The primary aim of the paper is to analyze the provided subjective and objectives information to diagnose and develop a management plan for acute care visit patient based case study. Second, the paper intents to give us an overview on how to apply the national diabetes guidelines to the patient management plan. Lastly, the paper intents to demonstrate mastery of SOAP note writing when executing and writing a diagnosis and development of the management plan for a patient seeking for acute care visit.
Assessment
ICD 10 Code
The primary diagnosis is diabetes mellitus type II with ICD 10 code E 11.610, coupled with diabetic neuropathic and arthropathy. There is an increase in frequency of micturition and weight gain.
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The secondary diagnosis is obesity with ICD 10 code E66.0- resulting from excess calories.
The differential diagnosis is the diabetes inspidus with ICD 10 code E23.2. It is evident due to increased fatigue, frequent urination and low energy levels.
Some of the patient pertinent positive and negative findings include the presence of the patient fatigued with less energy, gaining weight since menopause. This diagnosis was chosen based on the patient lack of weight loss as well as being fatigued all time. The client will receive a Tylenol on a daily basis for knee pain with daily multivitamin to boost her immune and normal body operation. More so, the medications aim to ease the pain and relieve the patient fever if the client happen to be subjected to muscle aches, headache among other body conditions. Tylenol as well as multivitamin are the best medication for the patient given that she is irritated on how she regularly wake up at least twice a night to urinate and frequently urinating during the day ( Ralston et al,. 2014 ).
Plan
Diagnostics
Random blood glucose test is done to help keep track of symptoms and manage diabetes .
Fasting blood glucose test is done in order to detect diabetes mellitus.
Glycosylated hemoglobin test is done to determine how well the patient diabetes is being controlled over time.
Medications
Healthy eating with regular exercise as well as taking Lorcaserin (Belviq) medication
Diabetes medication or insulin therapy using Phentermine-topiramate (Qsymia) medication
Blood sugar monitoring using Orlistat (Xenical) medication
Education
Healthy eating considering high fiber and low fat foods.
Regular exercise considering aerobic exercise regularly
Diabetes medication or insulin therapy. Dose of Sulfonylureas combined with diet and exercise (Sussman et.al, 2015).
Blood sugar monitoring. Check and record your blood sugar level every day. These steps will help keep your blood sugar level closer to normal, which can delay or prevent complications.
Referrals
It is recommended to undergo bariatric surgery to maintain and reduce blood levels. Blood sugar levels return to normal in 55 to 95 percent of people with diabetes, depending on the procedure performed. Surgeries that bypass a portion of the small intestine have more of an effect on blood sugar levels than do other weight-loss surgeries (Sussman et.al, 2015).
Follow up
The next follow up to return to PCP appointment is on 22 nd April 2018, 1400hrs.
Medication Costs
Sulfonylureas. These medications help your body secrete more insulin. Examples of medications in this class include glyburide (DiaBeta, Glynase), glipizide (Glucotrol) and glimepiride (Amaryl). Possible side effects include low blood sugar and weight gain. The costs of the medication is $31 with Glynase (glyburide micronized) costing $17 and Glucotrol XL (glipizideer) costing $14. Therefore, the monthly cost of the prescription would range between $30 and $50. In future practices of medication I would use the pricing resources.
SOAP Note
S: Symptoms includes frequent urination and weight gain. Current medications: Tylenol daily for knee pain and daily multivitamin. PMH: Has left knee arthritis. As a child, the patient had chicken pox and mumps and therefore, the required vaccinations needs to be updated.
O: CBC: WBC 6,000/mm3 Hgb 12.9 gm/dl Hct 40% RBC 4.6 million MCV 92 fl MCHC 34 g/dl RDW 13.8%. UA: pH 5, SpGr 1.015, Leukocyte esterase negative, nitrites negative, 1+ glucose; 1+ protein; negative for ketones.
CMP: Sodium 138, Potassium 4.2, Chloride 101, CO2 29, Glucose 90, BUN 12, Creatinine 0.7, GFR est non-AA 90 mL/min/1.73, GFR est AA, 101 mL/min/1.73, Calcium 9.4, Total protein 7.6, Bilirubin, total 0.7, Alkaline phosphatase 72, AST 25, ALT 29, Anion gap 8.11, Bun/Creat 17.7, Hemoglobin A1C: 7.7 %, TSH: 2.30, Free T 4 0.7, Cholesterol: TC 228 mg/dl, LDL 143 mg/dl; VLDL 36 mg/dl; HDL 37mg/dl, Triglycerides 232 and EKG: normal sinus rhythm
A: Patient suffering from diabetes mellitus, E11.65
Frequent micturition, R35.0
Hemoglobin A1C: 7.7 %, R73.09
P: Random blood glucose test should be done to help keep track all symptoms and manage diabetes. More so, fasting blood glucose test should be done in order to detect diabetes mellitus. Last, Glycosylated hemoglobin test should also be done to determine how well a person's diabetes is being controlled over time.
References
American Diabetes Association. (2015). Standards of medical care in diabetes—2015 abridged for primary care providers. Clinical diabetes: a publication of the American Diabetes Association, 33 (2), 97.
Chamberlain, N. R., & Yates, H. A. (2000). Use of a computer-assisted clinical case (CACC) SOAP note exercise to assess students' application of osteopathic principles and practice. Journal of the American Osteopathic Association, 100 (7), 437.
Franklin, M., Burns, L., Perez, S., Yerragolam, D., &Makenbaeva, D. (2018). Incidence of type 2 diabetes mellitus and hyperlipidemia in patients prescribed dasatinib or nilotinib as first-or second-line therapy for chronic myelogenous leukemia in the US. Current medical research and opinion, 34 (2), 353-360.
Kasper, D., Fauci, A., Hauser, S., Longo, D., Jameson, J., &Loscalzo, J. (2015). Harrison's principles of internal medicine, 19e.
Kibble, J., Hansen, P. A., & Nelson, L. (2016). Use of modified SOAP notes and peer-led small-group discussion in a Medical Physiology course: addressing the hidden curriculum. Advances in physiology education , 30 (4), 230-236.
Kettenbach, G. (2015). Writing SOAP notes . FA Davis Company.
Ralston, J. D., Revere, D., Robins, L. S., & Goldberg, H. I. (2014). Patients' experience with a diabetes support programme based on an interactive electronic medical record: qualitative study. Bmj , 328 (7449), 1159.
Sussman, J. B., Kerr, E. A., Saini, S. D., Holleman, R. G., Klamerus, M. L., Min, L. C., ... & Hofer, T. P. (2015). Rates of deintensification of blood pressure and glycemic medication treatment based on levels of control and life expectancy in older patients with diabetes mellitus . JAMA internal medicine, 175 (12), 1942-1949.
