment: no carotid bruits; femoral, popliteal, and
dorsalis pedis pulses 2+ bilaterally
• Neurological assessment: diminished vibratory sense to the
forefoot, absent ankle reflexes, monofilament (5.07 Semmes-
Weinstein) felt only above the ankle
Lab Results
Results of laboratory tests (drawn 5 days before the office visit)
are as follows:
• Glucose (fasting): 178 mg/dl (normal range: 65–109 mg/dl)
• Creatinine: 1.0 mg/dl (normal range: 0.5–1.4 mg/dl)
• Blood urea nitrogen: 18 mg/dl (normal range: 7–30 mg/dl)
• Sodium: 141 mg/dl (normal range: 135–146 mg/dl)
• Potassium: 4.3 mg/dl (normal range: 3.5–5.3 mg/dl)
• Lipid panel • Total cholesterol: 162 mg/dl (normal:
PLEASE SEE THE ATTACHED SOAP TEMPLATE AND FILL THE
EMPTY AREAS ACCORDING TO THE CASE STUDY
PROVIDED.
ALSO IN THE REVIEW OF SYSTEM AND PHYSICAL EXAM,
UPDATE TGHE SECTION ACCORDING TO THE CASE
NO PLAGIO MORE THAN 10%
REFERENCES AND CITATIONS REQUIRED
DIFFERENTIAL DIAGNOSIS WITH RATIONAL AND CITATIONS
TREATMENT MUST INCLUDE ENTIRE MEDICATION ORDER
LIKE, ROUTE FREQUENCY AND DOSAGE
**## FNUSOAPSTEMPLATE.docx**
SOAP NOTE
| | | |
| — | — | — |
| **Patient Initials** | **Pt. Encounter Number:** |
| **Date:** | **Age:** | **Sex:** |
| **Allergies:** | **Advanced Directives:** | |
| **SUBJECTIVE** |
| **CC:** |
| **HPI:**<br>**_Onset:_**<br>**_Location:_**<br>**_Duration:_**<br>**_Characteristics:_**<br>**_Aggravating Factors:_**<br>**_Relieving Factors:_**<br>**_Treatment:_** |
| **Medications:** |
| **PMH**<br>**Medication Intolerances:** none<br> <br>**Chronic Illnesses/Major traumas:** none<br> <br>**Screening Hx/Immunization Hx:**<br>**Hospitalizations/Surgeries:** denies |
| **Family History:** |
| **Social History:**<br>Denies smoke, the use of alcohol or illegal street medications. |
| **ROS** |
| **General:** Denies any fever, chills, or fatigue. Denies any change in energy level | **Cardiovascular:** Denies any chest pain, palpitations, or edema. |
| **Skin:** Denies any rash, bruises, or delayed healing of wounds. Freckles noted to bilateral arms, legs, and face. | **Respiratory:** Denies to shortness of breath at times. Denies cough. |
| **Eyes:** Denies any changes in vision. Denies the use of any corrective lenses. | **Gastrointestinal:** Denies N/V/D. No complaints of abdominal pain. |
| **Ears:** Denies any ear pain. Denies any changes in hearing. | **Genitourinary/Gynecological:** Denies any urgency, frequency, or dysuria. No history of vaginal disvharge. |
| **Nose/Mouth/Throat:** Denies any sinus issues at this time. Denies any throat pain or sinus drainage. | **Musculoskeletal:** Denies joint pain. Denies any jaw pain. |
| **Breast:** Denies lumps, no pain or changes in the skin. Admits to self-breast examinations every couple of weeks. | **Neurological:** Alert and oriented. Denies any history of seizures or weakness. |
| **Heme/Lymph/Endo:** No history of night sweats. Negative HIV status. Tolerates heat and cold appropriately. | **Psychiatric:** Alert and oriented. Denies any history of seizures or weakness. |
| **OBJECTIVE** |
| **Weight BMI** | **Temp** | **BP** |
| **Height** | **Pulse** | **Resp** |
| **General Appearance:** Well-nourished and groomed adult female. Alert and oriented, answers questions appropriately, no acute distress noted. Dressed appropriately for the environment and situation. |
| **Skin:** Skin warm, dry, and intact. No lesions or rashes noted. Appropriate color for ethnicity. |
| **HEENT:** Head is symmetrical and normocephalic without lesions. Hair is evenly distributed. Face is symmetrical, no erythema or rash noted. Eyes: PERRLA. EOMs intact. Ears: Bilateral TMs pearly grey with positive light reflex. Nose: Nasal mucosa pink, normal turbinates. No septal deviation noted. Neck: full ROM, no tracheal deviation, no masses noted, no thyromegaly or nodules noted. Throat: Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. |
| | |
| — | — |
| **Cardiovascular:** Regular rate and rhythm, no murmur, gallops, or rubs noted. Capillary refill less than 3 seconds. Pulses 3+ throughout. No edema noted. |
| **Respiratory:** Symmetrical chest wall. Respiration even and unlabored. Lungs clear to auscultation bilaterally anterior and posterior. |
| **Gastrointestinal:** Abdomen soft, non-tender, no distended, bowel sounds present. |
| **Genitourinary:** Bladder no distended, genitalia no assessed |
| **Breast:** No pain. No discharge, dimpling, or wrinkling. Color of skin is appropriate. |
| **Musculoskeletal:** Full ROM noted in all 4 extremities as patient moved around the exam room. |
| **Neurological:** Patient is alert and oriented. Speech is clear. Posture is erect. Balance stable and normal gait noted. |
| **Psychiatric:** Patient is alert and oriented. Patient answers questions appropriately. Dressed appropriately for the environment and situation. Patient maintains eye contact during examination. |
| **Lab Tests** none |
| **Special Tests** |
| **Diagnosis** |
| Primary Diagnosis:<br>Differential Diagnosis: |
| **Plan/Therapeutics** |
| Plan: <br>Further testing:<br>· Medication: <br>· Education<br>· Non-medication treatment<br>· Referral: |
| | |
| · | Follow up in 2 weeks for results. |
References
**## FNUSOAPSTEMPLATE.docx**
SOAP NOTE
| | | |
| — | — | — |
| **Patient Initials** | **Pt. Encounter Number:** |
| **Date:** | **Age:** | **Sex:** |
| **Allergies:** | **Advanced Directives:** | |
| **SUBJECTIVE** |
| **CC:** |
| **HPI:**<br>**_Onset:_**<br>**_Location:_**<br>**_Duration:_**<br>**_Characteristics:_**<br>**_Aggravating Factors:_**<br>**_Relieving Factors:_**<br>**_Treatment:_** |
| **Medications:** |
| **PMH**<br>**Medication Intolerances:** none<br> <br>**Chronic Illnesses/Major traumas:** none<br> <br>**Screening Hx/Immunization Hx:**<br>**Hospitalizations/Surgeries:** denies |
| **Family History:** |
| **Social History:**<br>Denies smoke, the use of alcohol or illegal street medications. |
| **ROS** |
| **General:** Denies any fever, chills, or fatigue. Denies any change in energy level | **Cardiovascular:** Denies any chest pain, palpitations, or edema. |
| **Skin:** Denies any rash, bruises, or delayed healing of wounds. Freckles noted to bilateral arms, legs, and face. | **Respiratory:** Denies to shortness of breath at times. Denies cough. |
| **Eyes:** Denies any changes in vision. Denies the use of any corrective lenses. | **Gastrointestinal:** Denies N/V/D. No complaints of abdominal pain. |
| **Ears:** Denies any ear pain. Denies any changes in hearing. | **Genitourinary/Gynecological:** Denies any urgency, frequency, or dysuria. No history of vaginal disvharge. |
| **Nose/Mouth/Throat:** Denies any sinus issues at this time. Denies any throat pain or sinus drainage. | **Musculoskeletal:** Denies joint pain. Denies any jaw pain. |
| **Breast:** Denies lumps, no pain or changes in the skin. Admits to self-breast examinations every couple of weeks. | **Neurological:** Alert and oriented. Denies any history of seizures or weakness. |
| **Heme/Lymph/Endo:** No history of night sweats. Negative HIV status. Tolerates heat and cold appropriately. | **Psychiatric:** Alert and oriented. Denies any history of seizures or weakness. |
| **OBJECTIVE** |
| **Weight BMI** | **Temp** | **BP** |
| **Height** | **Pulse** | **Resp** |
| **General Appearance:** Well-nourished and groomed adult female. Alert and oriented, answers questions appropriately, no acute distress noted. Dressed appropriately for the environment and situation. |
| **Skin:** Skin warm, dry, and intact. No lesions or rashes noted. Appropriate color for ethnicity. |
| **HEENT:** Head is symmetrical and normocephalic without lesions. Hair is evenly distributed. Face is symmetrical, no erythema or rash noted. Eyes: PERRLA. EOMs intact. Ears: Bilateral TMs pearly grey with positive light reflex. Nose: Nasal mucosa pink, normal turbinates. No septal deviation noted. Neck: full ROM, no tracheal deviation, no masses noted, no thyromegaly or nodules noted. Throat: Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. |
| | |
| — | — |
| **Cardiovascular:** Regular rate and rhythm, no murmur, gallops, or rubs noted. Capillary refill less than 3 seconds. Pulses 3+ throughout. No edema noted. |
| **Respiratory:** Symmetrical chest wall. Respiration even and unlabored. Lungs clear to auscultation bilaterally anterior and posterior. |
| **Gastrointestinal:** Abdomen soft, non-tender, no distended, bowel sounds present. |
| **Genitourinary:** Bladder no distended, genitalia no assessed |
| **Breast:** No pain. No discharge, dimpling, or wrinkling. Color of skin is appropriate. |
| **Musculoskeletal:** Full ROM noted in all 4 extremities as patient moved around the exam room. |
| **Neurological:** Patient is alert and oriented. Speech is clear. Posture is erect. Balance stable and normal gait noted. |
| **Psychiatric:** Patient is alert and oriented. Patient answers questions appropriately. Dressed appropriately for the environment and situation. Patient maintains eye contact during examination. |
| **Lab Tests** none |
| **Special Tests** |
| **Diagnosis** |
| Primary Diagnosis:<br>Differential Diagnosis: |
| **Plan/Therapeutics** |
| Plan: <br>Further testing:<br>· Medication: <br>· Education<br>· Non-medication treatment<br>· Referral: |
| | |
| · | Follow up in 2 weeks for results. |
References
**## CASEANDINSTRUCTIONS.pdf**
Read the case scenario presented below and create a plan of
care using the SOAP Note Template.
Case Scenario:
A.B. is a retired 69-year-old man with a 5-year history of type 2
diabetes. Although he was diagnosed in 1997, he had symptoms
indicating hyperglycemia for 2 years before diagnosis. He had
fasting blood glucose records indicating values of 118–127 mg/dl,
which were described to him as indicative of “borderline diabetes.”
He also remembered past episodes of nocturia associated with
large pasta meals and Italian pastries. At the time of initial
diagnosis, he was advised to lose weight (“at least 10 lb.”), but no
further action was taken.
Referred by his family physician to the diabetes specialty clinic,
A.B. presents with recent weight gain, suboptimal diabetes
control, and foot pain. He has been trying to lose weight and
increase his exercise for the past 6 months without success. He
had been started on glyburide (Diabeta), 2.5 mg every morning,
but had stopped taking it because of dizziness, often
accompanied by sweating and a feeling of mild agitation, in the
late afternoon. A.B. also takes atorvastatin (Lipitor), 10 mg daily,
for hypercholesterolemia (elevated LDL cholesterol, low HDL
cholesterol, and elevated triglycerides). He has tolerated this
medication and adheres to the daily schedule.
During the past 6 months, he has also taken chromium picolinate,
gymnema sylvestre, and a “pancreas elixir” to improve his
diabetes control. He stopped these supplements when he did not
see any positive results. He does not test his blood glucose levels
at home and expresses doubt that this procedure would help him
improve his diabetes control. “What would knowing the numbers
do for me?” he asks. “The doctor already knows the sugars are
high.”
A.B. states that he has “never been sick a day in my life.” He
recently sold his business and has become very active in a variety
of volunteer organizations. He lives with his wife of 48 years and
has two married children. Although both his mother and father had
type 2 diabetes, A.B. has limited knowledge regarding diabetes
self-care management and states that he does not understand
why he has diabetes since he never eats sugar. In the past, his
wife has encouraged him to treat his diabetes with herbal
remedies and weight-loss supplements, and she frequently scans
the Internet for the latest diabetes remedies. During the past year,
A.B. has gained 22 lb. Since retiring, he has been more physically
active, playing golf once a week and gardening, but he has been
unable to lose more than 2–3 lb. He has never seen a dietitian
and has not been instructed in self-monitoring of blood glucose
(SMBG).
A.B.’s diet history reveals excessive carbohydrate intake in the
form of bread and pasta. His normal dinners consist of 2 cups of
cooked pasta with homemade sauce and three to four slices of
Italian bread. During the day, he often has “a slice or two” of
bread with butter or olive oil. He also eats eight to ten pieces of
fresh fruit per day at meals and as snacks. He prefers chicken
and fish, but it is usually served with a tomato or cream sauce
accompanied by pasta. His wife has offered to make him plain
grilled meats, but he finds them “tasteless.” He drinks 8 oz. of red
wine with dinner each evening. He stopped smoking more than 10
years ago, he reports, “when the cost of cigarettes topped a buck-
fifty.” The medical documents that A.B. brings to this appointment
indicate that his hemoglobin A1c (A1C) has never been <8%. His
blood pressure has been measured at 150/70, 148/92, and
166/88 mmHg on separate occasions during the past year at the
local senior center screening clinic. Although he was told that his
blood pressure was “up a little,” he was not aware of the need to
keep his blood pressure ≤130/80 mmHg for both cardiovascular
and renal health. A.B. has never had a foot exam as part of his
primary care exams, nor has he been instructed in preventive foot
care. However, his medical records also indicate that he has had
no surgeries or hospitalizations, his immunizations are up to date,
and, in general, he has been remarkably healthy for many years.
Physical Exam
A physical examination reveals the following:
• Weight: 178 lb;
height: 5'2"; b
Body mass index (BMI): 32.6 kg/m2
• Fasting capillary glucose: 166 mg/dl
• Blood pressure: lying, right arm 154/96 mmHg; sitting, right arm
140/90 mmHg
• Pulse: 88 bpm;
respirations 20 per minute
• Eyes: corrective lenses, pupils equal and reactive to light and
accommodation, Fundi-clear, no arteriovenous nicking, no
retinopathy
• Thyroid: nonpalpable
• Lungs: clear to auscultation
• Heart: Rate and rhythm regular, no murmurs or gallops
• Vascular assessment: no carotid bruits; femoral, popliteal, and
dorsalis pedis pulses 2+ bilaterally
• Neurological assessment: diminished vibratory sense to the
forefoot, absent ankle reflexes, monofilament (5.07 Semmes-
Weinstein) felt only above the ankle
Lab Results
Results of laboratory tests (drawn 5 days before the office visit)
are as follows:
• Glucose (fasting): 178 mg/dl (normal range: 65–109 mg/dl)
• Creatinine: 1.0 mg/dl (normal range: 0.5–1.4 mg/dl)
• Blood urea nitrogen: 18 mg/dl (normal range: 7–30 mg/dl)
• Sodium: 141 mg/dl (normal range: 135–146 mg/dl)
• Potassium: 4.3 mg/dl (normal range: 3.5–5.3 mg/dl)
• Lipid panel • Total cholesterol: 162 mg/dl (normal:
PLEASE SEE THE ATTACHED SOAP TEMPLATE AND FILL THE
EMPTY AREAS ACCORDING TO THE CASE STUDY
PROVIDED.
ALSO IN THE REVIEW OF SYSTEM AND PHYSICAL EXAM,
UPDATE TGHE SECTION ACCORDING TO THE CASE
NO PLAGIO MORE THAN 10%
REFERENCES AND CITATIONS REQUIRED
DIFFERENTIAL DIAGNOSIS WITH RATIONAL AND CITATIONS
TREATMENT MUST INCLUDE ENTIRE MEDICATION ORDER
LIKE, ROUTE FREQUENCY AND DOSAGE
**## FNUSOAPSTEMPLATE.docx**
SOAP NOTE
| | | |
| — | — | — |
| **Patient Initials** | **Pt. Encounter Number:** |
| **Date:** | **Age:** | **Sex:** |
| **Allergies:** | **Advanced Directives:** | |
| **SUBJECTIVE** |
| **CC:** |
| **HPI:**<br>**_Onset:_**<br>**_Location:_**<br>**_Duration:_**<br>**_Characteristics:_**<br>**_Aggravating Factors:_**<br>**_Relieving Factors:_**<br>**_Treatment:_** |
| **Medications:** |
| **PMH**<br>**Medication Intolerances:** none<br> <br>**Chronic Illnesses/Major traumas:** none<br> <br>**Screening Hx/Immunization Hx:**<br>**Hospitalizations/Surgeries:** denies |
| **Family History:** |
| **Social History:**<br>Denies smoke, the use of alcohol or illegal street medications. |
| **ROS** |
| **General:** Denies any fever, chills, or fatigue. Denies any change in energy level | **Cardiovascular:** Denies any chest pain, palpitations, or edema. |
| **Skin:** Denies any rash, bruises, or delayed healing of wounds. Freckles noted to bilateral arms, legs, and face. | **Respiratory:** Denies to shortness of breath at times. Denies cough. |
| **Eyes:** Denies any changes in vision. Denies the use of any corrective lenses. | **Gastrointestinal:** Denies N/V/D. No complaints of abdominal pain. |
| **Ears:** Denies any ear pain. Denies any changes in hearing. | **Genitourinary/Gynecological:** Denies any urgency, frequency, or dysuria. No history of vaginal disvharge. |
| **Nose/Mouth/Throat:** Denies any sinus issues at this time. Denies any throat pain or sinus drainage. | **Musculoskeletal:** Denies joint pain. Denies any jaw pain. |
| **Breast:** Denies lumps, no pain or changes in the skin. Admits to self-breast examinations every couple of weeks. | **Neurological:** Alert and oriented. Denies any history of seizures or weakness. |
| **Heme/Lymph/Endo:** No history of night sweats. Negative HIV status. Tolerates heat and cold appropriately. | **Psychiatric:** Alert and oriented. Denies any history of seizures or weakness. |
| **OBJECTIVE** |
| **Weight BMI** | **Temp** | **BP** |
| **Height** | **Pulse** | **Resp** |
| **General Appearance:** Well-nourished and groomed adult female. Alert and oriented, answers questions appropriately, no acute distress noted. Dressed appropriately for the environment and situation. |
| **Skin:** Skin warm, dry, and intact. No lesions or rashes noted. Appropriate color for ethnicity. |
| **HEENT:** Head is symmetrical and normocephalic without lesions. Hair is evenly distributed. Face is symmetrical, no erythema or rash noted. Eyes: PERRLA. EOMs intact. Ears: Bilateral TMs pearly grey with positive light reflex. Nose: Nasal mucosa pink, normal turbinates. No septal deviation noted. Neck: full ROM, no tracheal deviation, no masses noted, no thyromegaly or nodules noted. Throat: Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. |
| | |
| — | — |
| **Cardiovascular:** Regular rate and rhythm, no murmur, gallops, or rubs noted. Capillary refill less than 3 seconds. Pulses 3+ throughout. No edema noted. |
| **Respiratory:** Symmetrical chest wall. Respiration even and unlabored. Lungs clear to auscultation bilaterally anterior and posterior. |
| **Gastrointestinal:** Abdomen soft, non-tender, no distended, bowel sounds present. |
| **Genitourinary:** Bladder no distended, genitalia no assessed |
| **Breast:** No pain. No discharge, dimpling, or wrinkling. Color of skin is appropriate. |
| **Musculoskeletal:** Full ROM noted in all 4 extremities as patient moved around the exam room. |
| **Neurological:** Patient is alert and oriented. Speech is clear. Posture is erect. Balance stable and normal gait noted. |
| **Psychiatric:** Patient is alert and oriented. Patient answers questions appropriately. Dressed appropriately for the environment and situation. Patient maintains eye contact during examination. |
| **Lab Tests** none |
| **Special Tests** |
| **Diagnosis** |
| Primary Diagnosis:<br>Differential Diagnosis: |
| **Plan/Therapeutics** |
| Plan: <br>Further testing:<br>· Medication: <br>· Education<br>· Non-medication treatment<br>· Referral: |
| | |
| · | Follow up in 2 weeks for results. |
References
**## CASEANDINSTRUCTIONS.pdf**
Read the case scenario presented below and create a plan of
care using the SOAP Note Template.
Case Scenario:
A.B. is a retired 69-year-old man with a 5-year history of type 2
diabetes. Although he was diagnosed in 1997, he had symptoms
indicating hyperglycemia for 2 years before diagnosis. He had
fasting blood glucose records indicating values of 118–127 mg/dl,
which were described to him as indicative of “borderline diabetes.”
He also remembered past episodes of nocturia associated with
large pasta meals and Italian pastries. At the time of initial
diagnosis, he was advised to lose weight (“at least 10 lb.”), but no
further action was taken.
Referred by his family physician to the diabetes specialty clinic,
A.B. presents with recent weight gain, suboptimal diabetes
control, and foot pain. He has been trying to lose weight and
increase his exercise for the past 6 months without success. He
had been started on glyburide (Diabeta), 2.5 mg every morning,
but had stopped taking it because of dizziness, often
accompanied by sweating and a feeling of mild agitation, in the
late afternoon. A.B. also takes atorvastatin (Lipitor), 10 mg daily,
for hypercholesterolemia (elevated LDL cholesterol, low HDL
cholesterol, and elevated triglycerides). He has tolerated this
medication and adheres to the daily schedule.
During the past 6 months, he has also taken chromium picolinate,
gymnema sylvestre, and a “pancreas elixir” to improve his
diabetes control. He stopped these supplements when he did not
see any positive results. He does not test his blood glucose levels
at home and expresses doubt that this procedure would help him
improve his diabetes control. “What would knowing the numbers
do for me?” he asks. “The doctor already knows the sugars are
high.”
A.B. states that he has “never been sick a day in my life.” He
recently sold his business and has become very active in a variety
of volunteer organizations. He lives with his wife of 48 years and
has two married children. Although both his mother and father had
type 2 diabetes, A.B. has limited knowledge regarding diabetes
self-care management and states that he does not understand
why he has diabetes since he never eats sugar. In the past, his
wife has encouraged him to treat his diabetes with herbal
remedies and weight-loss supplements, and she frequently scans
the Internet for the latest diabetes remedies. During the past year,
A.B. has gained 22 lb. Since retiring, he has been more physically
active, playing golf once a week and gardening, but he has been
unable to lose more than 2–3 lb. He has never seen a dietitian
and has not been instructed in self-monitoring of blood glucose
(SMBG).
A.B.’s diet history reveals excessive carbohydrate intake in the
form of bread and pasta. His normal dinners consist of 2 cups of
cooked pasta with homemade sauce and three to four slices of
Italian bread. During the day, he often has “a slice or two” of
bread with butter or olive oil. He also eats eight to ten pieces of
fresh fruit per day at meals and as snacks. He prefers chicken
and fish, but it is usually served with a tomato or cream sauce
accompanied by pasta. His wife has offered to make him plain
grilled meats, but he finds them “tasteless.” He drinks 8 oz. of red
wine with dinner each evening. He stopped smoking more than 10
years ago, he reports, “when the cost of cigarettes topped a buck-
fifty.” The medical documents that A.B. brings to this appointment
indicate that his hemoglobin A1c (A1C) has never been <8%. His
blood pressure has been measured at 150/70, 148/92, and
166/88 mmHg on separate occasions during the past year at the
local senior center screening clinic. Although he was told that his
blood pressure was “up a little,” he was not aware of the need to
keep his blood pressure ≤130/80 mmHg for both cardiovascular
and renal health. A.B. has never had a foot exam as part of his
primary care exams, nor has he been instructed in preventive foot
care. However, his medical records also indicate that he has had
no surgeries or hospitalizations, his immunizations are up to date,
and, in general, he has been remarkably healthy for many years.
Physical Exam
A physical examination reveals the following:
• Weight: 178 lb;
height: 5'2"; b
Body mass index (BMI): 32.6 kg/m2
• Fasting capillary glucose: 166 mg/dl
• Blood pressure: lying, right arm 154/96 mmHg; sitting, right arm
140/90 mmHg
• Pulse: 88 bpm;
respirations 20 per minute
• Eyes: corrective lenses, pupils equal and reactive to light and
accommodation, Fundi-clear, no arteriovenous nicking, no
retinopathy
• Thyroid: nonpalpable
• Lungs: clear to auscultation
• Heart: Rate and rhythm regular, no murmurs or gallops
• Vascular assessment: no carotid bruits; femoral, popliteal, and
dorsalis pedis pulses 2+ bilaterally
• Neurological assessment: diminished vibratory sense to the
forefoot, absent ankle reflexes, monofilament (5.07 Semmes-
Weinstein) felt only above the ankle
Lab Results
Results of laboratory tests (drawn 5 days before the office visit)
are as follows:
• Glucose (fasting): 178 mg/dl (normal range: 65–109 mg/dl)
• Creatinine: 1.0 mg/dl (normal range: 0.5–1.4 mg/dl)
• Blood urea nitrogen: 18 mg/dl (normal range: 7–30 mg/dl)
• Sodium: 141 mg/dl (normal range: 135–146 mg/dl)
• Potassium: 4.3 mg/dl (normal range: 3.5–5.3 mg/dl)
• Lipid panel • Total cholesterol: 162 mg/dl (normal:
PLEASE SEE THE ATTACHED SOAP TEMPLATE AND FILL THE
EMPTY AREAS ACCORDING TO THE CASE STUDY
PROVIDED.
ALSO IN THE REVIEW OF SYSTEM AND PHYSICAL EXAM,
UPDATE TGHE SECTION ACCORDING TO THE CASE
NO PLAGIO MORE THAN 10%
REFERENCES AND CITATIONS REQUIRED
DIFFERENTIAL DIAGNOSIS WITH RATIONAL AND CITATIONS
TREATMENT MUST INCLUDE ENTIRE MEDICATION ORDER
LIKE, ROUTE FREQUENCY AND DOSAGE
**## FNUSOAPSTEMPLATE.docx**
SOAP NOTE
| | | |
| — | — | — |
| **Patient Initials** | **Pt. Encounter Number:** |
| **Date:** | **Age:** | **Sex:** |
| **Allergies:** | **Advanced Directives:** | |
| **SUBJECTIVE** |
| **CC:** |
| **HPI:**<br>**_Onset:_**<br>**_Location:_**<br>**_Duration:_**<br>**_Characteristics:_**<br>**_Aggravating Factors:_**<br>**_Relieving Factors:_**<br>**_Treatment:_** |
| **Medications:** |
| **PMH**<br>**Medication Intolerances:** none<br> <br>**Chronic Illnesses/Major traumas:** none<br> <br>**Screening Hx/Immunization Hx:**<br>**Hospitalizations/Surgeries:** denies |
| **Family History:** |
| **Social History:**<br>Denies smoke, the use of alcohol or illegal street medications. |
| **ROS** |
| **General:** Denies any fever, chills, or fatigue. Denies any change in energy level | **Cardiovascular:** Denies any chest pain, palpitations, or edema. |
| **Skin:** Denies any rash, bruises, or delayed healing of wounds. Freckles noted to bilateral arms, legs, and face. | **Respiratory:** Denies to shortness of breath at times. Denies cough. |
| **Eyes:** Denies any changes in vision. Denies the use of any corrective lenses. | **Gastrointestinal:** Denies N/V/D. No complaints of abdominal pain. |
| **Ears:** Denies any ear pain. Denies any changes in hearing. | **Genitourinary/Gynecological:** Denies any urgency, frequency, or dysuria. No history of vaginal disvharge. |
| **Nose/Mouth/Throat:** Denies any sinus issues at this time. Denies any throat pain or sinus drainage. | **Musculoskeletal:** Denies joint pain. Denies any jaw pain. |
| **Breast:** Denies lumps, no pain or changes in the skin. Admits to self-breast examinations every couple of weeks. | **Neurological:** Alert and oriented. Denies any history of seizures or weakness. |
| **Heme/Lymph/Endo:** No history of night sweats. Negative HIV status. Tolerates heat and cold appropriately. | **Psychiatric:** Alert and oriented. Denies any history of seizures or weakness. |
| **OBJECTIVE** |
| **Weight BMI** | **Temp** | **BP** |
| **Height** | **Pulse** | **Resp** |
| **General Appearance:** Well-nourished and groomed adult female. Alert and oriented, answers questions appropriately, no acute distress noted. Dressed appropriately for the environment and situation. |
| **Skin:** Skin warm, dry, and intact. No lesions or rashes noted. Appropriate color for ethnicity. |
| **HEENT:** Head is symmetrical and normocephalic without lesions. Hair is evenly distributed. Face is symmetrical, no erythema or rash noted. Eyes: PERRLA. EOMs intact. Ears: Bilateral TMs pearly grey with positive light reflex. Nose: Nasal mucosa pink, normal turbinates. No septal deviation noted. Neck: full ROM, no tracheal deviation, no masses noted, no thyromegaly or nodules noted. Throat: Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. |
| | |
| — | — |
| **Cardiovascular:** Regular rate and rhythm, no murmur, gallops, or rubs noted. Capillary refill less than 3 seconds. Pulses 3+ throughout. No edema noted. |
| **Respiratory:** Symmetrical chest wall. Respiration even and unlabored. Lungs clear to auscultation bilaterally anterior and posterior. |
| **Gastrointestinal:** Abdomen soft, non-tender, no distended, bowel sounds present. |
| **Genitourinary:** Bladder no distended, genitalia no assessed |
| **Breast:** No pain. No discharge, dimpling, or wrinkling. Color of skin is appropriate. |
| **Musculoskeletal:** Full ROM noted in all 4 extremities as patient moved around the exam room. |
| **Neurological:** Patient is alert and oriented. Speech is clear. Posture is erect. Balance stable and normal gait noted. |
| **Psychiatric:** Patient is alert and oriented. Patient answers questions appropriately. Dressed appropriately for the environment and situation. Patient maintains eye contact during examination. |
| **Lab Tests** none |
| **Special Tests** |
| **Diagnosis** |
| Primary Diagnosis:<br>Differential Diagnosis: |
| **Plan/Therapeutics** |
| Plan: <br>Further testing:<br>· Medication: <br>· Education<br>· Non-medication treatment<br>· Referral: |
| | |
| · | Follow up in 2 weeks for results. |
References