Adult health and gerontology
| Title | Adult health and gerontology | Prefered Language style | English (U.S.) |
| Type of document | Other (Not listed) | Number of pages/words | 3 Pages Double Spaced (approx 275 words per page) |
| Subject area | Nursing | Academic Level | Master |
| Style | APA | Number of sources/references | 1 |
| Order description: | |||
| SOAP TEMPLATE Theme: Diabetes type II of a 67 years male with co-morbities. (use a scenario at will) Chief Complaint: History of Present illness: Past Medical History: Past Surgical history: Family History: Social History: Medications: Allergy: Immunization Review of System General: Head: Eyes: Nose: Mouth/Throat: Neck: Thorax/lungs/Respiration: Cardiovascular: Peripheral Vascular: Gastrointestinal: Genitourinary: Skin/Integumentary: Musculoskeletal: Endocrine/Metabolic/Hematologic: Psychological: Neurological: Objective Physical Exam Vitals: General: HEENT: Neck: Lungs: Cardiovascular: Gastrointestinal: Musculoskeletal: Skin/Integumentary: Lower extremities: Rectal: Genitourinary: Neurologic Psychic Lab and tests results: Assessment and Listed Problems Diagnostic differentials: Plan of Care Diet Medications: Laboratory: Imaging: Education: Appointment: Clinical Reflection References |
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SOAP TEMPLATE
Subjective
Chief Complain:
History of Present illness:
Past Medical History:
Past Surgical history:
Family History:
Social History:
Medications:
Allergy:
Immunization
Review of System
General:
Head:
Eyes:
Nose:
Mouth/Throat:
Neck:
Thorax/lungs/Respiration:
Cardiovascular:
Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Skin/Integumentary:
Musculoskeletal:
Endocrine/Metabolic/Hematologic:
Psychological:
Neurological:
Objective
Physical Exam
Vitals:
General:
HEENT:
Neck:
Lungs:
Cardiovascular:
Gastrointestinal:
Musculoskeletal:
Skin/Integumentary:
Lower extremities:
Rectal:
Genitourinary:
Neurologic
Psychic
Lab and tests results:
Assessment and Listed Problems
Diagnostic differentials:
Plan of Care
Diet
Medications:
Laboratory:
Imaging:
Education:
Appointment:
Clinical Reflection
References
SOAP TEMPLATE
Subjective
Chief Complain: The patient suffers from has coronary heart disease, hypertension, type 2 diabetes, osteoporosis and gout.
History of Present Illness: The patient has type 2 diabetes, coronary heart disease, and hypertension
Past Medical History: In the past, the patient has suffered from the following conditions: hypothyroidism, osteoporosis, and gout.
Past Surgical history: the patient has a surgical history of the surgical history of right hip replacement, cataract on both eyes, gastric bypass and cholecystectomy surgery.
Family History: some of the patient’s conditions can be passed on from one generation to the next, i.e. they can be inherited. These conditions include coronary heart disease, type 2 diabetes, and hypertension.
Social History: the patient diet may have contributed to some of the health conditions. The patient was taking in a lot of proteins rich in uric acid which caused gout (Neogi, 2011). The patient’s diet and lack of physical exercise which increase the likelihood of getting osteoporosis.
Medications: The patient is currently on metformin which is the medication for type 2 diabetes. The patient is also using ACE (Angiotensin-converting enzyme) inhibitors and ARBs (Angiotensin II Receptor Blockers) to manage coronary heart disease and hypertension (Cooper-DeHoff et al., 2010). The patient can use levothyroxine to treat hypothyroidism and allopurinol which limit the amount of uric acid the body generates.
Allergy: the patient does not have any prior records of allergy
Immunization: the patient does not have any record of immunization history.
Review of System
General: the patient is a 67year old male who is coming from type 2 diabetes. Additionally, the patient has had a history of past conditions and surgery, and they include hypertension, coronary artery disease, osteoporosis, hypothyroidism, and gout and surgical history of right hip replacement, cataract on both eyes, gastric bypass and cholecystectomy surgery).
Head: the patient does not have any condition that affects their head.
Eyes: The patient had cataracts in both eyes. This condition was cured through surgery.
Nose: the patient does not have any condition that affects their nose.
Mouth/Throat: the patient has a history of hypothyroidism. This condition was however resolved through the use of prescribed medication.
Neck: the patient does not have any condition that affects their neck
Thorax/lungs/Respiration: the patient does not have any condition that affects their Thorax and lungs.
Cardiovascular: the patient has coronary artery disease.
Peripheral Vascular: the patient also suffers from hypertension.
Gastrointestinal: the patient has a history of gastric bypass and cholecystectomy surgery
Genitourinary: the patient does not have any history of genitourinary infection.
Skin/Integumentary: the patient has a history of gout infection which is characterized by swelling especially around joints.
Musculoskeletal: the patient has a history of hip failure and osteoporosis,
Endocrine/Metabolic/Hematologic: the patient does not have any history of endocrine disorders.
Psychological: the patient does not have any history of any psychological conditions.
Neurological: the patient does not have any history of the neurological condition.
Objective
Physical Exam: The patient has normal physical examination findings.
Vitals: the patient has high blood pressure and has a regular pulse pressure.
General: from a general perspective, the patient does not have any signs of an infection (patients with type 2 diabetes are often well-appearing).
HEENT: the patient has cataract
Neck: the patient does not have any anomaly on his neck
Lungs: the patient has normal atherosclerosis
Cardiovascular: the patient has coronary artery disease
Gastrointestinal: the patient has a history of gastric bypass and cholecystectomy surgery
Musculoskeletal: the patient has osteoporosis and hip failure
Skin/Integumentary: the patient has a gout infection which is characterized by swelling especially around joints.
Lower extremities: the patient does not exhibit additional signs of a new symptom.
Rectal: the patient does not have any rectal condition.
Genitourinary: the patient does not have any genitourinary infection.
Neurologic: the patient does not have any history of the neurological condition
Psychic: the patient does not have any history of any psychological conditions
Lab and tests results: the patient has high blood pressure, high sugar levels, clogged arteries, and edema. The patient has been diagnosed with hypertension, coronary artery disease, osteoporosis, hypothyroidism, and gout.
Assessment and Listed Problems
- The patient suffers from type 2 diabetes
- The patient has coronary heart disease
- The patient has hypertension
Diagnostic differentials:
- Patients with this condition usually do not have any specific differentiating symptom or sign
- Type 1 diabetes. May patients with this condition are not obese and have symptoms such as polydipsia, weight loss and polyuria (“Type 2 diabetes mellitus in adults Differential Diagnosis”, 2019).
- Latent autoimmune diabetes in adults (LADA). This condition is regarded as a subset of type 1 diabetes. Most times it is misclassified as type 2 diabetes.
Plan of Care
Medications: the patient is currently on metformin which is the medication for type 2 diabetes. The patient is also using ACE (Angiotensin-converting enzyme) inhibitors and ARBs (Angiotensin II Receptor Blockers) to manage coronary heart disease and hypertension (Cooper-DeHoff et al., 2010). The patient can use levothyroxine to treat hypothyroidism and allopurinol which limit the amount of uric acid the body generates.
Management: to manage type 2 diabetes, coronary artery condition and hypertension the patient should conduct regular exercise which lowers blood pressure, helps the insulin work effectively, and also decreases the risk of heart disease.
Diet: the patient should focus on eating well so that he can manage blood sugar levels and also manage his body weight. The patient should take a lot of fruits and vegetables and avoid a lot of cholesterol, salt and meat.
Laboratory: the patient should conduct constant blood glucose monitoring to monitor blood glucose levels. The patient should also go for regular checkups so that doctors can monitor his hypertension and coronary heart disease.
Imaging: the patient should undergo a computerized tomography so that doctors can look for calcium deposits which can cause CAD.
Education: the patient should ensure he takes this medication and watches his diet, performs regular exercise. Learning on how to implement these actions will help the patient manage his conditions.
Appointment: the patient should go for regular checkups so that doctors can monitor his vital signs.
Clinical Reflection: the patient should follow the treatment plan to manage type 2 diabetes and comorbidities.
References
Cooper-DeHoff, R. M., Gong, Y., Handberg, E. M., Bavry, A. A., Denardo, S. J., Bakris, G. L., & Pepine, C. J. (2010). Tight blood pressure control and cardiovascular outcomes among hypertensive patients with diabetes and coronary artery disease. Jama, 304(1), 61-68.
Neogi, T. (2011). Gout. New England Journal of Medicine, 364(5), 443-452.
Type 2 diabetes mellitus in adults Differential Diagnosis. (2019). Epocrates Online. Retrieved from https://online.epocrates.com/diseases/2435/Type-2-diabetes-mellitus-in-adults/Differential-Diagnosis
