NR 601 Wk 6 SOAP NOTE Mrs S Case

NR 601 Wk 6 SOAP NOTE Mrs S Case

NR 601 Wk 6 SOAP NOTE Mrs S Case

Patient Information:

Ms. S. age 62 Black Female

S.

CC: Unable to lose weight after changing eating habits and increasing activity.  Reports extreme thirst during exercise and increased urination throughout the day

HPI:

Onset: last 3 months

Location: no specific location

Duration: throughout the day

Characteristics: Increased thirst, hunger and frequent urination

Aggravating Factors: Need more fluids with exercise

Relieving Factors: none

Treatment: None

Current Medications: None

Allergies: None reported

PMHx: No report given

Soc Hx:  No reported hx of tobacco, no ETOH, No illicit drug use.

Fam Hx: No family history given

ROS:

HEENT: Are you having any blurred vision or changes in visual acuity? Are there any changes in your hearing? Any nasal congestion or drainage and are you experiencing a dry mouth at all? NR 601 Wk 6 SOAP NOTE Mrs S Case

 

Skin: Have you noticed if your skin is dry or itchy?

           

Cardiovascular: Have you had any chest pain, difficulty in breathing, or heart palpitations?

 

Respiratory: Do you have a dry or wet cough? Are you feeling short of breath?

 

Gastrointestinal: Have you had any abdomen distention or pain?

 

Genitourinary: How many pregnancies and have you had gestational diabetes with any of them?

ALLERGIES:  No history of asthma, hives, eczema or rhinitis.

O.

Physical exam:

General: obese female in not acute distress, blood pressure 145/90, heart rate 100, respirations 20 height 5’1”; weight 210 pounds

HEENT: unremarkable NR 601 Wk 6 SOAP NOTE Mrs S Case

CV: S1 and S2 RRR without murmurs or rubs

Lungs: Clear to auscultation

Abdomen– soft, round, nontender with positive bowel sounds present; no organomegaly; no abdominal bruits

NR 601 Wk 6 SOAP NOTE -Mrs S Case

Diagnostic results:

Labwork:

CBC: normal

UA: 2+ glucose; 1+ protein; negative for ketones

CMP: BUN/Creat. elevated; Glucose is 300 mg/dL

Hemoglobin A1c: 12%

Thyroid panel: normal

LFTs: normal

Cholesterol: total cholesterol (206), LDL elevated; HDL is low

EKG: normal

A.

Differential Diagnoses

Non-Insulin dependent diabetes mellitus ICD-10CM-Code E11.9 NIDDM is an ailment involving hyperglycemia and insulin resistance and predominantly occurs after the age of 50 years.  Hyperglycemia is a blood glucose reading above 100 mg/dl.  The patient will generally present with fatigue, weight loss, and fasting blood glucose of <200 (Reinehr, 2013).  Ms. S. has polydipsia, polyuria, fatigue, and polyphagia. The one symptom she is not reporting is weight loss, this could contribute to diet and or that she is not in ketoacidosis and has not started to burn off excess calories. NR 601 Wk 6 SOAP NOTE Mrs S Case

Insulin dependent diabetes mellitus ICD-10CM Code E10.9 is a chronic disorder characterized by the pancreas not producing enough insulin.  In this condition, glucose needs insulin to enter in the cells and be used for energy. If cells cannot use glucose the blood glucose levels in become extremely high. Symptoms associated with IDDM is excessive eating and drinking, weight loss, frequent urination throughout the day, lethargy, fatigue, tachycardia, and kussmaul breathing (Reinehr, 2013).

As indicated above Ms. S is having symptoms of DM but to be certain the following test would need to be completed; BUN/Creatine, A1C, Fasting blood glucose, and an UA to see if ketones are in urine After labs and symptoms are assessed a diagnosis for insulin dependent or non-insulin dependent diabetes should be made. NR 601 Wk 6 SOAP NOTE Mrs S Case

Metabolic Syndrome ICD-10CM- Code: E88.81 is a group of risk factors thought to be linked to insulin resistance.  It can occur in patients with normal glucose tolerance, prediabetes, and diabetes. Metabolic. Symptoms of metabolic syndrome include abdominal obesity, an elevated triglyceride level, Low level of HDL cholesterol, elevated blood pressure and fasting glucose of < 100 mg/dl (Ferri, 2017)  Ms. S. reports she is trying to lose weight which indicates she is overweight, this is a symptom of metabolic syndrome in addition to abdominal girth > 37 in male and > 31 in females, elevated blood glucose, elevated blood pressure.  Because I am not sure of vitals or blood glucose I would rule this out as being the less likely diagnosis.

NR 601 Wk 6 SOAP NOTE Mrs S Case

Labs and Diagnostics:

1. Repeat CBC, UA, CMP, Fasting blood glucose, in two weeks (Esherick, 2016)
2. Microalbuminuria stat (Esherick, 2016)
3. Screen for diabetic retinopathy(Esherick, 2016)
4. Screen for Cardiovascular disease (Esherick, 2016)
5. Diabetic Neuropathy(Esherick, 2016)

Rx:

1. Metformin Sig: 500mg PO BID Disp: 60 tablets No refills
2. Hydrochlorothiazide Sig: 12.5 mg Po QD Disp: 30 tablets No refills

Education:

NR 601 Wk 6 SOAP NOTE Mrs S Case

1. Check blood glucose by finger stick 3 times a week (Esherick, 2016)
2. Keep diary of blood glucose checks (Esherick, 2016)
3. Inspect bottom of feet daily with a mirror to look for skin tears, cracks or sores and report to primary care any concerns (Esherick, 2016)
4. Do not cut your own toenails (Esherick, 2016).
5. Do Not skip or stop taking Metformin as this will increase blood glucose levels, symptoms such as diarrhea is known to occur if it becomes intolerable call your primary care provider (Hostalek, Gwilt, & Hildermann, 2015).
6. Consider wearing medical alert bracelet for diabetes (Ferri, 2017).
7. Healthy diabetic eating includes (The Diabetic Exchange List, 2017)

• Limiting foods that are high in sugar
• Eating smaller portions, spread out over the day
• Being careful about when and how many carbohydrates you eat
• Eating a variety of whole-grain foods, fruits and vegetables every day
• Eating less fat
• Limiting your use of alcohol

Referral/Consults:

NR 601 Wk 6 SOAP NOTE Mrs S Case

1. Consult with podiatry for foot care (Ferri, 2017)
2. Consult with Ophthalmology for diabetic retinopathy (Ferri, 2017)
3. Diabetic education course to help manage disease (Ferri, 2017) (At the Veterans Medical Centers this is offered to all Veterans who are diagnosed with diabetes and can be retaken at any time and is free to Veterans)

NR 601 Wk 6 SOAP NOTE Mrs S Case

Follow up:

1. Return visit in 2 weeks for recheck of blood work and symptom management.
2. If diabetes cannot be controlled with oral medication a consult for Endocrinologist will need to be considered (Ferri, 2017).

NR 601 Wk 6 SOAP NOTE Mrs S Case References

Esherick, J. (2016). Tarascon Primary Care Pocketbook (4th ed.). Burlington , MA: Jones & Bartlett.

Ferri, F. (2017). Ferri’s clinical advisor 2017. Philiadelphia, PA: Elsevier.

Hostalek, U., Gwilt, M., & Hildermann, S. (2015, Juen). Therpeutic use of metformin in prediabetes and diabetes prevention. National Library of Medicine National Institute of Health, 75(10), 1071-94.

The Diabetic Exchange List. (2017). Retrieved April 6, 2017, from American Diabetes Association: http://glycemic.com/DiabeticExchange/The%20Diabetic%20Exchange%20List.pdf