Review the below case study. Detailed information on the case study is provided in the document. Use the soap note template to develop the Focus soap note
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, and 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 pressure. Her blood pressure at presentation is 165/90.
(note: the thyroid is part of the endocrine system, and should be assessed in the ROS and the PE)
Ms. Lewis is a 63 y/o female who is alert awake oriented to time, place, situation. 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. Please document negative findings as you would with a real patient instead of writing ‘normal’ or ‘negative’) Write this as a focused soap note for : CC: morning hypoglycemia. Base your HPI, ROS, and PE on this CC
(All other Review of System and Physical Exam findings are negative other than stated.
Please describe what your negative ROS and PE findings would be rather than writing ‘negative” or “normal”)
Remember to include the following:
Three differential diagnoses With Your Rationale (One Paragraph Only For Each Dx With Citations & References)
Your Primary Dx (One Of The 3) And Why You Chose This (so a total of 3 – the first being your primary diagnosis)
Your Treatment Plan: Prescriptions, Referrals, Testing, Follow Up (**If you are the primary care NP, do not write : “refer to PCP”
EDUCATION
REFLECTION
