Posted: June 14th, 2023

The patient is a 67-year-old black male with a chief complaint

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 evaluation? 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

________________________

Subjective

The patient is a 67-year-old black male with a chief complaint of fatigue and shortness of breath.
He has a history of type 2 diabetes mellitus, hypertension, and heart failure.
He is currently taking insulin, lisinopril, hydrochlorothiazide, and carvedilol.
He is a retired construction worker and lives alone.
He has no significant family history.
Objective

Vital signs: BP 140/90 mmHg, HR 80 beats/min, RR 20 breaths/min, SpO2 95% on room air
Weight: 258 lbs, Height: 5’4″
BMI: 47.5
General: Well-developed, well-nourished male in no acute distress
HEENT: Pupils equal, round, and reactive to light; Sclerae anicteric; Neck veins flat
Lungs: Clear to auscultation bilaterally
Heart: Regular rate and rhythm, no murmurs, rubs, or gallops
Abdomen: Soft, non-tender, non-distended
Extremities: No edema
Assessment

Type 2 diabetes mellitus with diabetic polyneuropathy
Hypertension with heart failure
Bilateral primary osteoarthritis of the knee
Hyperlipidemia
Obesity
Long-term use of insulin
Long-term use of aspirin
Plan

Continue current medications
Start metformin 500 mg twice daily
Start lifestyle modification program (diet, exercise, weight loss)
Refer to cardiologist for evaluation of heart failure
Refer to physical therapist for evaluation of osteoarthritis
Monitor blood pressure, blood sugar, and lipid levels
Schedule follow-up appointment in 1 month
Reflection notes

My “aha” moment was when I realized that the patient’s fatigue and shortness of breath were likely due to his underlying medical conditions.
I would do differently in a similar patient evaluation by spending more time discussing the patient’s lifestyle and risk factors. I would also make sure to refer the patient to a dietitian and a physical therapist.