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soap note for one of the STDs

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Soap note for OVARIAN CANCER Sample Solution

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Unit 6 Assignment – Clinical Preparation Tool 1

Unit 6 Assignment – Clinical Preparation Tool 1 Kindly Order A Plagiarism-Free Paper Here: Unit 6 Assignment – Clinical Preparation Tool 1 Instructions Choose one diagnosis from the Substance-Related and Addictive Disorders group American Psychiatric Association. (2013). Diagnostic and statistical…

Three Objectives: List three differential diagnoses based on the information provided Formulate a treatment plan for the primary diagnosis Provide educational and health promotion tips Patient Information Initials: Z.Z Age: 66 years old Gender: female Race: African American Historian: patient 1 1 Subjective Data Chief complaint (CC): Increasing tiredness, urination, thirst and hunger.” History of Present Illness (HPI): The patient ZZ is a 66-year-old African American female who presents to the clinic with complaints of increasing tiredness, hunger, and thirst. She reports that she has been feeling like this for months and thought it was due to exhaustion from her volunteering work. She tries taking it slow, resting and sleeping more, but she still feels the same or even worst. Her son asked her to see the provider after she started having intermittent blurry vision two weeks ago; he thinks it might be something else going on. She denies chest pain, shortness of breath, palpitation, cough, weight loss and fever. Allergies: No known food or drug allergies Current medications: Hydrochlorothiazide 12.5 mg daily Lisinopril 10 mg daily Atorvastatin 20mg daily Past Medical History (PMH): Childhood illnesses: No significant childhood illness Adult illnesses: Hypertension, Hyperlipidemia Immunization: Influenza 09/2021, Tdap booster 06/2018, Shingles 02/2019. Covid-19 booster 01/2022, Pneumococcal 08/2019 Surgeries: No past surgical history Family Medical History Father – deceased at 60yr had hypertension, stroke, and heart attack Mother – Living – has hypertension and diabetes type 2 Son – alive and healthy Social history: Occupation – a retired teacher Major hobbies – enjoys reading, watching TV and volunteering in church or soup kitchen Family status – Divorced with one son who lives nearby. Tobacco – never smoked or used an illicit drug Alcohol use – one glass of red wine once or twice a week Living environment – lives in a one-bedroom apartment Exercise- once or twice a week Diet –loves to eat out or order in Review of Systems: General: report tiredness, fatigue HEENT; Head: denies headache or dizziness. Eyes: report intermittent blurry vision, denies pain or visual loss Ears: denies hearing loss or difficulty, pain, or discharge. Nose: denies runny nose, sneezing, nasal drainage, or nasal congestion Throat: denies sore throat, dryness, and hoarseness Cardiovascular: denies chest pain or palpitation Respiratory: denies shortness of breath or difficulty breathing Gastrointestinal: denies abdominal pain, diarrhea or constipation, nausea, and vomiting Genitourinary: reports increased frequency and nocturia, denies dysuria, hematuria, or urine incontinence Musculoskeletal: denies joint pain, swelling and stiffness Skin: denies rash or itching. Neurological system: denies tremors, seizures, vertigoThree Objectives: Psychiatric: denies anxiety, depression, impaired concentration, and psychosis. Endocrine: report increased thirst and hunger; denies heat or cold intolerance Hematology: denies abnormal bleeding Objective data Vital signs: Temp: 36.2, HR: 80, BP: 135/76, RR: 18, O2 sat.97%, 0/10 Height: 70 inches, Weight: 190lbs, BMI: 27.3 kg/m2 Physical Examination: General: the patient is pleasant and appropriate, well-groomed, and no acute distress noted HEENT: Head: Normocephalic Eye: PERRLA, EOM’s intact and symmetric, the sclera is white, no discharge, peripheral vision grossly intact, Ear: hearing grossly intact. canals clear with no cerumen, tympanic membranes intact, pearly gray, intact with light reflex Nose: nasal mucosa reddened and moist without obvious drainage Throat: oropharynx pink and moist Neck: Supple, trachea midline Respiratory: Symmetrical with respiration, lungs clear to auscultation, no rhonchi, stridor, wheezing, or crackles Cardiovascular: the heart is normative at the 5th ICS. Normal sounds S1 and S2 are present without murmurs and pericardial rub. Peripheral arterial pulse is present and normal. There are no palpable bruits Abdomen: soft, benign, non-tender, normal bowel sounds in all quadrants Genitourinary: deferred Rectal: deferred Skin: no lesions or rashes. Musculoskeletal: no joint pain and tenderness Neurological: speech clear and coherent, alert and oriented to person, place, time and situation Psychiatric: appropriate mood and affect. Maintained good eye contact throughout the interview and examination. Diagnostic Testing and Results: CBC- to rule out infection CMP- to check blood sugar level Glycated hemoglobin testing (A1C) – to assess the patient average blood sugar level in the past 3 months Lipid panel – to check cholesterol and triglycerides levels Thyroid-stimulating hormone (TSH) – to assess thyroid function Random blood glucose test – to check blood sugar level Urine Analysis (dipstick UA) – to rule out infection (UTI) Results: WBC – WNL Glucose – 118 mg/dL (high) A1C – 7.0 % Total cholesterol – 205 mg/dL LDL – 110 mg/dL HDL – 100 mg/dL TSH – 4.9 mIU/L Glucose test – 200 mg/dL UA – ++ Glucose 0.9 mmol/L; no leukocytes Assessment Primary diagnosis: Type 2 diabetes E11.9- in this type of diabetes, the body does not make enough or use insulin well; that is, the pancreas does not produce enough insulin, or the cells are resistant to insulin, thereby taking in less sugar (Abrilla et al., 2021). It is considered adult-onset diabetes because it is more common in middle-aged and older adults. Its symptoms include tiredness, increased hunger or thirst, unplanned weight loss, frequent urination and blurred vision ( Abrilla et al., 2021). The risk factor includes being overweight or obese, lack of physical exercise, or having a family history of diabetes (Martenstyn et al., 2020). The patient is diabetic base on the labs above, especially the AIc, which indicates the average blood sugar level for three months. The patient has type two diabetes instead of type one because of her age (older), is overweight, has symptoms that appear gradually, and has a family history (Abrilla et al., 2021). Differential diagnosis: Type 1 Diabetes mellitus E10.9: in type one diabetes, the body’s immune system destroys the cell that produces insulin, thereby preventing the pancreas from making insulin (Leslie et al., 2021). Its symptoms are similar to type 2 diabetes, which are increased thirst and urination, hunger, blurred vision, fatigue and unexplained weight loss (Sawyer et al., 2022). It is considered Juvenile diabetes because it is primarily diagnosed in children or teens (Sawyer et al., 2022). Its symptoms develop suddenly, but adults with type 1 diabetes have a longer symptomatic period than children and teens because their loss of insulin secretory capacity usually is less pronounced (Leslie et al., 2021). Though the presentations are the same, the patient is less likely to have type one diabetes due to her age, onset, and history. Hyperthyroidism E05.0- in hyperthyroidism, the thyroid gland makes more thyroid hormones than the body needs. Excess thyroid hormone production speeds up the body

Three Objectives: List three differential diagnoses based on the information provided Formulate a treatment plan for the primary diagnosis Provide educational and health promotion tips Patient Information Initials: Z.Z Age: 66 years old Gender: female Race: African American Historian: patient…

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