What major problems can you identify with this patient?
Case Information: CC/PMI: GB is a 65 year-old male who comes in for a check-up on the request of his spouse. His last check-up was 10 years ago. He has no complaints other than some leg numbness and tingling from time-to-time, increased urination, and feeling thirsty and tired most of the time. SH: no smoking or alcohol consumption PMH: hypertension Physical Examination: GEN: well-nourished, slightly obese male VS: BP 170/100, HR 70, RR 12, T 98.7, Wt 89kg, Ht 5’8″ HEENT: PERRLA COR: RRR, NMRG CHEST: CTA NEURO: monofilament test shows decreased peripheral sensation EXT: normal Laboratory (fasting): Na 140 Cl 100 BUN 28 BG 250 K 4.3 HCO3 24 SCr 1.9 ALT 35 AST 40 Ca 9.0 Cholesterol 250 Triglycerides 300 HDL 35 LDL 155 Urine microalbumin/creatinine: 100 mcg/mg Important considerations for creating a SOAP note: 1. What major problems can you identify with this patient? 2. What subjective/objective information in the case supports each of those problems? Please list only information that pertains to each problem under each problem. 3. What is your assessment and plan for each problem? 4. Provide pharmacological and non-pharmacological care (don’t forget to be specific). Will you discontinue any medication that the patient is currently taking and/or add any new medications? 5. Include your therapeutic goals for each problem (use the subjective and objective information listed above to help you) 6. How will you monitor each problem and each medication included in your plan? 7. When will you suggest following up with the patient? 8. Is there any laboratory monitoring that will need to be conducted to assure the safety of the patient?
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