WEEK 11 SOAP

Student Name:

Course Name:

Assignment Due Date:

Week 3 SOAP Note

Subjective Data:

Chief Complaint: coughing, follow-up lab results.

History of Present Illness: 37 year-old- Hispanic male, , who presents to the clinic for a follow up visit on abnormal triglyceride levels that were done 2 weeks ago, and a complaint of intermittent non-productive coughing x 2 weeks with mild clear nasal drainage and watery eyes. Cough worsens at night in supine position interfering with his sleep and is decreased during the day. Denies any. Constitutional symptoms or associated symptoms such as nasal congestion, headache, dyspnea or chest pain. Does anything make it better? Any OTC remedies? That all goes below.

Medications:

Lisinopril 20 mg once a day

Simvastatin 20 mg once a day

Metformin 1000 mg twice a day

Glimepiride 4 mg once a day

OTC- Loratadine 10mg once a day

Allergies: No known drug allergies or food allergies. Has seasonal allergies during spring and summer.Possibly environmental as well.

Past Medical History: hypertension, hyperlipidemia, diabetes, and seasonal allergies.

Past Surgical History: No past surgical history.

Personal/Social History: smokes one pack of cigarettes per day for 7 years. Still currently smoking. Drinks alcohol on occasion. Denies any drug use. States he does not exercise regularly and is not on any special diet, but is trying to start a diet and exercise program.

Immunizations: Up-to-date. Last DTAP was 2 years ago, flu shot was in November 2012.

Family History:. His father has diabetes and hypertension. His mother has hypertension and arthritis. He has one brother, still living with no medical problems. He is single, and has no children.

Review of Systems:

General: admits he is mildly obese, no recent weight change or loss, no fever, fatigue, or weakness.

Skin: reports no rashes, mumps, sores, itching, dryness.

Eyes: No changes in vision. No vertigo. No eye pain. Has watery eyes. Need to explain positive finding using the 7 variables

Ears: No recent hearing loss. No tinnitus. No ear discharge or ear pressure.

Nose: Seasonal allergies for which he takes Claritin but has been out for two months. Now symptoms are worsening. No nasal congestion. Has mild watery clear nasal discharge intermittently for three months with occasional cough at night. No epistaxis.

Throat: Denies sore throat. No hoarseness. No bleeding gums or dry mouth.

Neck: Denies neck pain or stiffness.

Respiratory: See HPI. Non-productive cough. No hemoptysis. No wheeze.

Cardiovascular: No palpitations, chest pain, edema, shortness of breath. States having history of diet controlled hypertension. Takes periodic readings at local pharmacy and ranges 130-140 systolic and 70 to 80 systolic. Has had difficulty controlling hyperlipedimia due to diet- likes eating fried food.

Gastrointestinal: No nausea, vomiting, diarrhea, constipation.

Endocrine: History DM type 2 which is control via diet and medication. Does not recall latest HgB A1C reading- last reading six months ago

Objective Data:

T: 36.5 Celsius (oral), BP 111/75, P: 96, RR: 16, wt: 119 kg Need BMI

Generalized appearance is well with moderate obesity. Remember, you need BMI to determine overweight versus obese.

Skin: No rashes noted. No lumps or nodules.

Head: Normocephalic, Atraumatic.

Ears: Tympanic membranes are gray, non-bulging and freely mobile with no erythematous. Ear canal patent bilaterally with minimal cerumen. No drainage noted.

Nose: Nares patent bilaterally. No discharge. Mucosa pink and moist. Septum midline. No edema over frontal or maxillary sinuses. No sinus tenderness to percussion. Moderate clear nasal discharge noted.

Pharynx: Oral mucosa pink, moist. Posterior oropharynx has no erythema, exudate, or lesions. Tonsillar pillars are 2+ without exudate. Uvula rises evenly. Gag reflex intact. No hoarseness.

Neck: Neck supple, non-tender without lymphadenopathy, masses or thyromegaly.

Cardiac: Rhythm regular, no murmurs. Normal S1 and S2. No S3, S4 or murmurs. No peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds. No carotid bruits.

Respiratory: Unlabored respirations. Symmetrical chest expansion. Clear to auscultation bilaterally. No rales, rhonchi, wheezing or diminished breath sounds.

Abdominal: Positive bowel sounds throughout all 4 quadrants. Soft, non-distended, non-tender throughout with palpation. No guarding or rebound. No masses. No hepatomegaly, spleen is nontender with palpation.

GU: Not assessed.

Neuro: Gait normal. Oriented to person, place and time.

Labs: glucose 305, Hemoglobin A1C 11.4, Triglycerides 409.

Assessment:

Diagnosis 1: Hypertriglyerceridemia (diabetes, liver disease, medications)

Differential Diagnoses:

1. Hypertriglyerceridemia: This condition occurs in diabetic patients due to the insulin resistance, which often results in increased free fatty acid delivery to the liver, causing peripheral lipolysis (Subramanian, & Chait, 2012). This is the primary diagnosis because elevated triglyceride levels were confirmed by blood work. Patient is obese, not on a diet plan, smokes, and has all the risk factors such as hypertension and diabetes. This is the primary diagnosis.

2. Diabetes type 2,Poorly controlled: This condition occurs when the body has problems with insulin resistance, causing a disorder of the metabolism that manages blood glucose in the blood stream. Hypertriglyceridemia can occur secondary to diabetes, which in most cases, this is the cause of the condition. Further, diabetes causes high, very low-density lipoprotein cholesterol (VLDL-C) which is a form of fatty acids that are present in obese patients, along with more abnormal lipid profile such as high triglyceride (TG), high total cholesterol (TC), low high-density lipoprotein cholesterol (HDL-C) and high total cholesterol/high-density lipoprotein cholesterol (TC/HDL-C) ratio (Breuer, Medizin, Gorlitz, 2001).

3. Liver disease: Liver disease can occur from high levels of triglycerides in the blood, diabetes, obesity, and certain medications (Mayo Clinic, 2012). The most common cause of dyslipidemia is from over-production of endogenous TGs, which is a form of free fatty acids that is produced by the liver (Breuer, Medizin, Gorlitz, 2001).

4. Medications: Some medications can contribute to hypertriglyceridemia, such as second-generation antipsychotic medications, corticosteroids, and non-cardioselective beta-blocker antihypertensives (Subramanian, & Chait, 2012; Yuan, Al-Shali, & Hegele, 2007). However, in this case the patient is not taking any of the medications that may increase the risk for hypertriglyceridemia.

Diagnosis 2: Seasonal Allergies

Differential Diagnoses:

1. Seasonal allergies: Seasonal allergies are seen more frequently from early spring to late fall, and can sometimes vary depending on the location of where an individual lives (Moyad, 2008). The symptoms can include rhinorrhea, itchiness of the nose and eyes, lacrimation, sneezing, and even headaches are common at times (LeBlond, Brown, & DeGowin, 2009). Postnasal drainage with supine position triggers cough to occur. Patient reports clear nasal drainage and lacrimation, and denies fever and sore throat. Reports history of seasonal allergies (Seller, & Symons, 2012). Anterior clear nasal discharge was noted on assessment (Holmes, & Scullion, 2012). Patient also reported coughing to be worsen at night when he laid in a supine position, which usually occurs with postnasal drip when the discharge drips to the back of the throat due to gravity, triggering the reflex to cause coughing to occur (Porth, & Matfin, 2009). This is likely to be the primary diagnosis due to the symptoms presented and his history of seasonal allergies.

2. Allergic rhinitis: This condition is pretty similar to seasonal allergies. It even has the same symptoms as seasonal allergies. The only difference between allergic rhinitis and seasonal allergies is the cause of the symptoms. Allergic rhinitis is usually cause by a triggering factor such as pollens, animal hair, medicines, chemical, whereas in seasonal allergies, it would normally occur certain time of the year (LeBlond, Brown, & DeGowin, 2009). However, depending on the location, some individuals may get seasonal allergies all year long (Moyad, 2008).

3. Sinusitis: This condition is usually accompanied by coughing, rhinorrhea, and watery eyes. Patient denies fevers, chills, or other complaints. No tenderness to sinuses with percussion noted on assessment. No deviation to nasal septum. Nasal turbinate boggy, pink, and glistening. No epistaxis. Nasal cavity has clear discharge noted. Sinusitis is unlikely to be the diagnosis because there is no sinus tenderness (Seller, & Symons, 2012).

4. Upper respiratory infection: The patient does have the cough, the lacrimation and rhinorrhea, but this condition is usually accompanied by a low grade fever and malaise, which he denies of any during the assessment. Lung sounds clear bilaterally. URI is unlikely to be the diagnosis because there is no fever (Seller, & Symons, 2012).

Plan:

1. Pulmonary: Chest xray ordered for coughing x 2 weeks to rule out pneumonia (Huether, & McCance, 2012).

2. Endocrine: Actos increased to 30 mg by mouth (PO) every day (QD) from 15 mg. Lantus started at 15 units subcutaneous (SubQ) every night before sleep (QHS) to maintain morning fingerstick blood sugar between 130 to 150. Add 1 unit to 15 units of Lantus every night until morning fingerstick blood sugar is between 130 to 150.

3. Cardio: Discontinue simvastatin and start gemfibrozil 600 mg QD. The combination of both these medications increases the adverse risk for rhabdomyolysis (Curtin, & Jones, 2007). The first-line agent of drug treatment for hypertriglyceridemia is fibrates (Subramanian, & Chait, 2012).

4. Respiratory: Cetirizine 10 mg orally once a day reduces the symptoms of seasonal allergies. Regular daily dose treatment has been shown to be more effective than as needed basis (Holmes, & Scullion, 2012).

5. ENT: Diphenhydramine 25 mg PO QHS as needed (PRN) to reduce symptoms such as rhinorrhea and to reduce the risk of side effects of drowsiness during day time. Diphenhydramine is usually not recommended due to its drowsiness side effect, but it is effective in reducing rhinorrhea (Holmes, & Scullion).

6. Health Promotion: Decrease in salt and fatty food intake, exercise 2 to 3 times per week lasting 30 minutes each time, and be compliant with medications. Do not drive after taking diphenhydramine due to the side effect of drowsiness. Drink plenty of fluids to maintain hydration and increase expectorant. Avoid allergen or trigger factors such as staying in doors on high-polluted days, pets with furs, pollens, etc. (Holmes, & Scullion, 2012).

7. Send to lab for allergy testing.

8. Disease Prevention: Repeat blood work for blood glucose, hemoglobin A1C, and fasting lipid profile in 3.

9. Return in 2 weeks for a follow up appointment for re-evaluation of cough and allergy test, and in 2 months to review repeat lab results for blood glucose, hemoglobin A1C, and triglyceride levels.

10. Smoking cessation encourage. Given information regarding smoking cessation approaches. Will discuss further at next visit.

Reflection Notes

In this situation, I agree to the plan of care. The one thing I would have done differently is refer the patient to see an allergist instead of waiting to see him again during the follow-up appointment then referring him at that time. Sometimes it may take weeks for the patient to actually get into see an allergist. The sooner the patient is able to make an appointment, the better it will be for him because the symptoms can be controlled sooner. I would also recommend him to start taking fish oil. Fish oil has been shown to decrease triglyceride levels and reduce cardiovascular diseases (Oelrich, Dewell, & Gardner, 2013).

References

Breuer, H., Medizin, A. I., & Gorlitz, St. C. (2001). Hypertriglyceridemia: A review of clinical

relevance and treatment options: Focus on Cervistatin. Current Medical Research and Opinion, 17(1), 60-73. Retrieved from http://www.medscape.com/viewarticle/407814_1

Curtin, P., & Jones, W. (2007). Therapeutic rationale of combining therapy with gemfibrozil and

simvastatin. Journal of the American Pharmacists Association: Japha, 47(2), 140-146. Retrieved from http://www.japha.org/

Holmes, S., & Scullion, J. (2012). Allergic rhinitis: Assessment and treatment. Nurse

Prescribing, 10(5), 222. Retrieved from http://www.nurseprescribing.com/

Huether, S. E. & McCance, K. L. (2012). Understanding pathophysiology (5th ed.). St. Louis,

MO: Mosby.

LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2009). DeGowin’s diagnostic examination

(9th ed.). New York, NY: McGraw Hill Medical.

Moyad, M. (2008). Conventional, complementary, and alternative options for seasonal allergies.

Urologic Nursing, 28(3), 227-228. Retrieved from http://www.suna.org/unj

Oelrich, B., Dewell, A., Gardner, C. D. (2013). Effect of fish oil supplementation on serum

triglycerides, LDL cholesterol and LDL subfractions in hypertriglyceridemia adults. Nutrition Metabolism and Cardiovascular Diseases, 23(4), 350-357. Retrieved from http://www.sciencedirect.com/science/journal/09394753

Porth, C. M., & Matfin, G. (2009). Pathophysiology: Concepts of altered health states (8th ed.). Philadelphia, PA: Lippinocott Williams & Wilkins.

Seller, R. H., & Symons, A. B. (2012). Differential diagnosis of common complaints (6th ed.).

Philadelphia, PA: W. B. Saunders Company.

Subramanian, S., & Chait, A. (2012). Hypertriglyceridemia secondary to obesity and diabetes.

Biochimica Et Biophysica Acta, 1821(5), 819-825. doi:10.1016/j.bbalip.2011.10.003

Yuan, G., Al-Shali, K. Z., & Hegele, R. A. (2007). Hypertriglyceridemia: Its etiology, effects,

and treatment. Canada Medical Association Journal, 176(8), 1113-1120. doi: 10.1503/cmaj.060963