Solved by verified expert:Please uploaded templete to create a patient with migraine headache. Please use chief complaint ” I have been having a head throbbing pain for two weeks off and on, but now it’s seems to be getting worse”. Make sure that the ROS relates to the finding of what the patient would report for symptoms of a migraine headache. The Physical exam should also relates to finding for the patient with migraine headache. You must include three differentials diagnose, with the correct ICD 10 code and the reason why you pick those based on the patient’s reports, and / findings from the phyical exam. Then used at least two- three evidence based guidelines to formulate a treatment plan, along with patient education. You must also include what labs, or imaging if any is needed. The phyical exam does not have to include all body systems, only one that is pertinent to what relates to finding the diagnose of headaches. Please remember that the uploaded is only an example and can be used as a templete to make the changes needed to fit the disease. And use APA format for references.
su_nsg6440_w2_soapd_q_doc._.doc
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Week 7-SOAP NOTE- eMedley # .4130346
Name: Pat
Date: 12/1917
Age: 66
Time: 10: 30 am
Sex: F
SUBJECTIVE
CC: “ I am here to establish as a new patient with doctor, and control my sugar”
HPI: Pt. has metform gave her bad cramp and diarrhea. Pt. has doing the South Beach diet, and doing very
well was 260 in Nov. and now 251. glucose check this morning 226. WE REVIEWED LABS AND SHE
HAS A HX OF UNCONTROLLED DIABETS AND SHE NAY BE GETING STEROID INJECTIONS IN
HER BACK SHE IS OBESE AND AT PRESENT TIME SHE IS ON MED AT ALL FOR DIABETES
SHE WAS DISMISSED BY HER ENDOCRINOLOGIST AND HER FAMILY DOCTOR DID NOT
BRING IN HER MEDS. Additionally reports: SHE HAS BEEN ON NEW INJECTIONS OF SOME
TYPE METFOTMIN WAS TID AND SHE STOPPED TBIS ALL TOGETHER WHEN SH HAD
DIARRHEA AND SHE JUST STOPPED HER GLIPIZIDE TOO.
Medications:
clonazepam 1mg tab
Take 1 tablet(s) twice a day by oral route.
EpiPen
As directed
glipizide 5mg tab
Take 1 tablet(s) twice a day by oral route.
MetFORMIN 500mg tab
Take 1 tablet(s) every day by oral route at dinner
Losartan 50 mg tablet
Take 1 tablet(s) every day by oral route
Morphine Sulfate CR 60 mg tab
Take 1 tablet(s) every 12hours by oral rount
Sertraline 150mg daily
PMH:
Anxiety Disorder: Y
Asthma: Y – when she smoked
Diabetes: Y
Heart Disease: Y
Hypertension: Y
Reflux/GERD: Y
Notes: stasis ulcers bilateral
Allergies: IODINE: Anaphylaxis, ,KEFLEX: Other, STATINS-HMG-COA REDUCTASE INHIBITORS: – LEG
PAIN, Beestings and shrimp causes anaphylaxis
Medication Intolerances: No Known Allergies to medications
Chronic Illnesses/Major traumas:
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Sleep terror disorder – Onset: 12/19/2017
Buffalo hump – Onset: 12/19/2017
Obesity – Onset: 12/19/2017
Cellulitis of lower limb – Onset: 12/19/2017
Lichen simplex chronicus – Onset: 12/19/2017
Type 2 diabetes mellitus – Onset: 12/19/2017
Degeneration of lumbar intervertebral disc – Onset: 12/19/2017
Umbilical hernia – Onset: 12/19/2017
Noncompliance with therapeutic regimen – Onset: 12/19/2017
Chronic depression – Onset: 11/02/2017
Angina pectoris – Onset: 11/02/2017 – currently stable
Generalized anxiety disorder – Onset: 11/02/2017
Conduction disorder of the heart – Onset: 11/02/2017 – Followed by Dr Garrett q 6 months. Port
Charlotte stable with sotolol
Coronary arteriosclerosis – Onset: 11/02/2017 – cardiac cath 6/27/2017 one artery mildly occluded.
per Dr Rosenfield followed by Dr Garrett
Essential hypertension – Onset: 11/02/2017
Hospitalizations/Surgeries
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Hernia Repair – 01/01/2010
Cholecystectomy – 01/01/1995
Hysterectomy – 01/01/1991
Tonsillectomy – 01/01/1958
Family History:
Mother: arthritis, heart disease
Father: cerebrovascular accident
Social History: denies drug use, alcohol, and smoke now
Live with others, exercise: none
ROS
General: Patient reports lethargy but reports
no fever. She reports frequent diarrhea but
reports no abdominal pain, no nausea, and no
vomiting
Cardiovascular: She reports no chest pain, no
arm pain on exertion, no shortness of breath
when walking, and no palpitations. She reports
no cough and no shortness of breath.
Skin: She reports no abnormal mole, no
jaundice, no rashes, and no laceration
Respiratory: Respiratory effort: no dyspnea.
Percussion: dullness or flatness. Auscultation: no
wheezing, rales/crackles, or rhonchi and breath
sounds normal, good air movement, and CTA
except as noted.
Eyes: no change in vision. Pt. denies blurry, or
discharge.
Gastrointestinal: HAD SURGERY FOR AN
UMBILICAL HERNIA AND THIS QUICKLY
RECURRED.
Ears : no lesions on external ear, normal. no
hearing loss.
Genitourinary/Gynecological
Nose/Mouth/Throat: she reports No sinus issues,
no hoarseness, or throat pain. No dental disease.
She reports no incontinence, no difficulty
urinating, no hematuria, and no increased
frequency.
Musculoskeletal: She reports arthralgias/joint
pain and back pain but reports no muscle aches
and no muscle weakness.
Breast: bilateral symmetrical with no tenderness,
lumps, or bumps
Neurological:
Heme/Lymph/Endo: No palatable lymph nodes,
thyroid is not palatable, pt. denies.
Psychiatric: Pt. spirt is well, denies depression,
or anxiety.
She reports no loss of
consciousness, no weakness, no
numbness, no seizures, no dizziness, no
migraines, no headaches, and no tremor
OBJECTIVE
Weight 251lbs BMI 39.9
Temp 97.9
BP 122/82
Height 5ft 7in
Pulse 76
Resp 18
General Appearance: healthy-appearing, well-developed, and obese. Level of Distress: NAD.
Ambulation: limited ambulation; ON WALKER.
Skin: Inspection and palpation: no rash; SHE HAS A SEVERE RASH OF BOTH LOWER LEG
EXCORIATED AND THIS APPEARS TO BE A VARAINT OF LICHEN SIMPLEX CHRONICUS
AND EASRLY CELLULITIS OF TEH RIGHT LEG THIS HAS BEEN CHRONIC SHE SAW A
DERMATOLOGIST WITH NO HELP.
HEENT: head is symmetrical with no lesion, hair is evenly distrusted. Eyes are without discharge,
redness, and vision has no changes. Neck: full ROM, no palatable nodes. No thyroid enlargement or
nodules. Oral mucosa moist and pink, with no lesions.
Cardiovascular: Apical Impulse: not displaced. Heart Auscultation: normal S1 and S2; no murmurs,
rubs, or gallops; and RRR. Neck vessels: no carotid bruits. Pulses including femoral / pedal: normal
throughout.
Respiratory: Respiratory effort: no dyspnea. Percussion: dullness or flatness. Auscultation: no
wheezing, rales/crackles, or rhonchi and breath sounds normal, good air movement, and CTA except
as noted.
Gastrointestinal: Inspection and Palpation: no tenderness or CVA tenderness and soft and nondistended; STRIAE. Liver: no hepatomegaly. Hernia: periumbilical.
Breast: no palatable mass, no tenderness, no dimpling.
Genitourinary: bladder is non-distended, no discharge or tenderness. No issue with urination or
bowel movement.
Musculoskeletal: Motor Strength and Tone: normal and poor tone. Joints, Bones, and Muscles: no
contractures, malalignment, or bony abnormalities and normal movement of all extremities
and tenderness. Extremities: no cyanosis, edema, varicosities, or palpable cord.
Neurological: patient is using a walker, gait is unstable.
Psychiatric: Insight: good judgement. Mental Status: active and alert, normal mood, and abnormal
affect. Orientation: to time, place, and person. Memory: recent memory normal and remote memory
normal.
.
Lab Test: None ordered
Special Tests: CT of the abdomen is ordered.
Diagnosis
Differential Diagnoses
SHE HAS STRIAE AND A BUFFALO HUMP
1. Degeneration of lumbar intervertebral disc
M51.36: Other intervertebral disc degeneration, lumbar region
2. Lichen simplex chronicus – USE CORTAID UNDER AN OCCLUSIVE DRESING
L28.0: Lichen simplex chronicus
3. Cellulitis of lower limb
L03.119: Cellulitis of unspecified part of limb
4. Essential hypertension
I10: Essential (primary) hypertension
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HIGH BLOOD PRESSURE: CARE INSTRUCTIONS
LEARNING ABOUT HIGH BLOOD PRESSURE
5. Coronary arteriosclerosis
I25.10: Atherosclerotic heart disease of native coronary artery without angina pectoris
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metformin 500 mg tablet Take 1 tablet(s) every day by oral route at dinner.
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glipizide 5 mg tablet Take 1 tablet(s) twice a day by oral route
6. Type 2 diabetes mellitus
E11.9: Type 2 diabetes mellitus without complications
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LEARNING ABOUT TYPE 2 DIABETES
TYPE 2 DIABETES: CARE INSTRUCTIONS
HEMOGLOBIN A1C
7. Hypercalcemia
E83.52: Hypercalcemia
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HYPERCALCEMIA: CARE INSTRUCTIONS
PTH, INTACT AND CALCIUM
8. Buffalo hump
R22.2: Localized swelling, mass and lump, trunk
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CORTISOL, A.M.
9. Generalized anxiety disorder
F41.1: Generalized anxiety disorder
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ANXIETY DISORDER: CARE INSTRUCTIONS
clonazepam 1 mg tablet Take 1 tablet(s) twice a day by oral route at bedtime
Plan/Therapeutics
o Plan:
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Order A1c, and Cortisol AM test
Prescribed Metformin, but educated the pat. That the common side effects
of Metformin is diarrhea therefore, we are going to use a lower dosage to
see if this will help. We also instructed her to take it in the evening, to get
better result.
We also started her on glipizide 5mg tab (Take 1 tablet every day).
We instructed her to keep a log of her glucose reading and to bring log in
next visit.
We praise her on a great job losing weight, and to continue with her hard
work.
Combination therapy allows a more individualized regimen aimed at
optimal glycemic control. Despite all the medications, however, a healthy
diet and regular exercise remain imperative in the management of diabetes.
Follow up in 4 weeks.
(“Standards of Medical Care in Diabetes-2017: Summary of Revisions,”
2017)
Evaluation of patient encounter: Patient was very open to suggested diagnostic work up, and agree to keep
the office up dated with any changes, whether improved or worsen. The patient health history and physical
exam is not very sensitive. Although, the treatment plan listed for this patient is “ best practice guideline”, I
personal have a different idea on treatment for this patient, in terms of A1c treatment. I would initiate
insulin for this patient to decrease glucose toxicity in order for the patient’s oral diabetic treatment to have
any tracking. Based on new guideline, obese, fasting plasma glucose is greater than >250mg/dl. In the other
hand I understood where he is coming from, we didn’t get a A1c result yet, and she has been trying hard to
loss weight, proof showing that she has lost 10lbs since the las visit which is four weeks ago.
References:
Buttaro, T., Trybulski, J., Bailey, P., Sandberg-Cook, J. (2013). Primary Care, 4th Edition. [South
University]. Retrieved from https://digitalbookshelf.southuniversity.edu/#/books/978-0-323-07501-5/
Standards of Medical Care in Diabetes-2017: Summary of Revisions. (2017, January 01). Retrieved from
http://care.diabetesjournals.org/content/40/Supplement_1/S4
…
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