The Assignment:
Complete the Focused SOAP Note Template provided for the patient in the case study.
Note: When completing your focus notes, list your primary diagnosis and 3 differential diagnoses with evidence-based rationales.
Melinda Morales is a 70-year-old woman coming to the office today for her semiannual visit. She reports no new concerns, her mood is good and she maintains eye contact throughout the visit. She is interested in finding out how her kidney function is doing, during her last visit to the
office she was diagnosed with chronic kidney disease, stage III. She states that she “feels fine” and wonders if she really has that diagnosis. She travels a few times a year with some friends and wants to continue to do as well as possible. Melinda has just returned from a month long
trip to Asia. She lives alone in a senior apartment community, her daughter Linda lives an hour away and sometimes travels with her mother. Linda is concerned about her mothers kidney function as well and asked her to inquire about any alternative or complementary medicine that might help with kidney function. VS: BP 150/82 Pulse 65 Resp 16 Temp 97.9 02 Sat 98% on room air Ht 67 inches Wt 150lbs Allergies: Bactrim – rash, shellfish – angioedema HPI: CKD III diagnosed 6 months ago, here for follow up visit, no new issues.
PMH: CKD III, HTN, mild depression, osteoarthritis both knees. Medications:
Hydrochlorothiazide 25mg 1 po daily
Prozac 20mg 1 po daily
Multivitamin 1 po daily
Naproxen 1 or 2 tabs 2 – 3 times a day for knee pain Diagnostics/assessments done: TEST RESULT REFERENCE
RANGE
GLUCOSE 92 65–99
SODIUM 143 135–146
POTASSIUM 3.6 3.5–5.3
CHLORIDE 100 98–110
CARBON DIOXIDE 25 19–30
CALCIUM 9.7 8.6–10.3
BUN 25 7–25
CREATININE 1.6 H 0.70–1.25
GLOMERULAR
FILTRATION RATE
(eGFR)
40 mL/min >or=60
mL/min/1.73m2
Previous Creatinine 6 months ago was 1.4, BUN 24, GFR was 42 mL/min
SOAP Templete linked in attachment as a download
