Centered SOAP Observe
Scholar’s Title
Institutional Affiliation
Course
Professor’s Title
Date
Affected person Data:
J, 71, F, Race
S (subjective)
CC (chief criticism): Fatigue, thinning hair, and dry skin.
HPI (historical past of current sickness): Ms. Juggenmeir is a 71-year-old Feminine who comes into your workplace with considerations of fatigue and dry skin. She is a retired Banker. She is alert awake oriented to time, place, scenario, ambulatory, and lives by herself. She does report elevated fatigue irrespective of how a lot sleep she will get. She can also be involved that she might have to come back off one among her meds as a result of her hair is thinning. She had labs performed and was knowledgeable they’d Assessment outcomes at this go to. Different pertinent diagnoses embrace Hypertension, Hyperlipidemia, and Vitamin D deficiency. She admits to not taking her vitamin D each day as prescribed.
Present Drugs:
Girls’s One A Day-Multivitamin each day
Chlorthalidone 25mg each day
Fish Oil 1 pill each day
Amlodipine 5mg p.o. each day
Losartan 100mg p.o. each day
Atorvastatin 40mg p.o. at bedtime each day
Aspirin 81mg p.o. each day
Ergocalciferol 50,000 models PO as soon as a month
Allergy symptoms: I.V. Distinction, ACE Inhibitors reactions.
PMHx: Hypertension, Hyperlipidemia, Vitamin D deficiency.
Soc and Substance Hx: Retired banker who lives by herself.
Fam Hx: No vital household historical past.
Surgical Hx: Prior surgical procedures.
Psychological Hx: No previous prognosis of psychological sickness.
Violence Hx: No historical past of violence.
Reproductive Hx: No vital reproductive historical past.
ROS (Assessment of signs):
GENERAL: No unintended weight reduction, achieve or fatigue.
HEENT:
• EyesNo visible loss or sclera.
• Ears, Nostril, Throat: No listening to loss, working nostril or sore throat.
SKIN: No lesions or itching.
CARDIOVASCULAR: No chest pains or discomfort.
RESPIRATORY: No shortness of breath of sputum.
GASTROINTESTINAL: No nausea, diarrhea, vomiting or blood within the stool.
GENITOURINARY: No burning sensation on urination.
NEUROLOGICAL: No historical past numbness, headache, stroke, or malfunctioning nerves.
MUSCULOSKELETAL: No again or muscle ache.
HEMATOLOGIC: No bleeding or bruising.
LYMPHATICS: No historical past of splenectomy.
PSYCHIATRIC: No historical past of psychological sickness or anxiousness.
ENDOCRINOLOGIC: No sweating or reviews of polyuria or polydipsia.
REPRODUCTIVE: No current being pregnant or menstrual cycle. Final menstrual interval is unknown.
ALLERGIES: No historical past of rhinitis or eczema.
O (goal)
Bodily examination:
Very important indicators: BP 137/82, HR 89, RR 20, Temp 98.1
Diagnostic assessments:
CXR- Final CXR confirmed no cardiopulmonary findings. WNL
TSH/Free T4, T3- as famous under in lab outcomes.
Primary Metabolic Panel and CBC as proven under.
Vitamin D Degree- as famous under in lab outcomes.
Diagnostic outcomes:
Take a look at Consequence Reference Vary
GLUCOSE 85 65-99
SODIUM 134 135-146
POTASSIUM Four.2 three.5-5.three
CHLORIDE 104 98-110
CARBON DIOXIDE 29 19-30
CALCIUM 9.Zero eight.6- 10.three BUN 20 7-25
CREATININE 1.01 Zero.70-1.25
GLOMERULAR FILTRATION RATE (eGFR) 76 >or=60 mL/min/1.73m2
TSH 23 Zero.Four-Four.Zero FREE T4 Zero.05 Zero.9-2.Four mcg/dl T3 three.Zero 2.Zero-Four.Four ng/dl
Vitamin D 1,25 OH 14 36-144
WBC 7.three three.Four- 10.eight RBC Four.31 135-146
HEMOGLOBIN 14 13-17.2
HEMATOCRIT 42% 36-50 MCV 90 80-100
MCHC 34 32-36
PLATELET 272 150-400
Ms. Juggenmeir is a 71 y/o feminine who’s alert awake oriented to time, place, scenario. She makes no uncommon motor actions and demonstrates no tics. She denies any visible or auditory hallucinations. She denies any suicidal ideas or ideations. She denies any falls or ache.
A (Assessment)
Differential diagnoses:
Alopecia
Alopecia is an autoimmune situation that causes the hair to start out thinning. The quantity of hair loss is completely different in several individuals (Strazzulla et al., 2018). The situation could also be hereditary, hormonal disturbance, or childbirth sickness. The hair can develop again with the Helpance of immune-suppressing remedy (Strazzulla et al., 2018).
Hyponatremia
Hyponatremia is a situation that happens when the sodium ranges within the physique are too low. Low sodium ranges trigger the physique cells to start out swelling (George et al., 2018). The frequent causes of the situation embrace coronary heart failure, diarrhea, diuretic use, renal illness, or liver illness. The illness is life-threatening and applicable motion is required to counter the signs (George et al., 2018).
Autoimmune Thyroiditis
The situation happens when the immune system assaults the thyroid gland resulting in swelling. The swelling impacts the flexibility to supply hormones as required (Koehler et al., 2019). The signs embrace fatigue, pale and dry skin, unexplained weight achieve, reminiscence lapses, elevated sensitivity to chilly, and constipation (Koehler et al., 2019). Sufferers ought to get speedy care to keep away from deterioration and worse well being problems.
P (plan)
The affected person would require further diagnostic assessments to look at the immune system. A referral to a doctor for the FT3 check and T4 check is important to look at the severity of the situation (Kennedy-Malone et al., 2019). For example, a rheumatologist successfully examines situations referring to autoimmune assaults.
The affected person would require immunotherapy medicine comparable to immunosuppressant medicine. You will need to deal with the affected person to make sure their well being will not be uncovered to infections as a result of suppressed immunity. A doctor ought to educate the affected person concerning the sickness and the suitable interventions (Koehler et al., 2019). The affected person needs to be underneath the watch of a doctor within the ward and be discharged after every week when the immune assault subsides. The affected person ought to take remedy and return to the clinic after two weeks. The autoimmune situations require applicable intervention. The affected person ought to proceed taking the present remedy.
The affected person ought to obtain info that vitamin D deficiency is without doubt one of the main causes of hair thinning (Koehler et al., 2019). Vitamin D is crucial in stimulating hair follicles. The deficiency causes alopecia which ends up in hair thinning in numerous patches.
The therapy plan ought to embrace vitamin D dietary supplements. The dietary supplements will restore the hair and strengthen the bones. It’s important to droop Chlorthalidone for the reason that situation reduces water and salt within the physique. The drug may very well be a contributing issue to situations comparable to hyponatremia.
Affected person training ought to embrace offering info on the danger components comparable to salt consumption (Munshi et al., 2019). The affected person ought to take lower than 2,300 milligrams (mg) each day. Eat wholesome meals comparable to complete grains, fruits, and fish are necessary. Taking meals with potassium is essential in reducing blood stress. The affected person ought to preserve an optimum physique weight top ratio. Extra weight may cause diabetes or hypertension (American Diabetes Affiliation, 2020). The affected person ought to train frequently to decrease the danger of weight problems, stress, and hypertension.
Reflection
I discovered that the situation requires applicable interventions since it may be life-threatening. I discovered that sufferers with numerous autoimmune problems ought to get an applicable checkup to keep away from deterioration of the situation.
Well being promotion ought to embrace consuming a nutritious diet, decreasing salt consumption, and exercising frequently. The affected person ought to droop Chlorthalidone remedy since it may contribute to one of many situations.
Provision of care ought to respect the cultural background, age, and spiritual beliefs. The affected person requires satisfactory care and checkup for the reason that age could pose numerous well being dangers.
References
American Diabetes Affiliation. (2020). Glycemic targets: Requirements of medical care in diabetes—2020. Diabetes Care, 43(Suppl. 1), S66–S76. https://doi.org/10.2337/dc20-S006
George, J. C., Zafar, W., Bucaloiu, I. D., & Chang, A. R. (2018). Threat components and outcomes of fast correction of extreme hyponatremia. Scientific Journal of the American Society of Nephrology, 13(7), 984-992.
Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Endocrine, metabolic, and dietary problems. In Superior follow nursing within the care of older adults (2nd ed., pp. 361–406). F. A. Davis.
Koehler, V. F., Filmann, N., & Mann, W. A. (2019). Vitamin D standing and thyroid autoantibodies in autoimmune thyroiditis. Hormone and Metabolic Analysis, 51(12), 792-797.
Munshi, M., Nathan, D. M., Schmader, Ok. E., Mulder, J. E., & Givens, J. (2019). Therapy of kind 2 diabetes mellitus within the older affected person. UpToDate. Retrieved June eight, 2020, from https://www.uptodate.com/contents/treatment-of-type-2-diabetes-mellitus-in-the-older-patient
Strazzulla, L. C., Wang, E. H. C., Avila, L., Sicco, Ok. L., Brinster, N., Christiano, A. M., & Shapiro, J. (2018). Alopecia areata: illness traits, scientific analysis, and new views on pathogenesis. Journal of the American Academy of Dermatology, 78(1), 1-12.
