Focused SOAP Note
Student’s Name
Institutional Affiliation
Course
Professor’s Name
Date
Patient Information:
E, 42, M
S.
CC (chief complaint): The patient is about to embark on a rigorous exercise program to lose weight. He hopes to lose at least 30 pounds by working out at the gym. He goes to visit his personal trainer for the first session and is surprised to hear his trainer suggest that he go to his primary healthcare provider for a checkup first.
HPI: E. is a 42-year-old male who wants to lose at least 30 pounds by working out at the gym. He was surprised when his trainer suggested he should first see a primary healthcare provider for a checkup. The patient has been healthy apart from the excess weight. He gains extra weight due to sitting behind his desk at work. He takes responsibility for his actions. He plans to exercise and lose weight due to the upcoming busy working season.
Current Medications: No current medication.
Allergies: No known food or drug allergies.
PMHx: No significant past medical history.
Soc & Substance Hx: He is not married and lives in a condominium. He takes responsibility for his lifestyle and prepares his food.
Fam Hx: No significant medical history.
Surgical Hx: No prior surgical procedures.
Mental Hx: No past mental diagnosis.
Violence Hx: No history of violence.
Reproductive Hx: Not sexually active and have no children.
ROS:
GENERAL: Excess weight. Wants to lose 30 pounds by working in the gym.
HEENT: Eyes: No visual problems. Ears, Nose, Throat: No hearing difficulty, congested nose or sore throat.
SKIN: No skin lesions or itching.
CARDIOVASCULAR: No chest pain or discomfort.
RESPIRATORY: No coughing or sputum.
GASTROINTESTINAL: No nausea, diarrhea, or vomiting.
GENITOURINARY: No difficulty in urination.
NEUROLOGICAL: No headache or numbness.
MUSCULOSKELETAL: No muscle or joint pain.
HEMATOLOGIC: No bleeding or anemia.
LYMPHATICS: No history of splenectomy.
PSYCHIATRIC: No history of mental illness.
ENDOCRINOLOGIC: No history of sweating, polyuria, or polydipsia.
REPRODUCTIVE: Not sexually active and no children.
ALLERGIES: No history of rhinitis, or eczema.
O.
Physical exam: Physical examination is not necessary since the focus is health promotion and prevention.
Diagnostic results: Body Mass Index (BMI)
A.
Differential Diagnoses:
Obesity
The patient is likely suffering from obesity as a result of the lifestyle. He sits for long hours behind his desk, putting him at risk of adding weight (Bluher, 2019). The problem can be an underlying cause, such as obesity.
Diabetes
Diabetes is one of the health conditions that can trigger weight gain. Patients with unintentional weight gain should get checked to avoid complications related to insulin regulation (American Diabetes Association, 2018). Diabetes is related to obesity since it comes from unregulated sugar levels in the body.
Cushing’s syndrome
Cushing’s syndrome is a condition that leads to unintentional weight gain. The condition occurs due to the excess stress hormone cortisol (Barbot et al., 2020). The stress hormone triggers weight gain and other health abnormalities. s
P.
The patient requires a medical check-up to ensure they are not suffering from any health condition causing weight gain. A comprehensive assessment is vital for the patient to start medication without delay.
Health promotion will involve adjusting the lifestyle to improve the patient’s health. For instance, the patient should take healthy meals and reduce large amounts, leading to the accumulation of fat (Bluher, 2019). The patient should avoid junk food, take more vegetables and fruits, and drink sufficient water.
A collaboration with the physical trainer is relevant to check the patient’s progress. A referral to a cardiologist is necessary to ensure the patient is not suffering from a heart condition that can trigger weight gain (Bluher, 2019).
It is vital to educate the patient about the measures to avoid weight gain. The measures include watching the diet, exercising regularly, taking sufficient water, and avoiding junk food. Changing the lifestyle, such as avoiding sitting for long hours, is critical for the patient’s health. The patient should consider walking or running to burn extra calories in the morning.
Therapeutic interventions should comprise mental Assessment and treatment. Living as a single at 42 years and working for long hours can expose the patient to mental illness. The Assessment should comprise questions to examine the patient’s health, such as drug and alcohol abuse. Poor lifestyles of abusing drugs can put patients at risk of weight gain.
Follow-up visits are critical to check whether the patient meets the expected milestones. For instance, the patient should report after two weeks and after one month. A follow-up after the first month should include details of the weight changes.
Reflection
I have learned that patients working for long hours can attribute their weight gain to sitting behind their desks, but they could be suffering from other health complications. A comprehensive health examination is critical for accurate diagnosis.
Appropriate treatment and collaboration with other healthcare workers are vital for treatment. Collaboration with the trainer is crucial in achieving the right health milestones. The collaboration should include physicians and psychotherapists to provide comprehensive care.
References
American Diabetes Association. (2018). Economic costs of diabetes in the US in 2017. Diabetes care, 41(5), 917-928.
Barbot, M., Zilio, M., & Scaroni, C. (2020). Cushing’s syndrome: overview of clinical presentation, diagnostic tools and complications. Best Practice & Research Clinical Endocrinology & Metabolism, 34(2), 101380.
Bluher, M. (2019). Obesity: global epidemiology and pathogenesis. Nature Reviews Endocrinology, 15(5), 288-298.
