Mrs G, a 55 year old Hispanic female, presents to the office for her annual exam. She reports that lately she has been very fatigued and just does not seem to have any energy. This has been occurring for 3 months. She is also gaining weight since menopause last year. She joined a gym and forces herself to go twice a week, where she walks on the treadmill at least 30 minutes but she has not lost any weight, in fact she has gained 3 pounds. She doesn’t understand what she is doing wrong. She states that exercise seems to make her even more hungry and thirsty, which is not helping her weight loss. She wants get a complete physical and to discuss why she is so tired and get some weight loss advice. She also states she thinks her bladder has fallen because she has to go to the bathroom more often, recently she is waking up twice a night to urinate and seems to be urinating more frequently during the day. This has been occurring for about 3 months too. This is irritating to her, but she is able to fall immediately back to sleep.
Current medications: Tylenol 500 mg 2 tabs daily for knee pain. Daily multivitamin
PMH: Has left knee arthritis. Had chick pox and mumps as a child. Vaccinations up to date.
GYN hx: G2 P1. 1 SAB, 1 living child, full term, wt 9lbs 2 oz. LMP 15months ago. No history of abnormal Pap smear.
FH: parents alive, well, child alive, well. No siblings. Mother has HTN and father has high cholesterol.
SH: works from home part time as a planning coordinator. Married. No tobacco history, 1-2 glasses wine on weekends. No illicit drug use
Allergies: NKDA, allergic to cats and pollen. No latex allergy
Vital signs: BP 129/80; pulse 76, regular; respiration 16, regular
Height 5’2.5”, weight 185 pounds
General: obese female in no acute distress. Alert, oriented and cooperative.
Skin: warm dry and intact. No lesions noted
HEENT: head normocephalic. Hair thick and distribution throughout scalp. Eyes without exudate, sclera white. Wears contacts. Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender. Nares patent without exudate. Oropharynx moist without erythema. Teeth in good repair, no cavities noted. Neck supple. Anterior cervical lymph nontender to palpation. No lymphadenopathy. Thyroid midline, small and firm without palpable masses.
CV: S1 and S2 RRR without murmurs or rubs
Lungs: Clear to auscultation bilaterally, respirations unlabored.
Abdomen- soft, round, nontender with positive bowel sounds present; no organomegaly; no abdominal bruits. No CVAT.
Labwork:
CBC: WBC 6,000/mm3 Hgb 12.5 gm/dl Hct 41% RBC 4.6 million MCV 88 fl MCHC 34 g/dl RDW 13.8%
UA: pH 5, SpGr 1.013, Leukocyte esterase negative, nitrites negative, 1+ glucose; small protein; negative for ketones
CMP:
Sodium 139
Potassium 4.3
Chloride 100
CO2 29
Glucose 126
BUN 12
Creatinine 0.7
GFR est non-AA 94 mL/min/1.73
GFR est AA 101 mL/min/1.73
Calcium 9.5
Total protein 7.6
Bilirubin, total 0.6
Alkaline phosphatase 72
AST 25
ALT 29
Anion gap 8.10
Bun/Creat 17.7
Hemoglobin A1C: 6.9 %
TSH: 2.35, Free T 4 0.8 ng/dL
Cholesterol: TC 230 mg/dl, LDL 144 mg/dl; VLDL 36 mg/dl; HDL 38mg/dl, Triglycerides 232
EKG: normal sinus rhythm
Use the categories below to create section headings for your paper. Review the APA Manual for paper format instructions.
Introduction: briefly discuss the purpose of this paper.
Assessment: review the provided case study information.
Identify the primary, secondary and differential diagnoses for the patient. Use the 601 SOAP note format as a guide to develop your diagnoses.
Each diagnosis will include the following information:
1. ICD 10 code.
2. A brief pathophysiology statement which his no longer that 2 sentences, paraphrased and includes common signs and symptoms of the diagnosis.
3. The patient’s pertinent positive and negative findings, including a brief 1-2 sentence statement which links the subjective and objective findings (including lab data and interpretation).
4. A rationale statement which summarizes why the diagnosis was chosen.
5. Do not include quotes, paraphrase all scholarly information and provide an intext citation to your scholarly reference. Use the Reference Guidelines document for information on scholarly references.
Plan (there are five (5) sections to the management plan)
1. Diagnostics. List all labs and diagnostic test you would like to order. Each test includes a rationale statement following the listed lab which includes the diagnosis for the test, the purpose of the test and how the test results will contribute to your management plan. Each rationale statement is cited.
2. Medications: Each medication is listed in prescription format. Each prescribed and OTC medication is linked to a specific diagnosis and includes a paraphrased EBP rationale for prescribing.
3. Education: section includes personalized detailed education on all five (5) subcategories: diagnosis, each medication purpose and side effects, diet, personalized appropriate exercise recommendations and warning sign for diagnosis and medications if applicable. All education steps are linked to a diagnosis, paraphrased, and include a paraphrased EBP rationale. Review the NR601 SOAP note guideline for more detailed information.
4. Referrals: any recommended referrals are appropriate to the patient diagnosis and current condition, is linked to a specific diagnosis and includes a paraphrased EBP rationale with in text citation.
5. Follow up: Follow up includes a specific time, not a time range, to return to PCP office for next scheduled appointment. Includes EBP rationale with in text citation.
Medication costs: in this section students will research the costs of all prescribed and OTC monthly medications. Students may use Good Rx, Epocrates or another resource (can use local pharmacy websites) which provides medication costs. Students will list each medication, the monthly cost of the medication and the reference source. Students will calculate the monthly cost of the case study patient’s prescribed and OTC medications and provide the total costs of the month’s medications. Reflect on the monthly cost of the medications prescribed. Discuss if prescriptions were adjusted due to cost. Discuss if will you use medication pricing resources in future practice.
SOAP note: A focused SOAP note, written on a separate page, follows the assignment. The SOAP note is written following the provided SOAP note format.
• The subjective section is organized to follow the SOAP note format. The ROS is focused, only pertinent body systems are included. Only provided information is included in the ROS. No additional data is added.
• The objective section is maintained as written, no additional information is added.
• The assessment section includes only the diagnoses and ICD 10 codes. Diagnosed are labeled as primary, secondary or differential diagnoses. Rationale is not included in the SOAP note.
• The plan includes 5 sections. Rationale is not included in the SOAP note.