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Complete the Focused SOAP Note Template provided for the patient in the case study

  • From Health Care, Clinical Medicine
  • Due on 31 Jul, 2021 08:13:00
  • Asked On 25 Jul, 2021 05:24:59
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Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:

  • Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. Provide a review of systems.
  • Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results?
  • Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential in or out. Explain you critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
  • Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.
  • Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. Follow APA 7th edition formatting.
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[Solved] Endocrine, Metabolic, and Nutritional Disorders

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  • Submitted On 27 Jul, 2021 01:00:31
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Endocrine, Metabolic, and Nutritional Disorders Week 9 Case 3: Diabetes  HPI: Ms. Lewis is a 63 y/o female who is brought to the office today by her daughter Anna with complaints of low fasting blood sugar. She reports that her morning fasting blood sugar has been 50–75 mg/dl when she does the fingerstick. HPI: Ms. Lewis lives at home alone and can perform all ADL’s independently. She reports taking medications as prescribed. Her last Hemoglobin A1C was done a month ago and was noted 11.5%. Other known history includes COPD, Hypertension, Vitamin D Deficiency, and Hyperlipidemia, and Lupus Erythematosus. Subjective: • She denies any visual or auditory hallucinations. • She denies any suicidal thoughts or ideations. • She denies any falls, denies any pain. Current Medications: Unknown Allergies: Omeprazole PMH: COPD, Hypertension, Vitamin D Deficiency, Hyperlipidemia, and Lupus Erythematosus. Social and Substance History: Unknown tobacco, alcohol, and drug use Family History: Family history unknown Surgical History: No surgical history reported ROS: NEGATIVE Objective: NORMAL • Vital signs: 97.2, 135/82, 90, RR 18 • Ms. Lewis is is AAOX4. • She makes no unusual motor movements and demonstrates no tics. Diagnostic Tests: • CXR- No cardiopulmonary findings, (WNL) • Basic Metabolic Panel and CBC – Remarkably Normal but fasting blood glucose this morning was elevated at 226, and a low platelet level of 42. • HA1C- 11.5% 30 days ago prior to today’s visit Differential diagnosis 1. Type 2 Diabetes: Ms Lewis has a primary diagnosis of type 2 diabetes which is also known as adult-onset diabetes. This is characterized by accumulation of Cells in the muscle Leading to resistance of insulin in the liver. Individuals with this disease often cannot produce sufficient insulin to manage the blood sugar level in their body causing them to develop Hyperglycemia, polyuria, increased thirst, fatigue, and blurry vision (Georgina, 2011). Risk factors include past medical history of obesity, older age, hypertension, hyperlipidemia, and family history of diabetes (CDC, 2019). Although there is no family medical history reported, Ms Lewis has a past medical history of hypertension, hyperlipidemia and she is 65 years old which puts her a higher risk of developing adult-onset diabetes. Additionally, upon assessment, these patients blood sugar level was 226 which is consistent with the diagnosis of diabetes but it imperative to further investigate the elevated blood sugar for instance asking the patient if she noticed increased urine production, excessive thirst, unintentional weight loss and if she manages her blood pressure properly. 2. (DKA) Diabetic ketoacidosis: The primary diagnosis of DKA is usually Conclusively diagnosed based on a patient’s recent lab results specifically an elevated glucose level. Although there is no reported past medical history of diabetes, I am assum...
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