Reports occasional constipation takes prune juice and

  • No School
  • AA 1
  • 8
  • 100% (3) 3 out of 3 people found this document helpful

This preview shows page 6 - 8 out of 8 pages.

Reports occasional constipation, takes prune juice and increases hydration with positive effects. Musculoskeletal : Reports intermittent back pain. Patient report numbness ang tingling at bilateral lower extremities. Active range of motion at upper extremities but limited ROM at bilateral lower extremities. Adequate muscle strength noted with push back on arms. Good grip. Normal spinal curvature. Stable gait with ambulation. Deep tendon reflex assessed + 2 noted bilateral knees. Lymphatic: No palpable lymph nodes.
Image of page 6

Subscribe to view the full document.

SOAP NOTE Page 6 of 8 Genitalia : Deferred. Patient assessed during routine and as needed OBGYN appointments Neurologic: Alert and oriented x 3. Normal gait. Cranial nerves II-XII intact. Noted to be slightly unstable with closed eyes. Able to regain stability < 1 minute. Reflexes are 2+ symmetric. Present labs/diagnostic tests: Random blood sugar check 349mg/dl ASSESSMENT : Patient is a 52-year-old female present to the clinic for diabetes follow up. Patient has a medical a history of diabetes mellitus type 2, STEMI, hypertension, obesity, dyslipidemia. Patient’s recent A1C level is 10.7 and came in with for a follow up with compliant of bilateral lower extremity pain. Differential Diagnosis: 1. Type 2 diabetes mellitus with diabetic neuropathy – E11.40 2. Localized Edema of feet- R609 3. Peripheral vascular disease, unspecified – I73.9 Final Diagnosis w/ ICD9 code and highlight data that support decision : 1. Type 2 diabetes mellitus with diabetic neuropathy: E11.40 - Patient reports symptoms has lasted since her last visit. She has been experiencing numbness or reduced ability to feel pain or temperature changes, tingling and burning sensation, Chronic Diagnosis: 1. Type 2 diabetes mellitus with diabetic neuropathy – E11.40 2. Elevated serum creatinine - R79.89 3. STEMI involving oth coronary artery – I21.09 4. Essential hypertension - 110 5. Morbid obesity - E66.01 6. Dyslipidemia - E78.5 PLAN :
Image of page 7
SOAP NOTE Page 7 of 8 References Brown, M. T., Bussell, J., Dutta, S., Davis, K., Strong, S., & Mathew, S. (2016). Medication adherence: truth and consequences. The American journal of the medical sciences , 351 (4), 387-399. Colloca, L., Ludman, T., Bouhassira, D., Baron, R., Dickenson, A. H., Yarnitsky, D., ... & Eccleston, C. (2017). Neuropathic pain. Nature reviews Disease primers , 3 , 17002. Gilron, I., Baron, R., & Jensen, T. (2015, April). Neuropathic pain: principles of diagnosis and treatment. In Mayo Clinic Proceedings (Vol. 90, No. 4, pp. 532-545). Elsevier.
Image of page 8
  • Fall '19
  • Diabetes mellitus type 2, Diabetic neuropathy, dyslipidemia

What students are saying

  • Left Quote Icon

    As a current student on this bumpy collegiate pathway, I stumbled upon Course Hero, where I can find study resources for nearly all my courses, get online help from tutors 24/7, and even share my old projects, papers, and lecture notes with other students.

    Student Picture

    Kiran Temple University Fox School of Business ‘17, Course Hero Intern

  • Left Quote Icon

    I cannot even describe how much Course Hero helped me this summer. It’s truly become something I can always rely on and help me. In the end, I was not only able to survive summer classes, but I was able to thrive thanks to Course Hero.

    Student Picture

    Dana University of Pennsylvania ‘17, Course Hero Intern

  • Left Quote Icon

    The ability to access any university’s resources through Course Hero proved invaluable in my case. I was behind on Tulane coursework and actually used UCLA’s materials to help me move forward and get everything together on time.

    Student Picture

    Jill Tulane University ‘16, Course Hero Intern

Ask Expert Tutors You can ask 0 bonus questions You can ask 0 questions (0 expire soon) You can ask 0 questions (will expire )
Answers in as fast as 15 minutes