Posted: December 12th, 2022

Patient to use 67 years black male with High blood pressure

Patient to use 67 years black male with High blood pressure, Diabetes Type 2 on insulin. Live alone and has home health

Weight 258 Height 5’4
Diagnosis :
Type 2 diabetes mellitus with diabetic polyneuropathy
Hypertensive heart disease with heart failure

Chronic diastolic (congestive) heart failure

Bilateral primary osteoarthritis of knee

Type 2 diabetes mellitus with hyperglycemia

Type 2 diabetes mellitus with other specified complication

Other hyperlipidemia

Morbid (severe) obesity due to excess calories

Body mass index [BMI] 45.0-49.9, adult

Long term (current) use of insulin

Long term (current) use of aspirin

Medications
Tresiba FlexTouch Subcutaneous 100 UNIT/ML 40u Tresiba FlexTouch Subcutaneous 100 UNIT/ML 40 units
daily. Take AM subcutaneous(SQ)if > 200mg/dl consistently,
If you have a piece of Chess Pie with a meal give patient 15 units of Novolog (C)
NovoLOG FlexPen Subcutaneous 100 UNIT/ML 15 units Decrease Novolog (orange pen) to 15 units before
meals…If you are having a small meal take only 10 units daily. (C)
Meloxicam Oral 7.5 MG 1 Tab(s) Daily/By mouth
Farxiga Oral 10 MG 1 Tab(s) Daily/By mouth
Ozempic (0.25 or 0.5 MG/DOSE) Subcutaneous 2 MG/1.5ML 2 once weekly till sample pen completed then
start ozempic 1mg sub q weekly
Cholecalciferol Oral 1.25 MG (50000 UT) 1 Tab(s) Daily/By mouth
amLODIPine Besylate Oral 10 MG 1 Tab(s) Daily By mouth
Aspirin Oral 81 MG 1 Tab(s) Daily By mouth
Carvedilol Oral 12.5 MG 1 Tab(s) Twice daily. By mouth
Furosemide Oral 40 MG 1 Tab(s) Twice daily. By mouth
Losartan Potassium-HCTZ Oral 100-25 MG 1 Tab(s) Daily By mouth
Potassium 20MG/By mouth/1(tab) Twice daily
Celecoxib Oral 200 MG 1 Cap(s) Daily By mouth

To prepare:

Review this week’s Learning Resources, including the Focused SOAP Note Template.
Select a patient who you saw at your practicum site during the last 3 weeks. With this patient in mind, consider the following:
Subjective: What details did the patient provide regarding his or her personal and medical history?
Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities and psychosocial issues. Choose a patient you saw at your practicum site in the last three weeks. Consider the following with this patient in mind:
Subjective: What information about the patient’s personal and medical history did he or she provide?
What observations did you make during the physical examination? Include any relevant positive and negative physical examination findings. Describe whether the patient had any morbidities or psychosocial problems.
Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 code for the diagnosis. What was your primary diagnosis and why?
Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
Reflection notes: What was your “aha” moment? What would you do differently in a similar patient Assessment?

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