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.

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

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.

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 sciences6(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 endocrinology14(2), 88-98.

 

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Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

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

 

Soap Note # ____ Main Diagnosis: Z00.01-Annual Wellness Check up

PATIENT INFORMATION

Name S.N.

Age: 55 yrs

Gender at Birth: Male

Gender Identity: Male

Source: Patient

Allergies: Denies food, environmental, or drug allergy

Current Medications: Denies use of medications. Takes no herbal medicines or supplement

medications.

PMH: He has no history of hospitalizations. Denies chronic illnesses such as cancer, HTN,

psychiatric diseases, asthma, or diabetes.

Immunizations: COVID 19 vaccine on 10/12/2021. He received the influenza vaccine on

5/2021. Tdap booster was given in 2010. He received all childhood immunizations but was

unable to recall the exact dates.

Preventive Care: RBS done on 20/3/2021. B.P. measurements taken on 20/3/2021

Surgical History: No history of recent or previous surgeries.

 

 

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Family History: Raised by biological parents. His mother is 78years and has HTN and diabetes.

Father is 85 years with no chronic illness. His maternal grandfather died at 80 years and had a

history of BPH and HTN.

Social History: He is a small-scale farmer. Married to one wife.Has three children. He neither

smokes nor drinks.

Sexual Orientation: He has one wife, and he is heterosexual

Nutrition History: He takes a balanced diet. He avoids fat-rich diets and processed foods. He

takes a fruit every day in the morning. He drinks seven glasses of water every day. He does not

drink sweetened drinks or coffee.

 

Subjective Data:

Chief Complaint: “I am feeling great, but I am here for my annual check-up.”

Symptom analysis/HPI: The patient’s last annual check-up was in May 2021. The patient

reports the absence of any abnormal laboratory or physical findings during that check-up. His

previous eye examination was on October 2021. His last dental review was in November 2021.

Colonoscopy and PSA test were done in January 2018. His previous B.P. screening, Blood Sugar

Screening were done in March 2021. Lip profile tests were done in January 2017. There were no

other current concerns or complaints by the patient.

Review of Systems (ROS

CONSTITUTIONAL: No fatigue, chills, general body weakness, night sweats, or fever

RESPIRATORY: No dyspnea, wheezing, chest pains, or cough

GASTROINTESTINAL: No nausea, abdominal pain, vomiting, or diarrhea

 

 

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NEUROLOGIC: No numbness, loss of consciousness, tingling, or confusion

HEENT: H: no dizziness, headache, or confusion. Eyes: no itching, pain, diplopia, or blurry

vision Ears: no pain, hearing loss, tingling sensation, or discharges Nose: No bleeding, itching,

or discharge o Throat: no sore throat, edema, or voice changes

CARDIOVASCULAR: no chest pains, palpitations,dizzness or edema

GENITOURINARY: no dysuria, discharge, urinary urgency, or hematuria

MUSCULOSKELETAL: no muscle pains, joint swelling, joint pain, or muscle spasms

SKIN: no hives, skin rashes, or hyperpigmentation

 

Objective Data:

VITAL SIGNS: BP-110/90 mmHg, RR 19, Pulse rate 70b/min . SPo2 is 100%. Height-180cm,

Weight-63kg, computed BMI-22.5

GENERAL APPEARANCE: A white male, seated, alert and well-nourished, with no signs of

respiratory distress. There is no pallor, jaundice, cyanosis, dehydration, edema, or

lymphadenopathy.

NEUROLOGICAL: Normal speechA& O x3, typical gait, no tremors, normal speech, no

cerebellar S/S, or motor-sensory loss.

RESPIRATORY: Chest wall is symmetrical, rises following respiration, no visible masses or

scars, no tenderness, percussion note is tympanic, bilateral entry of air, breath sounds were

normal following auscultation.

 

 

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CARDIOVASCULAR: Normoactive precordium, palpable apical pulse mid-clavicular line at

the 5 t h

ICS, regular H.R., no thrills, no heaves, On auscultation, there were no murmurs, and S1

and S2 were heard.

GASTROINTESTINAL: Flat abdomen, umbilicus everted, moving with respiration, no

masses, no tenderness or organomegaly; warm. Normoactive bowel sounds were heard.

INTEGUMENTARY: Dark, warm, and dry. No rashes, abrasions, lesions, or hives

HEENT: H: Normocephalic, no scars, masses, or bruises. E: Pupils are equal, round, and

reactive to light, with no discharges. E: no ear discharges or impacted wax N: Symmetrical,

patent nasal nares, no discharge or bleeding.

Neck: No distended veins or lymphadenopathy and supple

MUSCULOSKELETAL: No abnormalities, normal gait, normal reflexes, no deformities, and

normal ROM.

ASSESSMENT:

55-year-old S.N. came to our clinical for his annual check-up. There are no current complaints.

His last yearly check-up showed no abnormal findings. His past check-ups were eye exam,

dental exam, Prostate screening, colonoscopy, lipid profile check-up, and B.P. and B.S.

screenings mother has hypertension and diabetes. His maternal grandfather had a history of

hypertension and BPH. On general and physical examination, there were no abnormal findings

noted.

Main Diagnosis

-1. ICD Z00.00- Annual checkup with no abnormal findings.

 

 

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CDC recommends the performance of routine check-ups annually and lab testing to aid in

identifying any health disorders to facilitate early medications and management (CDC,2020).

The patient requires his annual check-up this year.

Preventative Service Task Recommended Screenings:

2. PSA screening-ICD 10 –CM Z12.5. This is essential for screening for malignant cancers of the

prostate.PSA screening is vital in all men above 50 years because of the risk of developing

prostate cancer (Catalona,2018). The patient is at risk of prostate cancer or BPH because of his

old age and a positive family history of BPH.

3. Update for immunization-ICD-10-CM-Z23-which is the encounter for immunization.CDC

recommends that every adult be given a single dose of Tdap and then Td or a booster for Tdap

after ten years (Hibberd,2020). Mr. SN has his immunization updated apart from Tdap.

4. Colonoscopy- ICD 10 -CM Z12.11, which is for encounter for screening for the malignant

cancers of the colon. Colonoscopy is a requirement for individuals above 50 years as it will help

in the early diagnosis of benign or malignant lesions in the rectum or the colon (Saito et

al.,2021).

5. Blood Pressure screening-ICD 10-CM Z01.30 is the encounter for assessing blood pressure

with no abnormal findings. B.P. should be regularly checked in adults above 50 years (Carey et

al.,2018). This patient is at risk of developing HTN because of the positive family of HTN.

6. Blood Sugar Screening- ICD 10-CM R73.09, the code for the HBa1c blood test. This will help

rule out diabetes mellitus and is a requirement for people above 45 years. The patient is at risk of

developing D.M. because of the positive family history.

 

 

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7. Lipid profile Check-ICD 10-CM Z13.220 in assessing lipid metabolism errors, the cholesterol

and lipid-protein levels in the blood (Vijan & Elmore, 2020). CDC recommends that adults

above 20 years have cholesterol check-ups every five years (CDC,2020).

 

PLAN:

Investigations

-CBC- To investigate the white blood cell differentials, RBC, and platelet

-Urinalysis-To assess any abnormalities in the urine

-UECs-To assess the electrolytes

-Lipid tests-Helps in the assessment of the levels of LDL, cholesterol, T.G.s, and HDL

-ECG and ECHO- To assess the electrical activity of the heart and any heart disorders

-Renal function tests-To assess any kidney problems

-TSH-For assessment of any thyroid disorders.

 

Education

1. Continue monitoring any health changes, and for any threatening health conditions, call,911

2. Have a physical exercise plan at least exercise four times a week

3. Continue with his diet and maximize taking a balanced diet, more fruits and vegetables, and

drinking seven glasses of water daily.

 

Follow-ups

 

 

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Advise the patient to return to the hospital after one week to assess his laboratory

findings. He can book an appointment or make a call in case of any health issues. His next

annual check-up is to be scheduled for January 2023.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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References

Carey, R. M., Whelton, P. K., & 2017 ACC/AHA Hypertension Guideline Writing Committee*.

(2018). Prevention, detection, evaluation, and management of high blood pressure in

adults: synopsis of the 2017 American College of Cardiology/American Heart

Association Hypertension Guideline. Annals of internal medicine, 168(5), 351-358.

https://doi.org/10.7326/M17-3203

Catalona, W. J. (2018). Prostate cancer screening. Medical Clinics, 102(2), 199-214.

https://doi.org/10.1016/j.mcna.2017.11.001

Diphtheria, tetanus, and pertussis vaccine recommendations. (2020). Centers for Disease Control

and Prevention. Retrieved January 31, 2021, from

https://www.cdc.gov/vaccines/vpd/dtap-tdap-td/hcp/recommendations.html

Hibberd, P. L. (2020). Tetanus-diphtheria toxoid vaccination in adults. UpToDate. Retrieved

February 1, 2021, from https://www.uptodate.com/contents/tetanus-diphtheria-toxoid-

vaccination- in-adults

Saito, Y., Oka, S., Kawamura, T., Shimoda, R., Sekiguchi, M., Tamai, N., … & Inoue, H. (2021).

Colonoscopy screening and surveillance guidelines. Digestive Endoscopy, 33(4), 486-

519. https://doi.org/10.1111/den.13972

Vijan, S., & Elmore, J. G. (2020). Screening for lipid disorders in adults. UpToDate. Waltham,

MA: UpToDate. https://www.medilib.ir/uptodate/show/4553