Michael:With furthering questioning of Mom you find that Michael has not wanted to play outdoors. He says he cant keep up with the other kids in gym class. He says he gets dizzy sometimes too.PEVSHeight: 48 inches weight 78 pounds BP 110/70 T 98.2 P 65 R 16.GeneralCaucasian male child, appears stated age, Alert and cooperative, appears tired and distracted. Skin: color is pale pink, no cyanosis or pallor. Skin cool, dry and intact. Poor turgor. No moles or skin changes. HEENT: head normocephalic. Hair thick and distribution even throughout scalp. Eyes: Sclera clear. Conjunctiva: white, PERRLA, EOMs intact. Ears: Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender Nose: Nares patent without exudate. Sinuses nontender to palpation.Throat: Oropharynx dry, no lesions or exudate. Tonsils bilaterally. Teeth in good repair, no cavities noted. Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses. Lungs: Lungs clear to auscultation bilaterally. Respirations unlabored.CV: Heart S1 and S2 noted, RRR, no murmurs, noted. PMI at 5th ICS. Peripheral pulses equally bilaterally. Abdomen: Abdomen round, soft, with hypoactive bowel sounds noted. No organomegaly noted. MS: reflexes WNL. Gait steady.LabsCBC:WBC 7, Hgb 14 Hct 40 RBC 4.3 MCV 78 MCHC 34 RDW 11.5Fasting glucose 136 mg/dLTSH: 2.6 mIU/L free T4 15 pmol/LMaryWith further questioning Mary reports feeling more short of breath when doing regular activities, finding it harder to keep up with the kids. Her appetite is less and she is finding it harder to concentrate. At times she feels lightheaded. She says her periods have been heavier since she had her twins but there has been no increased flow or irregular bleeding. LMP was one week ago and lasted four days.VSHeight: 64 inches, weight 155 pounds BP 115/86 T 99.0 P 62 R 16GeneralCaucasian female, appears stated age. Alert, oriented and cooperative. Gait normal. Skin: Skin warm, dry and intact, color is pale pink, no cyanosis or pallor. HEENT: head normocephalic. Hair thick and distribution even throughout scalp. Eyes: .Sclera clear. Conjunctiva: white, PERRLA, EOMs intact. Slight periorbital edema noted. Ears: Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender Nose: Nares patent without exudate. Sinuses nontender to palpation. Throat: Oropharynx moist, no lesions or exudate. Tonsils bilaterally. Teeth in good repair, no cavities noted. Tongue noted to have teeth indentations around the edges. Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses. Lungs: Lungs clear to auscultation bilaterally. Respirations unlabored.CV: Heart S1 and S2 noted, RRR, no murmurs, noted. Peripheral pulses equally bilaterally. Abdomen: Abdomen round, soft, with bowel sounds noted in all four quadrants. No organomegaly noted.Labs:CBC:WBC 8 Hgb 10.1 Hct33 RBC 3.2 MCV 74 MCHC 27.8 RDW 18.1TSH:6.5mIU/L antithyroid antibodies:1:1,800 Discussion part two:Summarize the history and results of the physical exam for each patient in a SOAP note for each case study patient. List the primary diagnosis with ICD 10 code. Include your rationale for choosing the primary diagnosis. The diagnostic rationale in the assessment section should include your patients symptoms, exam findings and the interpretation of all presented lab findings. Include one evidence-based journal article or clinical guideline that supports your rationale for each patient. Develop a complete evidence-based treatment plan for each patient that includes medications, any additional diagnostic tests, patient education, possible referrals, and a plan for follow up with you, the PCP. Each step of the plan must include an EBP citation. The guidelines for SOAP note documentation is located under Course Resources and can assist you in writing this post and your SOAP note.
