MS-NU661 Herzing University -SOAP Note For a 65-year-old male patient with the chief complaint of “I can’t see.”

A 65-year-old male with past medication history of type 2 diabetes on long-acting insulin, chronic kidney disease stage 3, tinnitus, dry mouth, and hypertension on losartan and metoprolol.  Presented to the clinic as a new patient with the chief complaint of “I can’t see.”  Has seasonal allergies and reaction to lisinopril described as cough.  Vital signs: blood pressure 159/98, pulse 56, respiratory rate 18, temperature 98.2, and oxygen saturation 99 % on room air.

Questions

Making  a SOAP note for your specific diagnosis using the patient scenario above.

1. The first letter of your last name A-H: Principal Diagnosis is Diabetic Retinopathy
2. The first letter of your last name I-R: Principal Diagnosis is Macular Degeneration
3. The first letter of your last name S-Z: Principal Diagnosis is Glaucoma
4. In your SOAP note, include additional information you would want to know about this patient (placing information in the correct SOAP section). As well as risk factors and excepted findings in the subjective and objective sections.
5. What other differential diagnoses would you have to be concerned about with a patient with a chief complaint of “I can’t see.”
6. Making a plan based on your specific diagnosis and any other abnormal findings in the case.

ANSWER

SOAP Note For a 65-year-old male patient with the chief complaint of “I can’t see.”

Subjective

The patient, a 65-year-old male, presents to the clinic with the chief complaint of “I can’t see.” Upon further inquiry, the patient reports a past medical history of type 2 diabetes managed with long-acting insulin, chronic kidney disease stage 3, tinnitus, dry mouth, and hypertension treated with losartan and metoprolol. He also mentions a history of seasonal allergies and a cough as a reaction to lisinopril. The patient states that he has noticed a decline in his visual acuity recently.

Objective

Vital signs obtained during the examination reveal a blood pressure of 159/98 mmHg, a pulse rate of 56 beats per minute, a respiratory rate of 18 breaths per minute, a temperature of 98.2°F, and oxygen saturation of 99% on room air. The patient appears well-nourished and in no apparent distress. Visual acuity testing reveals decreased acuity in both eyes. Fundoscopic examination reveals findings consistent with (specific diagnosis).

Assessment

Based on the patient’s symptoms and the objective findings, the principal diagnosis for this case is (specific diagnosis), in this case, (Diabetic Retinopathy/Macular Degeneration/Glaucoma).

Additional Information

To further assess and manage the patient appropriately, additional information would be helpful. It would be important to know the patient’s current glycemic control, specifically the most recent HbA1c level, as poorly controlled diabetes is a significant risk factor for diabetic retinopathy. The patient’s renal function should also be evaluated to determine the impact of chronic kidney disease on potential treatment options. Furthermore, it would be relevant to assess the patient’s ocular history, including any previous eye surgeries or eye conditions, as this could impact the management approach.

Risk Factors and Expected Findings

In the case of Diabetic Retinopathy, risk factors include poorly controlled diabetes, longer duration of diabetes, uncontrolled hypertension, and chronic kidney disease. Expected findings in the subjective section may include a gradual decline in visual acuity and changes in color perception. In the objective section, fundoscopic examination may reveal microaneurysms, hemorrhages, and exudates in the retina.

Differential Diagnoses

While the principal diagnosis is (specific diagnosis), other differential diagnoses should be considered for a patient presenting with a chief complaint of “I can’t see.” These may include cataracts, retinal detachment, optic neuritis, age-related macular degeneration, and other retinal vascular disorders.

Plan

The plan for this patient will depend on the specific diagnosis. In the case of (specific diagnosis), appropriate management strategies would involve optimizing glycemic control through medication adjustments and lifestyle modifications. Referral to an ophthalmologist would be necessary for further evaluation and potential intervention, such as laser photocoagulation or intravitreal injections. Blood pressure management should be addressed to reduce the risk of disease progression. Regular monitoring of visual acuity and ophthalmic examinations would be crucial to track changes in the patient’s condition over time.

Additionally, given the patient’s multiple comorbidities and medication history, it would be important to assess potential interactions or contraindications between medications. The patient should be educated on the importance of medication adherence, regular follow-up appointments, and self-monitoring of blood glucose levels.

In conclusion, the SOAP note for this patient with a chief complaint of “I can’t see” indicates the principal diagnosis of (specific diagnosis). Further evaluation and management should consider the patient’s risk factors, obtain additional information, and incorporate appropriate interventions to optimize glycemic control, manage comorbidities, and address ocular complications associated with the specific diagnosis. Regular follow-up and monitoring are essential for effective management and preservation of visual function.

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