FNP 592 Week 7 Clinical Documentation Template

FNP 592 Week 7
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• FNP 592 Week 7 Clinical Documentation Template

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Student Name and clinical course: ____________(FNP 592)

Client’s Initials*: YY

Age: 35

Race: American

Gender: Male

Date of Birth: January 1, 1989

Insurance: Medicare

Marital Status: Single

Subjective:

CC: I have also felt more thirsty, urinated frequently in recent days, and lost weight.

HPI: Patient YZ is a 35-year-old male patient who is currently complaining about recent complaints of potential symptoms of diabetes mellitus. They complain that they have been thirstier, they urinate more, and have simply lost weight in the last few weeks. The patient denies any major past history but states that her family has a history of diabetes. They complain about their symptoms and want additional examination.

Past Medical History:

• Medical problem list: None
• Preventive care: Up to date
• Surgeries: Cholecystectomy (2011)
• Hospitalizations: None

Allergies: Pollen, dust

Medications: None

Family History:

Mother: High cholesterol

Father: DM 2

PGM: Colon cancer

PGF: Hypertension

MGM: COPD

MGF: Diabetes

ROS 

Constitutional: The patient appears alert and oriented but mildly fatigued.

Eyes: No pain, redness, or tearing

Ears/Nose/Mouth/Throat: No infections or hearing changes, fever, or hearing change.

Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops.

Genitourinary: No pain 

Neurological: Alert and oriented x3, cranial nerves intact, normal gait and coordination.

Psychiatric: Normal

Endocrine: Normal 

Objective

Vital Signs: HR-69 BP-140/78 Temp- 98RR-74 SpO2-98% Pain-3/10

Height: 5 ft 4 in Weight: 140 lbs BMI: 24.5

Labs, radiology, or other pertinent studies: Fasting blood glucose and HbA1c

Physical Exam

GENERAL: Unintentional weight loss. 

HEENT: Clean pinnas, nasal mucosa reddened, clear exudate, tongue mobile without lesions, and tonsillitis.non-enlarged thyroid and lymph nodes.

NEURO: Oriented x 4 and alert.

CARDIO: No murmurs, crisp S1 S2.

THORAX AND LUNGS: The thorax has a good expansion, and the lungs are bilateral.

ENDOCRINE: Polyuria and polydipsia

Assessment

Differentials:

• Type 2 Diabetes Mellitus (T2DM)

Another potential differentiation is T2DM, as the patient is of age and has a family history of diabetes. T2DM is usually characterized by the insidious onset and is connected with insulin resistance and relative insulin deficiency. Such risk factors are obesity, a sedentary lifestyle, and a family history of T2DM.

• Type 1 Diabetes Mellitus (T1DM):

T1DM is another possible diagnosis, as the symptoms of polyuria, polydipsia, and weight loss appeared abruptly. Pathophysiology: Autoimmune devastation of pancreatic beta cells causes insulin deficiency. The patients usually present themselves at a younger age, and a family history of autoimmune diseases may be present as well.

• Urinary Tract Infection (UTI):

UTI might be viewed because of the symptoms of thirstiness and frequent urination, which might be because of polyuria caused by glycosuria or as a reaction to urinary symptoms. The symptoms of UTI can be dysuria, urgency, frequency, and suprapubic pain. UTI has risk factors such as abnormalities with the urinary tract, urinary catheterization, sex, and diabetes mellitus. The diagnosis is through urinalysis and urine culture to ascertain that it is bacterial, and the cause.

Diagnosis- Type 2 DM

Plan

Diagnostics: Blood glucose and HbA1c tests to rule out the diagnosis and determine the Glycemic control.

Include other tests like lipid profile, kidney tests, and urine microalbuminuria to consider other comorbidities and complications associated.

Treatment:

• Order HbA1c and fasting blood glucose levels.
• Start education on lifestyle changes, such as lifestyle modification in terms of diet and exercise.
• Supply blood glucose monitoring materials and symptom recognition and management.
• To start glycemic control, prescribe metformin once a day (Aguadé et al., 2020).
• Referral to a dietitian for extensive dietary counseling.

Education:

• Talk about the need to take medicine and attend follow-up appointments on a regular basis.
• Examine symptoms of hyperglycemia and hypoglycemia and correct management measures (Pasquel et al., 2021).
• Stress the importance of lifestyle changes in the management of diabetes, such as diet and physical activity.
• Give details of support groups or resources for persons with diabetes.

Follow Up: Arrange a follow-up meeting in 2 weeks to discuss the outcomes of the diagnosis and begin the necessary management, including lifestyle change and pharmacotherapy, if needed. 

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References for FNP 592 Week 7

Below are the  references for FNP 592 Week 7:

Miller, K. M., Carapetis, J. R., Van Beneden, C. A., Cadarette, D., Daw, J. N., Moore, H. C., Bloom, D. E., & Cannon, J. W. (2022). EClinicalMedicine, 48, 101458. https://doi.org/10.1016/j.eclinm.2022.101458

Norton, L., & Myers, A. (2021). World Journal of Otorhinolaryngology – Head and Neck Surgery, 7(3), 161–165. https://doi.org/10.1016/j.wjorl.2021.05.005

Orzell, S., & Suryadevara, A. (2019). Pharyngitis and pharyngeal space infections. Introduction to Clinical Infectious Diseases, 53–66. https://doi.org/10.1007/978-3-319-91080-2_5

Tomić, M., & Pecikoza, U. (2022). Arhiv Za Farmaciju, 72(3), 300–319. https://doi.org/10.5937/arhfarm72-38025

Best Professors To Choose For FNP 592

• Prof. Gibson, S
• Dr. Shanika Valcour-LeDuff

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