Introduction
The purpose of this paper is to demonstrate the ability to analyze the subjective and objective information from the case study to formulate a management plan using evidenced based guidelines. It also dem
...
Introduction
The purpose of this paper is to demonstrate the ability to analyze the subjective and objective information from the case study to formulate a management plan using evidenced based guidelines. It also demonstrates the student’s ability to write SOAP note in chronological order. In this case study the assessment, treatment plan, medication and its cost, and SOAP note will be discussed in detailed.
Assessment
Based on the chief complaints, subjective, and objective findings patient’s primary diagnosis is type 2 diabetes mellitus (E11). The pathophysiologic mechanism of type 2 diabetes involves insulin resistance and decreased insulin secretion by beta cells of pancreas (McCance, Huether, Brashers, & Rote, 2013). The genetic, epigenetic, and environmental factors interfere the ability to sense increased blood glucose, insulin synthesis, and insulin secretion, which causes type 2 diabetes. The prevalence of type 2 diabetes increased with age, is higher among African American female, but obesity, hypertension, physical inactivity, and family history predominantly increased the risk of type 2 diabetes (McCance et al., 2013). Polyuria, polydipsia, and polyphagia are the classis symptoms of diabetes, but patient may present with nonspecific symptoms such as fatigue, pruritus, recurrent infection, visual change, paresthesia, or weakness (McCance et al., 2013). Based on the information given, the pertinent positive findings include very fatigued, no energy, weight gain, increased hunger and thrust, and increased frequency of urination for past 3 month. The polydipsia, polyuria, and polyphagia also known as 3P are the hallmark symptoms of diabetes (American Diabetes Association [ADA], 2017). The laboratory finding indicates her hemoglobin A1C is 6.9%, total cholesterol is 230 mg/dl, LDL 144mg/dl, VLDL 36 mg/dl, HDL 38mg/dl and triglycerides 232. The hemoglobin A1C of ≥ to 6.5% is one
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