Chronic illness SOAP note and clinical decision making using 2 EBP

Chronic illness SOAP note and clinical decision making using 2 EBP

Instructions

Select a patient that you have encountered in your clinical practice with a chronic health problem.
Interview the client/family members. Include the following information-
Setting: Community clinic, Private practice, Skilled nursing facility, Home health

Clinical information:
Chief complaint, HPI, PMH, PSH, FH, ROS, PE, Diagnostic Testing, Medical Decision Making, Diagnosis/Clinical Impression, Plan/Interventions, Recommendations, Education, Health promotion

Use of Research Findings and other evidence in Clinical Decision Making

Choose 2 EBP resources influencing the care provided to your client. Discuss the similarities and differences that you read for those two EBP peer reviewed articles.

Submit scholarly paper, with writing style at the graduate level, including all of the following:

• Reviews topic and explains rationale for its selection in the context of client care.
• Evaluates key concepts related to the topic.
• Describes multiple viewpoints if this is a controversial issue or one for which there are no clear guidelines.
• Assesses the merit of evidence found on this topic i.e. soundness of research
• Evaluates current EBM guidelines, if available. Or, recommends what these guidelines should be based on available research.
• Discusses how the evidence did impact/would impact practice. What should be done differently based on the knowledge gained?
• Consider cultural, spiritual, and socioeconomic issues.

Solution

Week 7 Signature Assignment

SOAP Note

Patient Initials: R.T.                Age: 35 years old           Race: White       Gender: Male

SUBJECTIVE DATA:

Chief Complaint (CC): “I have been having frequent urination and fatigue for past few weeks.”

History of Present Illness (HPI): R.T. is a 35-year-old white male who has visited the community clinic unaccompanied. The patient reports that his reason for visiting the clinic today is to get assistance with the problem of frequent urination accompanied by fatigue. R.T. denies sore throat, persistent cough, or a headache. These symptoms began about 2 weeks ago and they seem not to go away. Besides, he feels extremely thirsty better parts of the day. His daily diet comprises of sandwiches with milk and sugar for breakfast. He also reports eating a lot of potato chips for lunch while at work and carbohydrate-rich foods with vegetables for dinner.

Location: Urinary system.

Onset: 2 weeks ago.

Characteristic/Quality: Frequent urination.

Associated symptoms: Fatigue and extreme thirst.

Timing: The frequency of urination is higher at night than during the day.

Exacerbating or relieving factors: None reported.

Severity or quantity: Quality of urine exceeds usual amount.

Medications: None

Allergies: No known drug or food allergies reported.

Past Medical History (PMH): Hypertension.

Past Surgical History (PSH): Denies surgical history.

Significant Family History: Maternal grandfather has diabetes, died at age 85yrs. Parents- HTN.

Sexual/Reproductive History: R.T. is sexually active and he is happily married with two children, a girl and a boy. He denies have extra-marital affairs.

Personal/Social History: R.T. is an accountant at a coffee factory in the community. He walks to work every day because the factory is near his current place of residence. R.T. denies cigarette and alcohol use. He is a Christian who goes to the church every Sunday. His daily diet comprises of sandwiches with milk and sugar for breakfast. He also reports eating a lot of potato chips for lunch while at work and carbohydrate-rich foods with vegetables for dinner. He occasionally eats meat.

Immunization History: Immunization records indicate that R.T. received all immunizations at the recommended ages.

ROS:

General: R.T. has reported a slight reduction in body weight since he started to experience his current symptoms a week ago. He feels fatigues, especially during the day when the sun is hot. He denies fever, nausea, or vomiting.

HEENT:

Head: Denies physical head injury. Does not report a headache.

Eyes: Reports a blurry vision during hot weather.

Ears: Denies ear and hearing problems.

Nose: Denies a runny nose, sneezing, or nasal congestion.

Throat: Denies a sore throat.

Neck: Denies pain or swelling in the neck region.

Respiratory: Denies tightness of the chest. Denies breathing difficulties. Denies having pain on the chest.

Cardiovascular/Peripheral Vascular: Denies chest tightness.

Gastrointestinal: No stomachache, no constipation, no abdominal pain.

Genitourinary: Does not report pain in the genitals. No vaginal itching. No pain during urination. Denies abnormal vaginal discharge. Reports increased urination frequency.

Musculoskeletal: Does not report joint pain. Reports fatigue.

Neurologic: Denies headache. Does not report numbness on fingers and toes.

Psychiatric: Denies occasional seizures, issues with memory, or feelings of hopelessness.

Skin: Denies itchiness or redness on the skin. No skin rashes reported.

Hematologic: Does not report anemia or any other blood-related disorders.

Endocrine: Reports extreme thirst. Reports frequent urination. Reports an increase in urine volume. Reports fatigue, no abnormal sweating at night.

Subjective Data Analysis

The subjective portion of the note has given a summary of the assessment information as reported by R.T. According to Sullivan (2019), the subjective assessment should begin by stating the patient’s chief complaint. This should be followed by a documentation of the patient’s history of patient’s illness (HPI) before describing medication history, allergies, past medical history, social history, surgical history, reproductive history, significant family history, immunization history, and a comprehensive review of systems. These guidelines have been followed when documenting the patient’s subjective data.

All pertinent data facts that can guide decision-making regarding the patient’s diagnosis has been included in this area. Relevant subjective data for the patient include frequent urination, fatigue, and extreme thirst that have existed for around two weeks. The patient has also reported blurry vision during hot weather. Risk factors to consider when making a diagnosis include a personal history of hypertension, a family history of hypertension and diabetes, and a diet full of calories and carbohydrates with few vegetables.

OBJECTIVE DATA:

Physical Exam:

Vital signs: Body temperature: 36.7 degrees Celcius, weight=87.5 lb., Height=48 inches, respiratory rate=18; oxygen saturation=99%.

General: R.T. looks healthy and is appropriately dressed for the weather. He is oriented to time, person, and place and sits upright on the evaluation table.

HEENT:

Head: Head is atraumatic and normocephalic. There is normal scalp hair distribution. No masses on scalp. No frontal sinus tenderness. No maxillary sinus tenderness. No supraclavicular lymphadenopathy. No axillary lymphadenopathy.

Eyes: Equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema on both eyes. Conjunctiva pink, no lesions, white sclera. Pupil: equal, round, reactive to light. Vision is blurry when there is excess sunlight. No retinopathic changes on both eyes, no hemorrhages. Normal eye convergence. EOMs intact bilaterally, no nystagmus. Visual acuity: Vision 20/20 right and left eyes.

Ear: Left and Right tympanic membrane intact and pearly gray, positive light reflex. Both ears responsive to whispered words.

Nose: Nasal mucosa moist and pink, septum midline on left and right.

Mouth & Jaws: No clicks, full ROM. Oral mucosa moist without ulcerations or lesions, uvula midline. Gag reflex intact.

Neck: Thyroid smooth without nodules. No evidence of goiter. No pain. Neck strength: 5/5.

Chest/Lungs: Oxygen saturation 99%. Anterior and posterior chest walls symmetric, no deformity or lesions. Thoracic expansion symmetric. Chest walls: normal fremitus. Chest: resonant. Absence of no adventitious sounds, muffled voice sounds.

Heart/Peripheral Vascular: Pulse: 2+, no thrill. RRR, S1, S2, no murmur with the diaphragm. Capillary Refill < 3 sec. Arteries: no bruit. No S3, S4 with the bell. No edema on the left and right legs.

Abdomen: No masses, soft, no tenderness. Abdomen protuberant, symmetric, no visible masses or lesions. All quadrants: normoactive. Liver span: 7 cm MCL on percussion. All quadrants: tympanic. Right & left flanks: no tenderness. Spleen percussion: no dullness.

Genital/Rectal: No masses on the kidney.

Musculoskeletal: Limbs and neck are without swelling, masses, or deformity. Elbows, ankles, and wrists without swelling, masses, or deformity. Fingernails and toenails: no ridges or abnormalities in nails, pink nail beds. Right and left shoulders: full ROM for all joints. Muscle strength on all joints: 5/5. Deep tendon reflexes of upper extremities: 2+.

Neurological: Coordination: smooth and accurate. Limb movements; smooth. Good sensation in left and right feet. Distal and proximal light touch sensation intact on both left and right arms and legs. Proximal and distal dull pain sensation intact on left and right arms and legs. Proximal and distal sharp pain sensation intact on left and right arms and legs. Position sense intact in fingers and toes.

Skin: No evidence of dry skin. No itchiness, No sores. No lesions.

Psychological: No signs of anxiety or surgery.

Lab tests and other procedures:

Urinalysis: Presence of glucose traces in urine. The presence of glucose in urine is indicative of type-2 diabetes (American Diabetes Association, n.d.).

Comprehensive Metabolic Panel (CMP): This test has revealed blood glucose level of 121 mg/dL. Normal range should be 70-99 mg/dl. The observed value exceeds the normal range which shows the presence of diabetes (American Diabetes Association, n.d.).

Hemoglobin A1C (HbA1c) tests: This is one of the standard tests for diabetes. The test has given an HbA1c value of 7.9%. This exceeds the normal value which should be below 5.7%. This confirms the presence of diabetes (American Diabetes Association, n.d.).

Thyroid Test: Results indicate elevated thyroid stimulating hormone levels in the blood and significantly reduced T4 levels. These results can be as a result of either diabetes or thyroid dysfunction. Thyroid function is normally impaired in patients with diabetes (Chaker et al., 2017).

Lipid Profile: Lipid profile test gives the blood concentrations of low density lipoprotein (LDL) cholesterol, high density lipoprotein (HDL) cholesterol, and total cholesterol (TC). Results indicate normal concentrations of low density lipoprotein cholesterol and total cholesterol. The concentrations of high density lipoprotein cholesterol are also normal. These results show the absence of hyperlipidemia (American Academy of Family Physicians, 2021).

Objective Data Analysis

Objective section of the SOAP note has summarized the results of physical exam. Objective assessment helps the healthcare professional to establish the actual pathological issues that might be contributing to the symptoms displayed by the patient (Dains et al., 2016; Ball et al., 2017). Relevant facts that capture every body system has been collected in this area. Pertinent objective findings that should be considered when making a diagnosis include; glycosuria, elevated blood glucose level of 121 mg/dL, HbA1c of 7.9%, and elevated thyroid stimulating hormone levels in the blood with significantly reduced T4 levels.

ASSESSMENT:

Differential Diagnoses

• Type 2 diabetes (primary diagnosis)
• Primary hypothyroidism due to destruction of the thyroid gland
• Secondary hypothyroidism due to hypothalamus or the pituitary gland dysfunction

Assessment Rationale and Analysis

1. Type 2 diabetes (primary diagnosis)

The pathophysiology of type 2 diabetes is associated with dysfunctional beta cells. Beta cells dysfunction causes insulin resistance. Individuals with insulin resistance have impaired glucose metabolism leading to high concentration of glucose in the blood and urine. Pathological changes due to type 2 diabetes usually cause fatigue and increased urination frequency as observed in patient R.T. (Galicia-Garcia et al., 2020).

1. Secondary hypothyroidism due to hypothalamus or the pituitary gland dysfunction

Secondary hypothyroidism is the type of hypothyroidism that occurs when the pituitary gland and hypothalamus are dysfunctional and the thyroid gland is normal. The pituitary gland and hypothalamus control the secretion of thyroid hormone by the thyroid gland. Their dysfunction is associated with low levels of thyroid hormones in the blood because the thyroid gland is unable to receive alerts to produce more. Besides, these two gland regulate urination by producing antidiuretic hormone. Urination control is hampered when they are dysfunctional. Most patients normally present with increased urination frequency (Chaker et al., 2017). Fatigue and increased urination frequency are common symptoms in secondary hypothyroidism but not increased blood glucose concentration.

1. Primary hypothyroidism due to destruction of the thyroid gland

Primary hypothyroidism is a type of thyroid dysfunction that occurs as a result of the destruction of the thyroid gland. Iodine insufficiency, excessive iodine intake, and autoimmune disease are the common causes of thyroid gland destruction (Chaker et al., 2017). These etiologies usually cause varied degrees of inflammation of the thyroid gland. Thyroid hormone production is affected in such a case leading to its low levels in the blood. As a physiological response, the body secrets thyroid-stimulating hormone (TSH).

This hormone plays a role in the secretion of thyroid hormone from the thyroid gland. As a result, the effected patients normally have reduced blood levels of thyroid hormones and elevated TSH levels as observed in the patient (Chaker et al., 2017). Fatigue, low blood levels of thyroid hormones, and increased TSH levels are commonly observed in individuals with primary hypothyroidism but not increased blood sugar levels.

Assessment Analysis

Thyroid function is normally impaired in patients with diabetes (Chaker et al., 2017). Therefore, it is important to treat patient R.T. for type 2 diabetes first and monitor his progress for at least one month before making a decision to treat hypothyroidism.

PLAN

Lab Tests

1. Perform oral glucose tolerance test: Oral glucose tolerance test is one of the tests that are used to confirm the diagnosis of type 2 diabetes. It tells how the body processes sugar. The presence of type 2 diabetes is confirmed by a glucose concentration of 200 mg/dl or higher (American Diabetes Association, n.d.).
2. Perform fasting plasma glucose test: Fasting plasma glucose test is another test used to confirm the presence of diabetes type 2. When conducting the test, the patient is not allowed to eat or drink anything except water before the test is done. Type 2 diabetes is confirmed with a blood glucose concentration of 126 mg/dl or higher (American Diabetes Association, n.d.).

Medication

• Prescribe Metformin: Metformin is recommended as the first-line treatment for patients presenting with mild symptoms of type 2 diabetes (Baker et al., 2021; Jeschke et al., 2016).

Metformin use

• Dosage: 500 mg taken orally
• Frequency: Twice a day
• Mechanism of Action: Minimizes the production of glucose from the liver and increases the body’s sensitivity to insulin.
• Contraindication: Severe renal disease and a history or diagnosis of a cardiovascular condition.
• Side effects: Diarrhea, abdominal pain, and nausea.
• Special instructions (drug adherence): The patient must be educated to take the medication as prescribed (Derek et al., 2019).

Patient Education

Education on Medication

• Educate R.T. about the risk factors of type 2 diabetes.
• Educate him about the symptoms of type 2 diabetes.
• Educate R.T. how to avoid risk factors of type 2 diabetes
• He should also be educated to adhere to the recommended treatment regimen (Baker et al., 2021)

Education for Meal and Diet

• Educate R.T. to consume a lot of water and avoid sugary drinks

• He should be taught to eat a lot of non-starchy vegetables
• Advise R.T. to consume fewer calories
• Educate him to eat whole grains (American Diabetes Association, 2020; Johansen et al., 2017).

Education for Physical Activity and Exercise, Engage in physical exercise to manage weight and improve physical fitness

• Educate R.T. to consider aerobic training for about 30 minutes to improve cardiovascular functioning
• Resistance training will help to improve muscle strength (Johansen et al., 2017).

Referrals

• Refer R.T. to a nutritionist to provide nutritional guidance to facilitate effective management of type 2 diabetes at home
• Refer R.T. to an endocrinologist to assess endocrine function and establish whether its dysfunction is association with the patient’s symptoms.
• Refer him to a physiotherapist to offer guidance on age-appropriate exercises (Johansen et al., 2017).

Follow-Up

• Advise the R.T. to return to the clinic after one month for evaluation and monitoring

Critical Thinking Evidence-Based Recommendations/Resource Comparisons

            The treatment recommendations that have been offered to the patient are supported by research evidence. The two evidence-based studies that have been used for clinical decision-making are; a publication by Jeschke et al. (2016) and another one by Johansen et al. (2017). Jeschke et al. (2016) conducted a randomized controlled trial to compare the efficacy of metformin and insulin in contributing to glycemic control in burned patients with hyperglycemia.

The researchers found that both metformin and insulin had equal efficacy in causing glycemic control. However, when compared to insulin, metformin was found to have stronger antipolytic effect. They concluded that metformin is effective and safe for use in patients who require glycemic control. These findings are aligned with the American Diabetes Association guidelines for treatment of type 2 diabetes.

Johansen et al. (2017) conducted a randomized controlled trial to compare the effectiveness of lifestyle interventions and medical therapy in causing glycemic control in patients with type 2 diabetes. From the study, the researchers found that lifestyle interventions that combine aerobic training, resistance training, dietary plans, and patient follow-up produced better glycemic control when compared to the use of medicinal therapy alone. The use of exercise and diet are as non-pharmacological interventions for type 2 diabetes is aligned with the American Diabetes Association guidelines.

The two articles have some similarities and differences. One of the similarities is that both of them are randomized controlled trials that focus on glycemic control. Besides, they both recognize the effectiveness of pharmacological interventions in facilitating glycemic control in patients with hyperglycemia. However, the two articles vary based on the objective of research. While Jeschke et al. (2016) conducted a randomized controlled trial to compare the efficacy of metformin and insulin in contributing to glycemic control in burned patients with hyperglycemia, Johansen et al. (2017) conducted a randomized controlled trial to compare the effectiveness of lifestyle interventions and medical therapy in causing glycemic control in patients with type 2 diabetes.

Impactful Practice

            Evidence contained in the two reviewed articles would impact clinical practice when handling patients with hyperglycemia such as those with type 2 diabetes. According to the American Diabetes Association (2020), the goal of treatment in patients with type 2 diabetes is to lower blood glucose concentration to normal level. This is normally achieved through both pharmacological and non-pharmacological interventions.

The drugs that are commonly used in the treatment of patients with type 2 diabetes are metformin and insulin. Evidence documented by Jeschke et al. (2016) would influence clinical practice in that it support the efficacy of both metformin and insulin in facilitating glycemic control in diabetic patients. This evidence should guide healthcare professionals when they are selecting medications to prescribe to patients with type 2 diabetes.

The American Diabetes Association has further recommended the use of exercise and diet in promoting the well-being and improving the quality of life of patients with type 2 diabetes (American Diabetes Association, 2020). As documented by Johansen et al. (2017), lifestyle interventions that combine exercise training and diet are effective in enhancing glycemic control when compared to the use of medical therapy alone. This evidence should guide healthcare professionals to combine medical therapy with lifestyle interventions and diet to help patients with type 2 diabetes to achieve positive health outcomes.

Cultural, Socio-Economic, and Spiritual Considerations

            Cultural, socio-economic, and spiritual considerations have been made during patient assessment and development of a treatment plan. For example, the healthcare professional has used simple language that the patient can easily understand. Additionally, the clinician has used culturally appropriate language, a factor that has helped to strengthen therapeutic relationship (Treas et al., 2018). The spiritual and socio-economic concerns of the patient have adequately been addressed during the healthcare delivery process.

References

American Academy of Family Physicians. (2020). Hyperlipidemia. https://www.aafp.org/afp/topicModules/viewTopicModule.htm?topicModuleId=13

American Diabetes Association. (n.d.). Diabetes. https://www.diabetes.org/a1c/diagnosis

American Diabetes Association. (2020). Glycemic targets: Standards of medical care in diabetes-2020. https://care.diabetesjournals.org/content/43/Supplement_1/S66.

Baker, C., Retzik-Stahr, C., Singh, V., Plomondon, R., Anderson, V., & Rasouli, N. (2021). Should metformin remain the first-line therapy for treatment of type 2 diabetes? Therapeutic Advances in Endocrinology and Metabolism, 12, 2042018820980225. doi: 10.1177/2042018820980225. PMID: 33489086; PMCID: PMC7809522.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2017). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Chaker, L., Bianco, A. C., Jonklaas, J., & Peeters, R. P. (2017). Hypothyroidism. Lancet (London, England), 390(10101), 1550–1562. https://doi.org/10.1016/S0140-6736(17)30703-1

Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

Derek, L., Geert, B., Susan, B., Felipe, C., Boris, D., Jeffrey, H., Irl, H., Marie, H., Mark, M., Hassan, M., & Alan, S. (2019). Treatment of diabetes in older adults: An endocrine society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 104 (5). 1520–1574, https://doi.org/10.1210/jc.2019-00198.

Galicia-Garcia, U., Benito-Vicente, A., Jebari, S., Larrea-Sebal, A., Siddiqi, H., Uribe, K. B., Ostolaza, H., & Martín, C. (2020). Pathophysiology of Type 2 Diabetes Mellitus. International Journal of Molecular Sciences, 21(17), 6275. https://doi.org/10.3390/ijms21176275

Jeschke, M. G., Abdullahi, A., Burnett, M., Rehou, S, & Stanojcic, M. (2016). Glucose control in severely burned patients using metformin: An interim safety and efficacy analysis of a phase ii randomized controlled trial. Annals of Surgery, 264(3), 518-27. doi: 10.1097/SLA.0000000000001845. PMID: 27355267; PMCID: PMC7859867.

Johansen, M. Y., MacDonald, C. S., & Hansen, K. B. (2017). Effect of an intensive lifestyle intervention on glycemic control in patients with Type 2 diabetes: A randomized clinical trial. JAMA, 318(7):637–646. doi:10.1001/jama.2017.10169

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia

Treas, L., Wilkinson, J., Barnett, K. & Smith, M. (2018). Basic nursing: Thinking, doing, and caring (2nd ed). Philadelphia, PA: F.A. Davis.