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NU611 Clinical Decision Making
Unit 8 Discussion
Clinical Practice
Post a discussion constructed as the ‘P’ (treatment plan) that completes the partial SOAP note accessed through the link below.
Include in the discussion:
Your treatment plan for the diagnosis that relates to the “chief complaint” – structure your Plan using the format outlined in your Typhon documentation policy (e.g. diagnostics, therapeutics, educational, consultation/collaboration)
Citations for each of the guidelines/evidence used to support the elements of your Plan
Construct a narrative discussion that identifies how your Plan either aligns with or does not align with the diabetes management regimen that is documented in the subjective data set (the ‘S’)
Attached file:
Week 8 SOAP NotePreview the document
Please be sure to validate your opinions and ideas with citations and references in APA format where appropriate.
The post and responses are valued at 20 points. Please review post and response expectations. Please review the rubric to ensure that your response meets criteria.
Estimated time to complete: 2 hours
Peer Response: Unit 8, Due Sunday by 11:59 pm CT
Clinical Practice
Instructions:
Construct a response to at least 2 of your peers commenting – ideally one who developed a Plan that encompassed all the same interventions that you did and one who did not.
Please be sure to validate your opinions and ideas with citations and references in APA format where appropriate.
Chief Complaint
The patient is a 67-year-old male, he presents to the clinic today with a chief complaint of
“feeling tired lately” and his “blood sugar has been between 170-200mg/dl before meals” when
he uses his blood sugar monitor. He also complains about “tingling sensations at the bottom of
my feet.”
History of Present Illness
Mr. V was first diagnosed with Type II diabetes in February 2017. He has had this
disease for a little over two years. His blood sugar has been elevated for the last several weeks.
In the morning when he wakes up he checks his blood sugar and reports that after a big evening
meal he feels exhausted and has elevated blood sugar the following morning. He has been taking
Farxiga 10mg 1PO QD, which has helped keep his blood sugar from spiking in the past, but now
it appears to no longer advantageous. Other methods needs to be investigated for achieving
stabilized blood sugar levels for this patient along with patient education and a diet and exercise
program.
Past Medical History
Mr. V reports a history of Atrial Fibrillation (AFIB) diagnosed 4/22/19 by a Cardiologist.
Diagnosed by primary care provider with Type II diabetes in 2017. He was diagnosed with
Hyperlipidemia in 2015. He sustained an injury to his chest during a mine collapse in 2011.
Allergies
He has no known drug, food, or environmental allergies.
Medications
Medications Mr. V takes:
• Farxiga 10mg 1po QD
• Lipitor 20 mg 1po QHS
• Metoprolol 25mg 1po BID
• Eloquis 5 mg 1po BID
Social History
Mr. V is married, he denies smoking, denies drinking alcohol, denies illicit drug use. He moved to the United States 5 years ago with his wife and two children from Russia. He is now retired, he worked as a miner throughout his working career. He has some challenges with the language and communicating, and likes to socialize with other Russians. Family History Mother: Deceased at 89, cardiovascular disease
Father: Deceased at 72, Type II Diabetes, cardiovascular disease
Male son: 26, healthy
Male son: 23, healthy
Sister: 60 years of age, Hyperlipidemia, Depression
Brother: Deceased at 63, Hep C, liver failure
Maternal Grandfather: Deceased at 67, cardiovascular disease
Maternal Grandmother: Deceased at 58, automobile accident
Paternal Grandfather: Deceased at 71, Type II Diabetes, cardiovascular disease
Paternal Grandmother: Deceased at 70, Hyperlipidemia, Hypertension
Health Maintenance
Patient received his yearly influenza vaccination in October of 2018. He had a colonoscopy October 2015. He received the shingles vaccination (Shingrix) in January 2018 and the 2nd vaccine injection May 2018, and he had his annual wellness exam, which also included an eye exam and hearing test. He received his pneumonia vaccine at the same time as his shingles vaccine in January 2018. He gets his teeth cleaned every 6 months, and has some periodontal disease which he is being treated for.
Review of Systems
ROS
General: feels tired and has elevated blood sugar/ denies fever or chills.
HEENT: denies headache, Ears and hearing are intact. Eyes denies blurry vision Nose and sinuses denies pain or blockage. Throat is not sore teeth are intact.
Neck: denies pain or nodules.
Cardiovascular: denies chest pain, has palpitations occasionally.
Respiratory: denies dyspnea, denies cough Gastrointestinal: denies constipation, regular bowel movements Genitourinary: patient gets up once in night to urinate, denies incontinence, nocturia, flank pain, burning or bleeding upon urination.
Peripheral vascular: denies extremity edema, coldness or leg cramps.
Musculoskeletal: denies pain or stiffness.
Endocrine: denies polydipsia, polyuria, has been feeling tired for the last few weeks.
Psychiatric: denies depression. Denies nervousness, anxiety, panic attacks, mood changes,
hearing voices, or desire to harm self or others. Denies trouble sleeping.
Neurological: reports tingling sensation soles of both feet noted over the past couple months
Physical Exam
Objective:
General: Caucasian male clean, AAOX3, good eye contact and speech, well developed.
Vital signs: Temp 98.6; pulse 73; blood pressure 130/80 ; respirations 18; O2 sat 96; wt 219lbs;
ht 6’; BMI 29.7
Skin: no cyanosis, warm, dry no signs of rash or sores
HEENT: head has no sign of injury; c/o headache. Eyes have no drainage, normal conjunctiva,
PERRLA. Ears and hearing are intact; no infection, Nose and sinuses have no drainage or pain.
Throat shows no redness, tongue and teeth intact
Neck: trachea midline, non-tender, no JVD
Respiratory: Respirations 18 breaths/ minute, breathe sounds clear and vesicular, no rhonchi, wheezes or crackles present. No cough present Cardiovascular: Apical pulse, arrhythmia noted, chest wall non-tender.
GI: Abdomen round, non -distended, without rash, palpable mass or organomegaly. Active bowel all 4 quadrants.
GU: No CVA tenderness
Peripheral vascular: skin pink, warm and dry and well perfused without edema, Nailbeds pink with <2 sec capillary refill Musculoskeletal Extremities are warm 0 edema. Radial and dorsal pedal pulses are all 2+ and symmetric. Full ROM all extremities Lymphatics: No Lymphadenopathy. Psychiatric: patient pleasant and cooperative Neurological: AAOX3, and cooperative. Cranial nerves II-XII intact. Normal gait. Maintains balance with eyes closed. Good, even strength and muscle tone. Reflexes are 2+ and symmetric with plantar reflexes. Rapid alternating movements intact. Monofilament testing bilateral feet demonstrates loss of protective sensation. Diagnostic Tests CBC, CMP, Lipid panel, HbA1c Assessment Dx: 1) DM II w Hyperglycemia Differential diagnosis 2) Diabetic Neuropathy 3) AFIB Diagnosis/Diagnoses 1) DM II w Hyperglycemia Code: E11.65 2) Diabetic Neuropathy Code: E08.40 3) AFIB Code: I48.9 The patient’s Hyperlipidemia is well managed on medication.

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