Laboratory For Diagnosis, Symptom And Illness Management

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Laboratory For Diagnosis, Symptom And Illness Management

Adult Wellness Check up

Must use the sample template for your soap note.

Use APA format and must include a minimum of 2 Scholarly Citations.

The Patient History, CC, HPI, Assessment, and Plan should be of your own work and individualized to your made-up patient. 

 

Student Name: Jose Angel Ortega Suarez

Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C

 

Soap Note # ____   Main Diagnosis: Type 2 Diabetes Mellitus

 

PATIENT INFORMATION

Name: JL

Age: Forty-two years

Gender at Birth:

Gender Identity: Female

Source: Patient

Allergies: None

Current Medications:

  • Tylenol (PRN)

PMH: The female patient, aged forty-two, presents a history of being constantly thirsty and hungry. She also complained of excessive urination and constantly feeling weak and exhausted. Laboratory For Diagnosis, Symptom And Illness Management

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Immunizations: She has completed all necessary immunizations, the last one being immunization against COVID-19 a year ago.

Preventive Care: Eating a healthy diet and walking once a week to keep feet

Surgical History: CS, seven years ago

Family History:

  • The patient’s mother, aged seventy, is diabetic
  • The patient’s father, aged seventy-four, has high blood pressure.
  • Sister aged thirty has no known medical problems

Social History: Patient drinks alcohol socially once in a while. She denies smoking cigarettes or any other addictive substances.

Sexual Orientation:  Straight

Nutrition History:  Patient often eats homemade meals on weekends but eats in restaurants on weekdays. Once a month, she has a family dinner at home with her parents and sister.

Subjective Data:

Chief Complaint: “I have been constantly weak and tired for the past month. I am also constantly thirsty and hungry. I have also concerned because I urinate too frequently.”

Symptom analysis/HPI:

The patient is a forty-two-year-old female. She presents with complaints of polyuria and frequent thirst and hunger. She also reports being lethargic and having episodes of dizziness.

Review of Systems (ROS)

CONSTITUTIONAL: Pt. denies losing weight. She reports episodes of general body weakness

NEUROLOGIC: Pt. reports dizziness. She denies having constant headaches

HEENT:  Pt. denies having any visual disturbances. She denies having nasal discharges or blockages. Pt. denies having throat pain or swellings in the neck region

RESPIRATORY: Pt. denies having difficulties in breathing or chest pains

CARDIOVASCULAR: Patient denies experiencing any tightness of the chest or tachycardia

GASTROINTESTINAL: Pt. denies having stomach pains, discomfort, or bloating. She denies any diarrhea or vomiting.

GENITOURINARY: Pt. reports constant urination and thirst. Laboratory For Diagnosis, Symptom And Illness Management

MUSCULOSKELETAL: Pt. denies having aches in the body muscles

SKIN: Patient denies having any discolorations or skin eruptions. She denies having any changes in the texture of her skin.

Objective Data:

VITAL SIGNS: Temp: 98.5, BP: 125/70mmHg, HT: 5’2, WT: 158lbs

GENERAL APPREARANCE: Patient is a well-groomed, obese woman with a pleasant demeanor

NEUROLOGIC: Pt. is alert and oriented to place and time

HEENT: Nasal mucosa is pink and moist with no ulcerations or discharges. Vision is 20/20 in both the left and right eye. The patient’s ears have no visible swellings or discharges. Throat has no signs of nodular swellings. The neck is supple with no tenderness or inflammations.

CARDIOVASCULAR: Pt.’s heart rate is normal, with no fluctuations, murmurs, or tachycardia

RESPIRATORY: Pt. has normal breathing sounds. No gallops or wheezes are noted

GASTROINTESTINAL: The abdomen is non-tender, with no palpable masses

MUSCULOSKELETAL: No aches or masses are noted in major muscles on palpation

INTEGUMENTARY: Patient’s skin has no discoloration or rashes.

 

ASSESSMENT:

Patient presents with complaints of being constantly weak and dizzy. She also reported that she had been urinating more frequently than usual in the past month and was constantly thirsty and hungry. A review of the body systems showed that the patient had polyuria and polyphagia. It also showed repeated episodes of dizzy spells and lethargy. A physical examination of the patient showed no abnormalities in the cardiovascular, respiratory, or gastrointestinal system.

Main Diagnosis

Type 2 diabetes mellitus without complications, whose ICD code value is E11. 9. It is a condition characterized by excessive blood sugar levels that result in the presenting symptoms, including constant thirst and hunger and frequent micturition (Zheng et al., 2018). It also causes patients to be constantly tired and experience unexplained weight loss.

Differential diagnosis

-Hyperthyroidism (ICD 10-EO3.9). The condition is marked by constant fatigue and weakness. Also, patients with the condition urinate and sweat frequently (Carpenter et al., 2019). The ailment can be ruled out by carrying out a diagnostic procedure to gauge the functionality level of the patient’s thyroid.

-Metabolic syndrome (ICD 10-E88.81). The condition is marked by frequent thirst and hunger and constant body weakness. It can be ruled out by carrying out diagnostic tests such as blood tests to determine blood cholesterol and triglycerides (Carpenter et al., 2019). The cholesterol and triglyceride levels in patients with the condition are usually abnormally high.

– Anemia (ICD 10- D64.9). The condition precipitates clinical manifestations such as body weakness and dizziness (Carpenter et al., 2019). However, it causes other symptoms absent in the patient, such as changes in the color of the skin and difficulties in breathing. Laboratory For Diagnosis, Symptom And Illness Management

PLAN:

Labs and Diagnostic Test to be ordered (if applicable)

  • – Random blood sugar: The patient’s blood will be drawn at no specific time and tested to determine the blood sugar levels (Zheng et al., 2018). A blood sugar level above 200mg/dl confirms that a patient has the ailment.
  • – Fasting blood sugar test-Patient’s blood is collected early in the morning before eating anything and tested to determine the blood sugar level (Zheng et al., 2019). If the value is higher than 126mg/l, then the patient has the condition

Pharmacological treatment:

  • The patient will be placed on an oral dose of metformin (Fortamet) tablets at 500mg Q12hrs (Zheng et al., 2018).

Non-Pharmacologic treatment:

A lifestyle modification program will be recommended to the patient to lower her basal blood sugar levels (Carpenter et al., 2019). It will include eating a healthy diet that has low sugar levels and engaging in a regular exercising program to reduce her body weight.

Education

The patient will be educated on the significance of constantly monitoring her blood sugar levels to avoid developing a medical crisis (Carpenter et al., 2019). She will also be enlightened on the significance of adhering to the prescribed treatment plan.

Follow-ups/Referrals:

The patient will be advised to visit the emergency on a follow-up visit after a month for a check-up to assess her tolerance to the prescribed medication. She will be referred to a dietitian for a recommendation of an appropriate diet plan that will help her lose weight and maintain low blood sugar levels.

 

 

 

References

Carpenter, R., DiChiacchio, T., & Barker, K. (2019). Interventions for self-management of type 2 diabetes: an integrative review. International journal of nursing sciences, 6(1), 70-91.

Zheng, Y., Ley, S. H., & Hu, F. B. (2018). Global aetiology and epidemiology of type 2 diabetes mellitus and its complications. Nature reviews endocrinology, 14(2), 88-98. Laboratory For Diagnosis, Symptom And Illness Management