Discussion: Low Blood Sugar SOAP Note

Discussion: Low Blood Sugar SOAP Note

Discussion: Low Blood Sugar SOAP Note

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Week 9: Endocrine, Metabolic, and Nutritional Disorders Nov 1.

Nutritional disorders in older adults may present in many different ways and be caused or affected by a number of patient factors and comorbidities. Consider a patient with decreased cognitive function and mobility who may experience undernutrition because of low variety and quantity of food consumed. Another patient suffering from obesity may experience fatty liver, diabetes, or colon cancer due to dietary fat intake. Issues such as food scarcity and cost also play a role in nutritional disorders for this population.

This week, you explore geriatric patient presentations nutritional disorders, as well as endocrine and metabolic disorders. You also examine assessment, diagnosis, and treatment for these disorders and complete a SOAP note.

Learning Objectives

Students will:

  • Evaluate patients presenting with endocrine, metabolic, or nutritional disorders
  • Develop differential diagnoses for patients with endocrine, metabolic, or nutritional disorders
  • Develop appropriate treatment plans, including diagnostics and laboratory orders, for patients with endocrine, metabolic, or nutritional disorders
  • Analyze the diagnosis and treatment of endocrine, metabolic, or nutritional disorders

Assignment: Assessing, Diagnosing, and Treating Endocrine, Metabolic, and Nutritional Disorders

Like many disorders affecting other systems, those related to endocrine, metabolic, and nutritional concerns have specific considerations for geriatric populations. Accurate history taking of symptoms associated with these disorders is essential for completing an assessment of the older adult, since onset of symptoms (for example, with some endocrine disorders) may appear more subtly than those in younger patients. It can also be difficult to determine onset and severity of illness in older adults.

Keep in mind special considerations for older adults as you complete your case analysis and SOAP note on endocrine, metabolic, and nutritional disorders.

Photo Credit: [Mark Hatfield]/[iStock / Getty Images Plus]/Getty Images

To prepare:

  • Review the case study provided by your Instructor.
  • Reflect on the patient’s symptoms and aspects of disorders that may be present.
  • Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the case.
  • Access the Focused SOAP Note Template in this week’s Resources.

The Assignment:

Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:

  • Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. Provide a review of systems.
  • Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results? Discussion: Low Blood Sugar SOAP Note
  • Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential in or out. Explain you critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
  • Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.
  • Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. Follow APA 7th edition formatting. Discussion: Low Blood Sugar SOAP Note

 

Week 9 Case 1: Low Blood Sugar

HPI: Ms. Lewis is a 63-year old female who comes into your office with concerns of low blood sugar in the morning, fasting.  She reports seeing blood sugar as low as 50 fasting in the mornings for the last few weeks.  She has a known history of Diabetes, Hypertension, Hyperlipidemia, and Chronic Osteoarthritis.  She also reports elevated blood pressures. Her blood pressure at presentation is 165/90.

RESOURCE FOR THIS WEEK: Review endocrine-related Evidence Based Practice Guidelines.

Ms. Lewis is a 63 y/o female who is AAOX4. She makes no unusual motor movements and demonstrates no tics.  She denies any visual or auditory hallucinations. She denies any suicidal thoughts or ideations. She denies any falls, denies any pain.

(All other Review of System and Physical Exam findings are negative other than stated.)

Vital Signs: BP 165/90, HR 89, RR 20, Temp 98.1

PMH: Hypertension, Hyperlipidemia, Diabetes, Chronic Osteoarthritis

Allergies: Penicillin, lisinopril

Medications:

Women’s One A Day-Multivitamin daily

Chlorthalidone 25mg daily

Fish Oil 1 tablet daily

Amlodipine 5mg p.o. daily

Atorvastatin 40mg p.o. at bedtime daily

Novolog 10 units with meals TID

Aspirin 81mg p.o. daily

Lantus 25 units Subcutaneous nightly

Ergocalciferol 50,000 units PO once a month

 

Social History: as stated in Case Study

ROS: as stated in Case study

 

Diagnostics/Assessments done:

  • CXR- Last cxr showed no cardiopulmonary findings. Within normal limits.
  • Basic Metabolic Panel and CBC as shown below
  • Vitamin D Level- as noted below in lab results
TEST RESULT REFERENCE RANGE
GLUCOSE 85 65-99
SODIUM 134 135-146
POTASSIUM 4.2 3.5-5.3
CHLORIDE 104 98-110
CARBON DIOXIDE 29 19-30
CALCIUM 9.0 8.6- 10.3
BUN 20 7-25
CREATININE 1.01 0.70-1.25
GLOMERULAR FILTRATION RATE (eGFR) 76 >or=60 mL/min/1.73m2

 

 

TEST RESULT REFERENCE RANGE
Vitamin D 1,25 OH 58 36-144

 

 

 

TEST RESULT REFERENCE RANGE
WBC 7.3 3.4- 10.8
RBC 4.31 135-146
HEMOGLOBIN 14 13-17.2
HEMATOCRIT 42% 36-50
MCV 90 80-100
MCHC 34 32-36
PLATELET 272 150-400

 

 

 

Rubric Detail

 

Select Grid View or List View to change the rubric’s layout.

Name: NRNP_6540_Week9_Assignment_Rubric

  Excellent Fair Poor
Create documentation in the Focused SOAP Note Template about the patient in the case study to which you were assigned.

In the Subjective section, provide:

• Chief complaint

• History of present illness (HPI)

• Current medications, checked against Beers Criteria

• Allergies

• Patient medical history (PMHx)

• Review of systems

9 (9%) – 10 (10%)

The response throughly and accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A thorough cross-check of medications against the Beers Criteria has been completed and appropriate alternative drugs recommended if applicable.

7 (7%) – 7 (7%)

The response describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis, but is somewhat vague or contains minor innacuracies. A cross-check of medications against the Beers Criteria has been completed but alternatives may be missing. Discussion: Low Blood Sugar SOAP Note

0 (0%) – 6 (6%)

The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. A cross-check of medications against the Beers Criteria has not been completed. Or, subjective documentation is missing.

In the Objective section, provide:

• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history

• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses

9 (9%) – 10 (10%)

The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.

7 (7%) – 7 (7%)

Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies.

0 (0%) – 6 (6%)

The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or, objective documentation is missing.

In the Assessment section, provide:

• At least three (3) differentials with supporting evidence. Explain what rules each differential in or out, and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.

23 (23%) – 25 (25%)

The response lists in order of priority at least three distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the conditions selected.

18 (18%) – 19 (19%)

The response lists three possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each.

0 (0%) – 17 (17%)

The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.

In the Plan section, provide:

• A detailed treatment plan for the patient that addresses each diagnosis, as applicable. Includes documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, and any planned follow up visits.

• A discussion related to health promotion and disease prevention taking into consideration patient factors, PMH, and other risk factors.
• Reflections on the case describing insights or lessons learned.

27 (27%) – 30 (30%)

The response thoroughly and accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. A thorough and accurate discussion of health promotion and disease prevention related to the case is provided. Reflections on the case demonstrate strong critical thinking and synthesis of ideas.

21 (21%) – 23 (23%)

The response somewhat vaguely or inaccurately outlines a treatment plan for the patient. The discussion on health promotion and disease prevention related to the case is somewhat vague or contains innaccuracies. Reflections on the case demonstrate adequate understanding of course topics.

0 (0%) – 20 (20%)

The response does not address all diagnoses or is missing elements of the treatment plan. The discussion on health promotion and disease prevention related to the case is vague, innaccurate, or missing. Reflections on the case are vague or missing.

Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. 9 (9%) – 10 (10%)

The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents the latest in standards of care and provides strong justification for treatment decisions.

7 (7%) – 7 (7%)

Three evidence-based resources are provided to support treatment decisions, but may not represent the latest in standards of care or may only provide vague or weak justification for the treatment plan.

0 (0%) – 6 (6%)

Two or fewer resources are provided to support treatment decisions. The resources may not be current or evidence-based, or do not support the treatment plan. Discussion: Low Blood Sugar SOAP Note

Written Expression and Formatting—Paragraph Development and Organization:

Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.

5 (5%) – 5 (5%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity.

A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.

3 (3%) – 3 (3%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time.

Purpose, introduction, and conclusion of the assignment is vague or off topic.

0 (0%) – 2 (2%)

Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time.

No purpose statement, introduction, or conclusion were provided.

Written Expression and Formatting—English writing standards:

Correct grammar, mechanics, and proper punctuation

5 (5%) – 5 (5%)

Uses correct grammar, spelling, and punctuation with no errors.

3 (3%) – 3 (3%)

Contains several (three or four) grammar, spelling, and punctuation errors.

0 (0%) – 2 (2%)

Contains many (≥ five) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list. 5 (5%) – 5 (5%)

Uses correct APA format with no errors.

3 (3%) – 3 (3%)

Contains several (three or four) APA format errors.

0 (0%) – 2 (2%)

Contains many (≥ five) APA format errors.

Total Points: 100  

Name: NRNP_6540_Week9_Assignment_Rubric

 

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