Exam (elaborations) NR 511 Week 6 SOAP NOTE Michael

Exam (elaborations) NR 511 Week 6 SOAP NOTE Michael Chief Complaint (CC): “unusually tired” History of present illness (HPI): A few weeks ago came down with the cold. Everyone in the family has been sick. Increased tiredness over that time. Lack of appetite and has lost weight. Always thirsty and has wet the bed last week. Past Medical History (PMH): Age 10. Mother reports general health as good: no childhood or chronic illnesses. Surgeries: none. Hospitalizations: none. Immunizations: UTD: allergies: Penicillin, gets a rash no ETOH, tobacco, illicit drugs. Sleeping 8-10 hours a night. Medications: daily multivitamin Family History (FH): Parents and siblings are in good health, Maternal grandmother: HTN and hyperlipidemia. Maternal grandfather: HTN and hyperlipidemia. Paternal grandparents deceased: Paternal grandmother: brain Ca, Paternal grandfather: leukemia Social History(SH): Good student, oldest of four children. Lives with parents, grandparents and siblings. Has 2 dogs and a cat. Review of Systems (ROS). General: (-) fever, (-) chills, (+) fatigue (-) nausea, (-) vomiting Ears: (-) pain Nose: (-)nasal congestion, (-) discharge Cardiovascular: (-) chest pain, (-) palpitation, (-) dizziness Respiratory: (-) Shortness of breath, (-)wheezes Gastrointestinal: (-) heartburn, (-) indigestion Lymphatics: (-) swelling 0: OBJECTIVE DATA Constitutional: alert, oriented and cooperative VS: Height: 48 inches weight 78 pounds BP 110/70 T 98.2 P 65 R 16.BMI: 23.8 General: Alert and cooperative, appears tired and distracted. HEENT: head normocephalic. Hair thick and distribution even throughout scalp. Eyes: Sclera clear. Conjunctiva: white, PERRLA, EOMs intact. Ears: Tympanic membranes gray and intact This study source was downloaded by from CourseH on :32:41 GMT -05:00 This study resource was shared via CourseH NR 511 Week 6 SOAP NOTE Michael with light reflex noted. Pinna and tragus nontender Nose: Nares patent without exudate. Sinuses nontender to palpation.Throat: Oropharynx dry, no lesions or exudate. Tonsils ¼ bilaterally. Teeth in good repair, no cavities noted. Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses. Cardiopulmonary: Heart S1 and S2 noted, RRR, no murmurs, noted. PMI at 5th ICS. Lungs clear to auscultation bilaterally. Respirations unlabored. Skin: color is pale pink, no cyanosis or pallor. Skin cool, dry and intact. Poor turgor. No moles or skin changes. Abdomen: Abdomen round, soft, with hypoactive bowel sounds noted. No organomegaly noted. Musculoskeletal: reflexes WNL. Gait steady. Testing Results: CBC: WBC 7, Hgb 14 Hct 40 RBC 4.3 MCV 78 MCHC 34 RDW 11.5 Fasting glucose 136 mg/dL TSH: 2.6 mIU/L free T4 15 pmol/L A: ASSESSMENT: 1: Hypergylcemia (ICD-10 R73.9)- is an abnormally high blood glucose level as a result of beta cell destruction (Dunphy, Winland-Brown, Porter, & Thomas, 2015). Common symptoms include polyuria, polydipsia, polyphagia, nocturnal enuresis, anorexia, weakness, fatigue, blurred vision, and vision changes (Dunphy et al., 2015). P: PLAN 1. Medications: No treatment until secondary confirmation (Pippitt & Gurgle, 2016). 2. Additional diagnostic tests. Hemoglobin A1C greater than or equal to 6.5% or another repeat fasting glucose greater than 126 mg/dl are needed to confirm diagnosis (Pippitt & Gurgle, 2016). Another confirmation would be a random glucose of greater than 200mg/dl with signs and symptoms of diabetes (Pippitt & Gurgle, 2016). EKG, urinalysis, fasting lipid profile, liver enzyme, and microalbuminuria (Dunphy et al., 2015). This study source was downloaded by from CourseH on :32:41 GMT -05:00 This study resource was shared via CourseH 3. Education: (Pippitt & Gurgle, 2016). If vomiting or diarrhea persist for 2 hours, a fever greather than 10, a glucose greater than 240mg/dl with ketones in urine seek medical attemtion (Dunphy et al., 2015). 4. Referrals: Refer to endocrinologist for new diagnosis and treatment (Pippitt & Gurgle, 2016). Referral to nutrition to help manage healthy eating choices (Pippitt & Gurgle, 2016). 5. Follow up. Return to the clinic in 48 hours for repeat fasting glucose (Pippitt & Gurgle, 2016). Mary S: SUBJECTIVE DATA Chief Complaint (CC): “I have not felt like I had any energy since I got that cold about 6 weeks ago” History of present illness (HPI): Reports feeling short of breath when doing regular activities, finding it harder to keep up with the kids. Her appetite is less and she is finding it harder to concentrate. At times she feels lightheaded. She says her periods have been heavier since she had her twins but there has been no increased flow or irregular bleeding. LMP: 1 weeks ago 2/2/2017 Past Medical History (PMH): Age 44. No chronic illness or injuries. Denied past illness or injuries. Hospitalized x 2 for childbirth, no surgeries. NKDA. Drinks alcohol socially, denies tobacco or illicit drug use. Sleeps 6-7 hours/night. No current medications. Takes a daily multivitamin and a B complex supplement. Family History (FH): Husband and father both smoke but not in the house. Parents are immigrants from Ireland. Mother has Hx of hypertension and hyperlipidemia. Father has Hx of HTN and hyperlipidemia. Siblings in good health. Social History(SH): Married. Lives with husband, 4 children, and parents. Works in an ordering department. Denies tobacco use. Denies illicit drug use. Drinks socially. High school graduate. Review of Systems (ROS). General: (-) fever, (-) chills, (+) fatigue, (+) cold intolerance Head: (-) headache Ears: (-) pain Eyes: (+) edema This study source was downloaded by from CourseH on :32:41 GMT -05:00 This study resource was shared via CourseH Nose: (-)nasal congestion, (-) discharge Mouth and throat, (-)sore throat, (-) difficulty swallowing, (-) swelling Cardiovascular: (-) chest pain, (-) palpitation, (-) dizziness Respiratory: (-) Shortness of breath, (-)wheezes Abdominal: (-)pain Lymphatics: (-) swelling, (-) tenderness 0: OBJECTIVE DATA Constitutional: alert, oriented and cooperative. Gait normal. VS: height 64 inches, weight 155 pounds BP 115/86 T 99.0 P 62 R 16. BMI: 26.6 HEENT: head normocephalic. Hair thick with distribution throughout scalp. Eyes: .Sclera clear. Conjunctiva: white, PERRLA, EOMs intact. Slight periorbital edema noted. Ears: Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender Nose: Nares patent without exudate. Sinuses nontender to palpation. Throat: Oropharynx moist, no lesions or exudate. Tonsils ¼ bilaterally. Teeth in good repair, no cavities noted. Tongue noted to have teeth indentations around the edges. Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses. Cardiopulmonary: Heart S1 and S2 noted, RRR, no murmurs, noted. Peripheral pulses equally bilaterally. Lungs clear to auscultation bilaterally. Respirations unlabored. Abdomen: Abdomen round, soft, with bowel sounds noted in all four quadrants. No organomegaly noted. Skin: Skin warm, dry and intact, color is pale pink, no cyanosis or pallor. Testing Results: CBC: WBC 8 Hgb 10.1 Hct 33 RBC 3.2 MCV 74 MCHC 27.8 RDW 18.1 TSH: 6.5 mIU/L antithyroid antibodies: 1:1,800 A: ASSESSMENT: 1: Hypothyroidism (ICD-10 E03.9)- is caused by a deficiency in the amount of TH produced by the thyroid gland (McCance, Huether, Brashers, & Rote, 2013). Early S&S include: fatigue, weight gain, constipation, cold intolerance, dry skin, headaches, myalgia, weakness,