Patient to use 67 years black male with High blood pressure, Diabetes Type 2 on insulin. Live alone and has home health
Weight 258 Height 5’4
Diagnosis :
Type 2 diabetes mellitus with diabetic polyneuropathy
Hypertensive heart disease with heart failure
Chronic diastolic (congestive) heart failure
Bilateral primary osteoarthritis of knee
Type 2 diabetes mellitus with hyperglycemia
Type 2 diabetes mellitus with other specified complication
Other hyperlipidemia
Morbid (severe) obesity due to excess calories
Body mass index [BMI] 45.0-49.9, adult
Long term (current) use of insulin
Long term (current) use of aspirin
Medications
Tresiba FlexTouch Subcutaneous 100 UNIT/ML 40u Tresiba FlexTouch Subcutaneous 100 UNIT/ML 40 units
daily. Take AM subcutaneous(SQ)if > 200mg/dl consistently,
If you have a piece of Chess Pie with a meal give patient 15 units of Novolog (C)
NovoLOG FlexPen Subcutaneous 100 UNIT/ML 15 units Decrease Novolog (orange pen) to 15 units before
meals…If you are having a small meal take only 10 units daily. (C)
Meloxicam Oral 7.5 MG 1 Tab(s) Daily/By mouth
Farxiga Oral 10 MG 1 Tab(s) Daily/By mouth
Ozempic (0.25 or 0.5 MG/DOSE) Subcutaneous 2 MG/1.5ML 2 once weekly till sample pen completed then
start ozempic 1mg sub q weekly
Cholecalciferol Oral 1.25 MG (50000 UT) 1 Tab(s) Daily/By mouth
amLODIPine Besylate Oral 10 MG 1 Tab(s) Daily By mouth
Aspirin Oral 81 MG 1 Tab(s) Daily By mouth
Carvedilol Oral 12.5 MG 1 Tab(s) Twice daily. By mouth
Furosemide Oral 40 MG 1 Tab(s) Twice daily. By mouth
Losartan Potassium-HCTZ Oral 100-25 MG 1 Tab(s) Daily By mouth
Potassium 20MG/By mouth/1(tab) Twice daily
Celecoxib Oral 200 MG 1 Cap(s) Daily By mouth.
To prepare:
Review this week’s Learning Resources, including the Focused SOAP Note Template.
Select a patient who you saw at your practicum site during the last 3 weeks. With this patient in mind, consider the following:
Subjective: What details did the patient provide regarding his or her personal and medical history?
Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities and psychosocial issues.
Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 code for the diagnosis. What was your primary diagnosis and why?
Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
Reflection notes: What was your “aha” moment? What would you do differently in a similar patient Assessment?
-Sample Answer-
Subjective: The patient is a 67-year-old black male who lives alone and has home health. He has a history of high blood pressure, type 2 diabetes, and diabetic polyneuropathy. He also has hypertensive heart disease with heart failure, bilateral primary osteoarthritis of the knee, and hyperlipidemia. He is morbidly obese with a BMI of 45-49.9. He is currently taking insulin and aspirin long term.
Objective: During the physical assessment, the patient’s blood pressure was elevated and he had signs of edema in his lower extremities. He also had dry skin and poor wound healing. He had limited range of motion in his knees due to osteoarthritis. The patient presented with several morbidities including diabetes, heart failure, and obesity. He also had psychosocial issues as he lives alone and has limited social support.
Assessment: The differential diagnoses for this patient include uncontrolled hypertension, uncontrolled diabetes, heart failure, and osteoarthritis. The primary diagnosis is uncontrolled hypertension and diabetes with complications including diabetic polyneuropathy, heart failure, and osteoarthritis. The ICD-10 codes for these diagnoses are I10 for hypertension, E11 for uncontrolled type 2 diabetes, I50.1 for congestive heart failure, and M17 for osteoarthritis.
Plan: The plan for diagnostics includes ordering blood tests to check for diabetes control, kidney function, and electrolyte levels. Further Assessment with an echocardiogram may be necessary to assess the severity of the heart failure. The primary treatment plan includes adjusting the patient’s medications to better control his blood pressure and diabetes, as well as initiating pharmacologic treatment for heart failure. Non-pharmacologic treatments such as weight loss and exercise may also be recommended. The patient will be referred to physical therapy for management of his osteoarthritis and will be advised to follow a healthy diet and stop smoking. Follow-up with the primary care provider and home health nurse will be scheduled to monitor the patient’s progress and adjust treatment as necessary.
Reflection notes: My “aha” moment in this patient Assessment was realizing the importance of addressing both the hypertension and diabetes in the treatment plan, as they are both contributing to the patient’s morbidities and overall poor health. In a similar patient Assessment, I would make sure to thoroughly assess for comorbidities and consider their impact on the treatment plan. I would also ensure that the patient has a clear understanding of their diagnoses and treatment plan and provide them with resources for self-management and support.
