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Assignment

Documentation Using SOAP or FARM

Completion requirements
Opened: Wednesday, 13 February 2013, 8:50 AM
Due: Tuesday, 19 February 2013, 8:50 AM
Please use the FARM or SOAP form to suggest a complete therapeutic plan for this lady
 
A 78 year old African American female with Type II diabetes is being discharged today after being admitted for heart failure exacerbation. She was admitted several days ago, and has been treated with insulin while in-house. The medical team is now deciding which diabetes medications to restart upon her discharge. The drugs she was on before she came here were: Metformin 850mg PO TID, pioglitazone 45mg PO daily, Losartan 50mg PO daily, Furosemide 40mg PO daily, carvedilol 25mg PO BID, simvastatin 20mg PO qhs, aspirin 81mg PO daily, and Tylenol Arthritis 650mg caps PRN joint pain. She has had diabetes for 6 years, as well as hypertension for about 30 years, and high cholesterol for about 10 years. She has also had osteoarthritis for 20 years. There is a history of diabetes in her mom and siblings, and her dad died of an myocardial infarction at age 42. She doesn’t smoke, drink or use illicit drugs. She lives alone but spends time with friends and family several times a week. Her diet before she was admitted included drinks sweetened with Splenda, about 4 carbs per meal, and low sodium intake. She takes daily walks and does tai-chi classes. Her serum creatinine is 1.2 and her weight it 64 kilograms. She also is noted to have edema, cough, jugular venous distention which has resolved since being admitted. Her blood glucose is close to her goal on glargine insulin 26 units nightly at bedtime, and lispro insulin 6 units TID before meals. 


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