Walden University Health & Medical Case Study

Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:

• Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. Provide a review of systems.
• Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results?
• Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential in or out. Explain you critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
• Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.
• Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. Follow APA 7th edition formatting.

Case Study 1:

HPI: Ms. Lewis is a 63-year old female who comes into your office with concerns of low blood sugar in the morning, fasting. She reports seeing blood sugar as low as 50 fasting in the mornings for the last few weeks. She has a known history of Diabetes, Hypertension, Hyperlipidemia, and Chronic Osteoarthritis. She also reports elevated blood pressures. Her blood pressure at presentation is 165/90.

RESOURCE FOR THIS WEEK: Review endocrine-related Evidence Based Practice Guidelines.

Ms. Lewis is a 63 y/o female who is AAOX4. She makes no unusual motor movements and demonstrates no tics. She denies any visual or auditory hallucinations. She denies any suicidal thoughts or ideations. She denies any falls, denies any pain.

(All other Review of System and Physical Exam findings are negative other than stated.)

Vital Signs: BP 165/90, HR 89, RR 20, Temp 98.1

PMH: Hypertension, Hyperlipidemia, Diabetes, Chronic Osteoarthritis

Allergies: Penicillin, lisinopril

Medications:

Women’s One A Day-Multivitamin daily

Chlorthalidone 25mg daily

Fish Oil 1 tablet daily

Amlodipine 5mg p.o. daily

Atorvastatin 40mg p.o. at bedtime daily

Novolog 10 units with meals TID

Aspirin 81mg p.o. daily

Lantus 25 units Subcutaneous nightly

Ergocalciferol 50,000 units PO once a month

Social History: as stated in Case Study

ROS: as stated in Case study

Diagnostics/Assessments done:

• CXR- Last cxr showed no cardiopulmonary findings. Within normal limits.
• Basic Metabolic Panel and CBC as shown below
• Vitamin D Level- as noted below in lab results

TEST	RESULT	REFERENCE RANGE
GLUCOSE	85	65-99
SODIUM	134	135-146
POTASSIUM	4.2	3.5-5.3
CHLORIDE	104	98-110
CARBON DIOXIDE	29	19-30
CALCIUM	9.0	8.6- 10.3
BUN	20	7-25
CREATININE	1.01	0.70-1.25
GLOMERULAR FILTRATION RATE (eGFR)	76	>or=60 mL/min/1.73m2

TEST	RESULT	REFERENCE RANGE
Vitamin D 1,25 OH	58	36-144

TEST	RESULT	REFERENCE RANGE
WBC	7.3	3.4- 10.8
RBC	4.31	135-146
HEMOGLOBIN	14	13-17.2
HEMATOCRIT	42%	36-50
MCV	90	80-100
MCHC	34	32-36
PLATELET	272	150-400