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Hello Please fallow instruction: Read the soap note. I need you to find me an ICD10-CODE for the fallowing Diabetes mellitus type 2 Hyperlipidemia Cervical Neoplasm Benign breast disease .Provide references not older than 5 years old for each treatment plan below (in APA format). The reference may come from a journal, a book, etc. Cite all sources using APA format. Include three differential diagnoses and support your diagnoses with supporting literature. Treatment Plan Mrs.C.C will be counseled regarding her: Breast cancer risk, Cardio vascular disease, Diabetes Mellitus type 2, life style diet, fibrocystic disease, hyperlipidemias mammogram elf Breast Cancer Risk Patient has an increased breast cancer risk due to first-degree family member and early menses and late pregnancies—increased estrogen exposure to the breast tissue. Alcohol has been associated with an increased risk of breast cancer, therefore, she is counseled to reduce her alcohol consumption as an intervention she can do to reduce her risk as well as her concern for developing this disease Fibrocystic disease will make self-breast examination less reliable; however, she is counseled to undergo yearly mammograms (tomosynthesis should be done if possible because of her cystic breast disease). Cardiovascular Disease Screening test showed Ms. Cross lipids are in the high-moderate to high range for the risk of heart disease. This would be the time to discuss diet intervention with weight reduction and increasing vegetables and reducing fats. Diabetes Patient’s fasting blood glucose and hemoglobin A1C levels categorize her as a prediabetic. An improved healthy diet and weight reduction to a norm BMI can reduce her risk of progressing to diabetes. This provides an opportunity to prevent neuropathy and accelerated CAD. Lifestyle/Diet: Increased exercise would assist in maintaining a normal BMI and would help in stress reduction. Cervical neoplasm risk Negative Pap smear means she only needs continued screening SOAP NOTE Name: C.C Date: Time: Age: 41 years Sex: Female SUBJECTIVE 155 pounds Chief complaint: “I’ am here today for a Wellness visit” HPI: 41 years old healthy Hispanic American female G2P2 presents to the clinic today for a wellness visit. Reported to have a history of history of fibrocystic breast disease, overweight with a BMI of 27.5. No complain of pain nor medical concern reported. Patient also likes to discuss a few concerns, specially her risks for breast cancer. Just recently both her mother who’s 63, and her first cousin on mother’s side were diagnosed with Intraductal breast cancer, experienced her first menarche at 10.5 years old, gave birth to her first son at the age of 33 and breastfed her children for only four months. Patient would like to know whether that increases her risk and if so how much. Mrs. C.C. reported to have a normal result of mammogram done last year where she was 40 years old. Patient father diagnose with hypertension and hyperlipidemia and her mother with type 2 diabetes. Medications: Patient is currently taking oral Vitamin E to help with fibrocystic breast PMH Patient denies any medical condition Allergies: No Known Allergy Medication Intolerances: None Chronic Illnesses/Major traumas Patient denies experienced any major trauma nor chronic illness Hospitalizations/Surgeries patient reported been hospitalized been hospitalized three times when she was giving birth each time to her two children and when she was doing her bilateral tubal ligation and getting a few dental procedures, also she have regular dental cleaning every six months . Patient denies been diagnose with elevated blood sugar, blood pressure, heart burn, upper and lower respiratory infection. Family History Patient denies her two sons and her brother having any health problem. Mother is 63 diagnose with breast cancer two month ago and diabetes. Her first cousin on mother’s side diagnose with breast cancer at the age of 44 years old. They both diagnose with intraductal breast cancer and had a lumpectomy and radiation done. Her father suffer from hypertension and hyperlipidemia and currently able to keep them under control, by taking her medications Social History Hispanic American currently employ in a school as Middle-school learning specialist female patient reported married for fourteen years, currently leaving with husband, her wonderful sixth and eight years old sons she is working hard during the week and cooking and gardening, denies smoking, but grew up around smokers. Patient drinks at least one glass of wine every day at dinner time. Patient does not engage in any exercise activities, except when she’s gardening and does housework and leaving in a safe environment. ROS General Female patient reported with weight gain, denies fatigue, fever, chills, night sweat nor change in energy level. Denies no difficulty falling asleep. Cardiovascular Patient denies chest pain, palpitations, orthopnea, nor edema. Skin Patient denies delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles Respiratory Patient denies having cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB Took flu shot Eyes Denies wearing corrective lenses, blurring, visual changes of any kind Gastrointestinal No complain of abdominal pain, denies having nausea, diarrhea, vomiting constipation, hepatitis, hemorrhoids, eating disorders, ulcers nor black tarry stools Ears Patient denies Ear pain, hearing loss, ringing in ears nor discharge Genitourinary/Gynecological Patient G2P2 Denies urine urgency no sign of urine frequency, burning, change or color of urine. Patient reported, that her tube is tied and feeling comfortable to have unprotected sex. Last pap done 3-4 years ago with normal result Patient reported to experience her first Menarche at 10 in half years old around the the summer time. Last menstrual period was two weeks ago regular and always expected every the 25th or 26th of the month. breast, Last mammogram 18 month ago she was 40 years old, which was normal, menstrual complaints, No complain of vaginal discharge reported vaginal discharge, pregnancy hx Nose/Mouth/Throat Patient reports getting few dental procedure done and regular cleaning every six months Denies sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness nor throat pain Musculoskeletal Patient denies back pain, joint swelling, stiffness or pain, fracture hx, nor osteoporosis Breast Patient reported to have bilateral cystic breast, that comes and go as her hormone change from her menstrual cycle and should be worried only if the cyst stays, but denies lumps, bumps or changes. Neurological Patient denies syncope, seizures, transient paralysis, weakness, paresthesias, nor black out spells Heme/Lymph/Endo Patient denies having HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold nor heat intolerance Psychiatric Patient denies depression, anxiety, sleeping difficulties, suicidal ideation/attempts, nor previous dx OBJECTIVE Weight 155 BMI 27.5 Temp 98.4F (oral) BP 134/74 Height 5’’3 Pulse 76 regular Resp 16 O2 sat 98% at room air General Appearance Healthy adult female Alert and oriented; answers questions appropriately. Appearing in no acute distress. Slightly somber affect at first, then brighter later. Skin Skin is clean, warm and dry with no lesions, rash seen observed with good turgor. HEENT Head is normocephalic, atraumatic and without lesions Facial features are symmetrical Hair thickness and evenly distributed for patient gender and age. Scalp no visible scalliness, masses lump, deformities, rashes, nevi or other lesions and non-tender. Temporal arteries non-tender to palpation Frontal and maxillary sinuses are nontender Eyes: PERRLA. EOMs intact. No conjunctiva or scleral injection. Right and left vision are 20/20 on the reading snile chart Ears: Normal appearance of the external Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized, no deformity, no discharge, normal earing with weber test. Nose: Nasal mucosa pink; normal turbinates. No sepal deviation, no discharge, no polyps Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Good dental hygiene, no oral odor Pharynx is nonerythematous and without exudate. Teeth are in good repair. Nails: Normal appearing nails without ridging, pitting or peeling Cardiovascular S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Nail with normal capillary refill 2 seconds. Pulses 3+ throughout. No edema. Respiratory Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally. No mass, no distention noted Gastrointestinal Abdomen obese; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly. Breast Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin. Genitourinary Bladder is non-distended; no CVA tenderness . External genitalia reveal coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness. No adnexal masses or tenderness. Ovaries are non-palpable. Rectal exam as appropriate: Differed Musculoskeletal Full ROM seen in all 4 extremities as patient moved about the exam room. Neurological Speech clear. Good tone. Posture erect. Balance stable; gait normal. Psychiatric Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately. Lab Tests result Pap smear: Normal Hemoglobin A1C Hemoglobin A1c 6.4 % fasting blood sugar 122 mg/d Lipidprofile panel, Cholesterol 239, hdl Hi Low-density lipoprotein (LDL) 159 gh-density lipoprotein (HDL) 45 Triglycerides 40 Mammography pending Urine culture – pending Special Tests Diagnosis Differential Diagnoses 1Cervical Neoplasm 2-Hyperlipidimia 3-Benign breast disease 4- Diabetes mellitus type 2 Diagnosis Diabetes mellitus type 2 Hyperlipidemia Plan/Therapeutics Plan: Non-medication treatments Education provided to patient to exercise, three times a day for at least 30 minutes, eat low fat, low carb diet, eat plenty of fruit and vegetables, salads and drink plenty of water. Limit amount of alcohol consumption. Do not smoke. Perform self-breast exam after your menstrual period. Consider having a yearly mammogram and pap smear done. Return in two weeks for your mammogram results. Evaluation of patient encounter Patient will be return in two weeks for further test result. References


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