SOAP Analysis: Patient with Type Two Diabetes Mellitus

SOAP Analysis

Patient Information

Mrs. X is 56 years old woman of African American origin, who regularly visits acute care settings. Mrs. X was examined by the provider Dr. Y.

Subjective Data

Chief Complaint: The patient suffers from back pain, a sore throat, as well as pain in the right shoulder, which persisted over a certain period of time. She was also diagnosed with Type Two Diabetes Mellitus.

History of Present Illness

Back Pain: Mrs. X complains of a back pain that has persisted over a period of two weeks, though the pain has escalated during the last week. X had to use a borrowed wheelchair for the past four days just to reduce the pain. X states that the pain becomes worse during walking or sitting and is only relieved when leaning forward. In other words, Mrs. X feels more pain, while any form of movement. X stated that the pain is occasionally felt in the legs. Past medical records of the patient indicated that X had a history of degenerative joint disease, as well as spinal stenosis. Magnetic Image Resonance showed the presence of spondylosis. In addition, a foraminal narrowing was shown within the central canal. X was previously prescribed with a standard regime of taking methadone to relief the back pain. The patient also indicated that she had taken Demerol, though the specific amount was not mentioned by the patient. X started taking Demerol after the operation on her toe amputation, since she had previously suffered from osteomyelitis. Nonetheless, no information showed that the patient had undergone any form of surgical procedure. X mentioned that she has diabetes, which had been complicated with osteomyelitis. She also said that she had suffered some epidural steroid infusion.

Sore Throat: Mrs. X reported that she had sore throat for two weeks and the pus had on several occasions come out from the back of her throat. The pus was white in nature. X also reported that the cough produces clear sputum, though the release slightly declined with time. X linked the cough with the pain felt on the left side of the body and more especially around the area surrounding the ribcage. She also mentioned that her fever rose on several occasions, but she denied any form of febrile weakness. She also stated that the pain shifted to the right shoulder after it had declined on the right side of the body. The patient stated categorically that she had not vomited or experienced any form of nausea. At the same time, X stated that she was not fragile and had no symptoms related to dysphagia. X did not take any medication to reduce the pain and she believed that she was getting better every day.

Shoulder pain: X indicated that she felt pain on the right-hand side for several days. She also mentioned that the pain had increased over the past week and that it had been consistent and did not radiate or revolve around the neck or the arm. X mentioned that there was no change noticed in the arms motion, though there was some form of pain, as she moved from one point to another. X had a burn on the right-hand side of the shoulder. She stated that the burn was caused by sleeping close to a healing pad. She stated that the burn would heal soon enough and it was a not a source of any form of infection or worry. Previous x rays conducted on the right-hand side of the shoulder indicated that she suffered from osteophytosis. X indicated that she currently utilized methadone and a lidoderm patch.

Diabetes Mellitus. The patient had been formerly diagnosed with Diabetes Mellitus Type Two. Nevertheless, Mrs. X had indicated that her blood sugar levels had been adequately controlled through the use of Metformin. Nonetheless, it was important to note that the patient felt the pins and needles effect when resting and the feeling has been consistent.

Depression: X reports being in a good mood, especially when the family is around. She states that she has adequate sleep and feels that her energy levels are quite high despite having some form of pain.

Review of Systems

X has a rounded face with blue eyes. The blood pressure is 132/78, while the height is 5’10’’. The Body Mass Index (BMI) is 32. The lung is clear and has no form of auscultation. The heart had no murmurs, while the body does not show any sign of edema. The chest wall has a scar without any form of erythema. Shortness of breath is noticed each time the patient attempts to engage in any form of exercise. At the same time, some of the sensory functions in the lower parts of the body, especially legs, are still intact, though diminishing gradually probably due to Diabetes. Moreover, X is allergic to some diabetes medication.

Past History

PMH: The past medical history of the patient indicates that patient suffered from Diabetes Mellitus Type Two and is currently undergoing Metformin treatment.

PSH: The patient has in the past undergone a surgery that led to a toe amputation.

Past Psychiatric Hx: The patient does not suffer from any form of depression symptoms.

Obstetrical History: X gave birth four times in the last 20 years. She has not been previously hospitalized for any other reason.

Medication: X is prescribed to take Metformin on a daily basis. To reduce pain, X has been taking Demerol. The woman has also indicated that she has used various over-the-counter drugs on several occasions. Other drugs that have been taken include Kenalog 0.1% cream, Aspirin 81mg, Citalopram HBR 40mg, Wellbutrin SR 100mg, Lidoderm 5% patch, Furosemide 80mg, Mg-oxide 400mg and Furosemide 80mg.

Dietary: X suffers from Diabetes Mellitus Type Two, and thus her dietary intake is directed towards the increase in fats consumption.

Immunization: X has been immunized against all the required diseases.

Health promotion: X has been screened for prostate cancer and found to be negative, while the blood pressure has been shown to be elevated.

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Family History

X was the last born in a family of five. Her four sisters are still alive, though their parents passed away. All of her four sisters have been diagnosed with Diabetes Mellitus Type Two. Her mother was also diagnosed with the same disease.

X has four children two of whom have shown symptoms related to Type Two Diabetes Mellitus. X is a widow and stays alone, while her children work in the neighboring town and periodically visit their mother. All of the four children have their families and are mainly focused on their careers. All of her children drink alcohol, while two of them smoke cigarettes. X states that she attempted to raise them based on a religious background, but they did not succeed in it as most of them rarely go to church. X currently lives alone, although she is surrounded by a community of people who care about her. She states that she’s going to church on a regular basis and it provides the consolation she needs in life. The family level of history can be considered or classified as focused HPI (History of Present Illness).

Objective Data

Vital signs: Pain 6/10, Wt 62.8kg Temp 36.9 C Ht 149.9cm, O2 sat 95% on RA-BP 131/76 HR 98.

General: X experiences some form of pain but does not show elevated levels of distress. Nevertheless, she has indicated that she is sitting in a wheelchair, which causes some inconveniences. X is also well-nourished and does not suffer from any form of malnutrition.

HEENT: The nasopharynx and the oral cavity are pink and moist.

Lymph nodes: The lymph nodes show no sign of having palpable masses and are non-tender.

Neck: No form of thyromegaly is illustrated. There is also no increased jugular venous distension.

Cardiovascular: Mrs. X has a regular heart rhythm and its rate is Normal S1, S2.

Chest: Some form of scattered wheezes have been noticed bilaterally, Still, there is no presence of rales or rhonchi. Egophony is equal across all the lobes and produces clear “E” sound.

Abdominal: Non-distended and non-tender.

Rectal: No examination was performed on the rectal.

Neurologic: The tongue protrudes in the right manner, and the uvula rises in the midline. Some form of extra-ocular movement is noted, while other parts of the central nervous system are functioning in a proper way. Fine touch sensations are responded in the normal manner and bilaterally. The spine flexion is forward and not symmetrical.

Musculoskeletal: Both shoulders experience the full range of motions without any form of significant abduction. The right shoulder shows some form of significant tenderness with no palpitation. The lumbar vertebrae experiences some form of exquisite tenderness. The leg raise motion test, as well as the back motion test, were not conducted due to the pain that the patient was feeling.

Billing Level: Focused.

Assessment

Back pain: X has on several occasions complained about spinal stenosis. It is most likely to be caused by foraminal narrowing that has been associated with degenerative diseases. Some of the other causes of pain include sprain or strain of the lumbar vertebrae, as well as any form of vertebral fracture. Other causes include any infection, as well as pelvic pain, which is likely to be ruled out. Strain and sprain have been indicated to play a major role in back pain as the most common cause of any age-related degenerative changes. Such forms account for approximately 70% of the low back pain (Balagu?, Mannion, Pellis?, & Cedraschi, 2012). At the same time, 30% of chronic pain is associated with other mentioned issues (Balagu? et al., 2012). In the above case, the most common cause of pain is more likely to be the stenosis and herniation.

The duration taken to treat the above condition has progressively caused the degenerative process, which has resulted in the back pain that is currently felt across the body. Imaging studies from the MRI show that there is likely to be some form of severe narrowing, especially at the lumbar levels. The clinical findings correspond to a case of neurogenic claudication, when the pain is ceasing as the individual moves forward. Mrs. X also indicated that she felt some form of radiation on the lower parts of the legs suggesting the presence of a narrowed foramen. The MRI has indicated that there is no metastatic progression.

Shoulder Pain: The previous x ray indicates that the there is a severe form of degenerative joint diseases that show the association with osteophytosis. It makes the pain that is currently being experienced in the shoulder more intensive. Some form of muscle spasms, as well as trapezius, is also seen in the right shoulder. The Lidoderm was utilized to reduce the pain felt in one arm.

Sore Throat: The HEENT exam failed to reveal any abnormalities, such as tonsillar swelling or bacterial pharyngitis. The physical history also failed to indicate any form of pneumonia or any other form of infection associated with it.

Diabetes Mellitus: The condition seemed to have been stabilized through the use of Metformin. Consequently, the medication intake should be encouraged.

Plan

Back Pain: The treatment plan should focus on controlling the pain felt by X, who has currently been on medication. X has been on Methadone treatment and has developed some form of reliance on the drug. She should be encouraged to use the drug, as well as Acetaminophen to reduce the pain. The use of NSAID should be discouraged at all costs, since it increases the risk of cardiac arrest, especially among old aged individuals (Pawlosky, 2013; Reddy & Roy, 2013).

Shoulder Pain: The patch should be removed immediately after the shoulder is healed. The main purpose of having the patch was to reduce the pain felt within the body (Brewer & Gregory, 2012). Pharmacological treatment will involve the use of Acetaminophen and Methadone. The two drugs will help ease the pain experienced by the patient.

Sore Throat: X should visit the medical setting in case there is any form of infection associated with the sore throat. Any antibiotic treatment would address the current problem adequately.

Diabetes Mellitus: The use of Metformin should be encouraged as it has been shown to regulate the blood sugar levels (Chen, Magliano, & Zimmet, 2012). The patient has indicated the pain and needle effect in some parts of the legs. It should be addressed by providing the requisite form of exercise.

Analysis

Objective and subjective data indicate that the patient suffers from back and shoulder pain. The use of the patch has been utilized to reduce the amount of pain being felt by the patient. MRI indicates that there is no form of metastasis, as the major cause of the pain comes from the degenerative process that is damaging the foramen. It directly results in osteophysis. In addition, the patient suffers from Diabetes Mellitus Type Two and has been experiencing this condition for a long period of time. Nevertheless, the condition has been broadly balanced through the use of Metformin (Shenavandeh, Anushiravani, & Nazarinia, 2014).

Strain and sprain have been indicated as the major causes of back pain. Other causes of back pain include infection and some forms of metastasis. 70% of back pain has been indicated to come from strain and sprain, while other 30% are associated with the other forms of chronic pain (Balagu? et al., 2012). The use of painkillers has been utilized in the past to reduce the amount of pain that is felt by the patient. In most cases, nonsteroid inflammatory drugs have not been utilized due to the cardiac effect (Pawlosky, 2013; Reddy & Roy, 2013). NSAIDS would also affect the treatment and the management of the Diabetes Mellitus condition. Use of NSAIDs are not effective in the management of the above condition, especially in patients suffering from Type 2 Diabetes Mellitus (Pawlosky, 2013; Reddy & Roy, 2013). Acetaminophen and Methadone are utilized to reduce the amount of pain, while the Metformin is utilized to control Diabetes Mellitus (Chen et al., 2012; Shenavandeh et al., 2014). The best option for the overcoming of pain is the use of pharmacologic treatment. Spinal surgery has produced different outcomes. In a study conducted among 97 patients who complained of leg pain for some years, some preferred surgery, while others preferred pharmacologic treatment. At the same time, a risk of mortality among the patients undergoing surgery was higher compared to pharmacologic treatment (Brewer & Gregory, 2012).