SOAP note Endocrine, health and medicine homework help

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User Generated

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wrrc2016

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Health Medical

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Use template I will upload it focus on endocrine disorders. The endocrine system consists of eight glands that are responsible for metabolism, growth and development, mood, sexual function, and reproduction. The eight glands are thyroid, parathyroid, hypothalamus, pituitary, adrenal, ovaries, testes, pineal, and pancreas. This patient is made up.

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Name: K.C Pt. Encounter Number:4854932 Date: 6/5/2-17 Age: 34 Sex: female SUBJECTIVE CC: Patient states, “I’ve had bad headaches” HPI: For about 3 months K.C has been progressively bothered by headaches that are left sided, typically throbbing, and can range from mild to moderately severe. Characteristically, her headaches are rated at 4 out of 10. She recently had a severe headache that she rated 8 over 10, she had to call off work, because of this headache. The headache was accompanied by nausea and vomiting. Her headaches have amplified in occurrence and now average once a week. The headaches usually last from 4 to 8 hours. However, the most recent headache, which was the most severe, lasted almost 12 hours. And throughout the headache bright lights was a nuisance to her and she just wants to lie down in a dark quiet room and try to sleep. Motrin provided little relief. She has noticed association with funk food but not with drinks. She has no other related symptoms, such as afebrile, no dental pain, no weakness, no numbness or loss of vision. She has no history of head injury or trauma. She recalls having comparable types of headache with nausea and vomiting that began at age 12 with her first period, recurred through her early 20s, then diminished to one every 2 or 3 months and disappeared until now. Medications: (List with reason for med ) Motrin by mouth 200mg x3 for headaches Multivitamin 1 tab daily PMH Allergies: NKA Medication Intolerances: NKA Chronic Illnesses/Major traumas NKA Hospitalizations/Surgeries “Have you ever been told that you have diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems, kidney problems, or psychiatric diagnosis?” Tonsillectomy, age 4, Appendectomy, age 16. G3, P3, 3 living children. Menarche age 12. Last menses 2 weeks ago. Family History Does your mother, father, or siblings have any medical or psychiatric illnesses? Is anyone diagnosed with: lung disease, heart disease, HTN, cancer, TB, DM, or kidney disease? Mother died, 68, stroke; had varicose veins, headaches, hypertension - Father died, 40, car accident - One brother, 53, has high blood pressure, otherwise well - One brother, 49, apparently well except for osteoarthritis - Daughter, 19, “migraine headaches,” otherwise well - Son, 21, well - Son, 20, well Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status ROS General Weight change, fatigue, fever, chills, night sweats, and energy level Cardiovascular Chest pain, palpitations, PND, orthopnea, and edema Skin Delayed healing, rashes, bruising, bleeding or skin discolorations, and any changes in lesions or moles Respiratory Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, and TB Eyes Corrective lenses, blurring, and visual changes of any kind Gastrointestinal Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, and black, tarry stools Ears Ear pain, hearing loss, ringing in ears, and discharge Genitourinary/Gynecological Urgency, frequency burning, change in color of urine. Contraception, sexual activity, STDs Female: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx Male: prostate, PSA, urinary complaints Nose/Mouth/Throat Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, and throat pain Musculoskeletal Back pain, joint swelling, stiffness or pain, fracture hx, and osteoporosis Breast SBE, lumps, bumps, or changes Neurological Syncope, seizures, transient paralysis, weakness, paresthesias, and black-out spells Psychiatric Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, and previous dx Heme/Lymph/Endo HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, and cold or heat intolerance OBJECTIVE Weight BMI Temp BP Height Pulse Resp General Appearance Healthy-appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first and then brighter later. Skin Skin is brown, warm, dry, clean, and intact. No rashes or lesions noted. HEENT Head is normocephalic, atraumatic, and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly gray with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa, pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair. Cardiovascular S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs. Capillary refills two seconds. Pulses 3+ throughout. No edema. Respiratory Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally. Gastrointestinal Abdomen obese; BS active in all the four quadrants. Abdomen soft, nontender. No hepatosplenomegaly. Breast Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin. Genitourinary Bladder is nondistended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness. No adnexal masses or tenderness. Ovaries are nonpalpable. (Male: Both testes are palpable, no masses or lesions, no hernia, and no uretheral discharge.) (Rectal as appropriate: No evidence of hemorrhoids, fissures, bleeding, or masses—Males: Prostrate is smooth, nontender, and free from nodules, is of normal size, and sphincter tone is firm). Musculoskeletal Full ROM seen in all four extremities as the patient moved about the exam room. Neurological Speech clear. Good tone. Posture erect. Balance stable; gait normal. Psychiatric Alert and oriented. Dressed in clean slacks, shirt, and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately. Lab Tests Urinalysis—pending Urine culture—pending Wet prep—pending Special Tests Diagnosis Include at least three differential diagnosis Final diagnosis ▪ Evidence for final diagnosis should be documented in your Subjective and Objective exams. PLAN including education o Plan: ▪ Further testing ▪ Medication ▪ Education ▪ Nonmedication treatments ▪ Follow-up o o Self-analysis and Clinical evidence based practice References
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Explanation & Answer

Attached.

Name: K.C

Pt. Encounter Number:4854932

Date: 6/5/2-17

Age: 34

Sex: female

SUBJECTIVE
CC:
Patient states, “I’ve had bad headaches”

HPI:
For about 3 months K.C has been progressively bothered by headaches that are left sided,
typically throbbing, and can range from mild to moderately severe. Characteristically, her
headaches are rated at 4 out of 10. She recently had a severe headache that she rated 8
over 10, she had to call off work, because of this headache. The headache was
accompanied by nausea and vomiting. Her headaches have amplified in occurrence and
now average once a week. The headaches usually last from 4 to 8 hours. However, the
most recent headache, which was the most severe, lasted almost 12 hours. And
throughout the headache bright lights was a nuisance to her and she just wants to lie
down in a dark quiet room and try to sleep. Motrin provided little relief. She has noticed
association with funk food but not with drinks. She has no other related symptoms, such
as afebrile, no dental pain, no weakness, no numbness or loss of vision. She has no
history of head injury or trauma. She recalls having comparable types of headache with
nausea and vomiting that began at age 12 with her first period, recurred through her early
20s, then diminished to one every 2 or 3 months and disappeared until now.
Medications: (List with reason for med )

Motrin by mouth 200mg x3 for headaches
Multivitamin 1 tab daily

PMH
Allergies:
NKA

Medication Intolerances:
NKA

Chronic Illnesses/Major traumas
NKA

Hospitalizations/Surgeries

“Have you ever been told that you have diabetes, HTN, peptic ulcer disease, asthma,
lung disease, heart disease, cancer, TB, thyroid problems, kidney problems, or
psychiatric diagnosis?”
Tonsillectomy, age 4, Appendectomy, age 16. G3, P3, 3 living children. Menarche age
12. Last menses 2 weeks ago.

Family History
Does your mother, father, or siblings have any medical or psychiatric illnesses? Is

anyone diagnosed with: lung disease, heart disease, HTN, cancer, TB, DM, or kidney
disease?
Mother died, 68, stroke; had varicose veins, headaches, hypertension - Father died, 40,
car accident - One brother, 53, has high blood pressure, otherwise well - One brother, 49,
apparently well except for osteoarthritis - Daughter, 19, “migraine headaches,” otherwise
well...