SOAP NOTE 2 TYPE II DIABETES
MALE PATIENT 65 YEARS OLD SEEN IN CLINIC. PT HAS HISTORY OF TYPE II DIABETES MELLITUS CONTROLLED, IDOPATHIC GOUT, MORBID OBESITY, HYPERTENSION, AND HYPERLIPIDEMIA. LABS: A1C 8.5, GLUCOSE 269. PT MEDICATIONS: LEVEMIR, METFORMIN, AMLODIPINE, ATOVASTATIN, GLIPIZIDE, HYDROXYZINE, OMPERAZOLE, TRAMADOL, HYDROCHLOROTHIAZIDE, VITAMIN D2.**ADD OTHER INFORMATION TO SOAP NOTE.**
Description
Complete a SOAP note on a patient from your current clinical experience.
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The patient must be an adult patient between the ages of 60-100 years old.
Select a patient presenting with a CHRONIC MEDICAL PROBLEM and utilize the rubric above to document a well-prepared SOAP note on this patient.
Utilize and ensure you provide citations for all references. Ensure you use two scholarly articles, including any of the required textbooks, to support your documentation. Ensure you utilize the rubric stated above to maximize your points fully.
To Prepare
Select a client that presents topics covered within the module assigned.
Create a Focused SOAP Note on this patient.
Review the Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.
Include at least three scholarly resources to support your assessment, diagnosis, and treatment planning.
SOAP Note Exemplar
Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
Objective: What observations did you make during the assessment?
Assessment: Discuss their review of systems (ROS). What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with Clinical Practice Guidelines.
Plan: In your presentation of the SOAP note, describe your treatment plan using clinical practice guidelines supported by evidence-based practice. Include a discussion on your chosen pharmacotherapeutic agents if prescribed or recommended. Include alternative treatments available and supported by valid research. All treatment choices must have a discussion of your rationale for the choice supported by valid research. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this treatment session?
Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow-up, discuss what your next intervention would be.