Soap Note Assignment | Buy assignments online

  Allergies: None.

Medication Intolerances: None.

Chronic diseases: Hypertension, Hyperlipidemia, and diabetes mellitus.

Major Trauma: None.

Surgical operations: Minor open and drainage three years ago.

Admissions: One time during the birth of her last born twenty years ago.

  Height: 5’ 5’’

cholesterol level=270mg/dL

1.      Deep Venous Thrombosis (I82.401). There is pain in the right lower limb. A physical exam reveals its pallor, and it is warm. According to Endig, Michalski, and Beyer-Westendorf (2016), discoloration of the skin accompanied by pain and warmth may indicate DVT.

2.      Superficial Thrombophlebitis (180.01). This patient may have this diagnosis given that she complains of pain in the right lower extremity. Physical examination reveals redness. These two symptoms are significant indicators of the diagnosis (Evans, & Ratchford, 2018).

3.      Arthritis (M19.90). The patient complains of pain in the knees of both extremities. She experiences stiffness, and there is slight swelling of the knees upon physical examination. These symptoms are significant indicators of arthritis (Souza, Neta, Gazzola, & Souza, 2017).

Arterial Insufficiency (I73.9). The primary diagnosis, as per the provided information, is arterial insufficiency. Although the patient has other diagnoses such as obesity and diabetes mellitus, the main problem that brought her to the hospital is knee pain and leg swelling. When she walks for more than 100 meters; pain in her lower extremities increases. She also has intermittent occurrences of cramping in legs, especially in the right lower extremity. However, when she rests, the pain disappears.  According to Aboyans et al. (2017), muscle pain that is triggered by activity in the extremities is an indicator of arterial insufficiency.  Physical exam reveals weak to absent dorsalis pedis pulse in the right lower extremity. Blood tests show a cholesterol level of 270mg/dL. Arterial insufficiency occurs due to reduced blood flow, which occurs as a result of fat deposition in the arteries (Aboyans et al., 2017). In this case, the patient has a high cholesterol level that confirms fat deposition in the arteries. Thus, although she has other diagnoses, the primary focus of treatment is to manage arterial insufficiency.

Further testing:  Doppler Ultrasound to evaluate blood flow

Medications: Medication administration has focused on managing symptoms and stopping the progression of the illness. Regarding the management of the symptoms, Aboyans et al. (2017) recommend pain relief. I this case, cilostazol has been given, and the patient will take 100mg twice a day by mouth for seven days. This drug will dilate blood vessels and reduce pain thus facilitating walking. According to Gerhard-Herman et al. (2017), reduced blood flow can cause clotting and exacerbate arterial insufficiency. For this reason, Plavix has been given, and the patient will take 75mg orally once a day for seven days to prevent blood clot thus facilitating recovery. The patient will combine these medications with metformin, propranolol, and benazepril that she is currently taking to manage diabetes and blood pressure.

Education: The patient has been told that diet contributes immensely to the development and progression of arterial insufficiency. Available evidence shows that physical activity and a balanced diet can improve the outcomes of patients with this diagnosis (Gerhard-Herman et al., 2017; Aboyans et al., 2017). Thus, she has been told to find time after pain relief to walk or jog so that she can achieve and maintain a healthy weight. She has also been advised to avoid eating foods with a high amount of salt to manage her blood pressure effectively. Much emphasis has been put on reduced alcohol intake, smoking cessation, and consumption of more fruits and vegetables to facilitate recovery.

Non-medication Treatments: She has been told to consume fiber and magnesium to accompany the food she consumes to facilitate a reduction of blood pressure.

Follow-up:  The medications she has been given will be over by the seventh day. Therefore, she will come back seven days from now to get additional drugs. Additionally, she will be helped to make a regular exercise schedule, which will be significant in helping her to manage her weight.