SOAP NOTE On Diabetes

Diabetes SOAP Note

 

Don't use plagiarized sources. Get Your Custom Essay on
SOAP NOTE On Diabetes
Just from $8/Page
Order Essay

Name xxxx

United State University

Course ::xxxx

Professor xxxx

Date xxxx

 

Diabetes SOAP Note

ID:

Client’s Initial: N.L. Age: 50; Race: Caucasian; Gender: Male; Date of Birth: Jan 1, 1972. He is unaccompanied and seems to be a reliable historian.

Subjective

CC: “I have been experiencing frequent urination, and fatigue”

HPI: Patient is a 50-year-old man who arrives at the clinic complaining of frequent urination. Aside from the increased frequency of urination, other symptoms include thirst, hunger, and tiredness. He reports that the symptoms have been going on for about two months. He has a past medical history of hypertension, which was diagnosed last year 2021. He reports he has not had any other long-term illnesses or allergies. He also reports that he has not taken any medication that have made his condition worse or helped. He reports drinking alcohol occasionally about 2 bottles of beer in a week. He denies any burning or pain while urinating, denies fever or chills.

Past Medical History:

· Medical Problem: Hypertension

· Surgeries: none

· Allergies: No known allergies

· Immunization: Fully immunized

· Current Medications: Lisinopril 10 mg po daily for Blood pressure

Family History:

Mother, age 78, has diabetes

Father, age 80, diseased, with history of hypertension

Brother, age 60, has diabetes

Social History

Living situation: He lives with his wife and 3 grandchildren in a safe environment.

Occupation: He is a high school teacher

Tobacco or marijuana use: Denies

Alcohol use: Drinks 5 bottles of beer in a week.

Diet: Vegan

Exercise: Rare physical activity

Review of System

Constitutional: The patient reports fatigue. Denies chills or fever.

Skin: Denies skin rashes, bruises, color changes, or lesions.

HEENT: Head: No previous head injury reported.

Eyes: Denies use of corrective lenses. No eye irritation, color blindness, dryness, or copious tears

were reported.

Ear: Denies experiencing hearing difficulties, ear pain, ear ringing, discharges, or hearing loss.

Nose: No nosebleed, loss of smell, nasal congestion, or pain reported.

Months/ throat: No bleeding gums or mouth wounds were reported. No sore throat and hoarseness were reported.

Respiratory: Denies difficulties in breathing, wheezing, or coughing.

Cardio: Denies chest pains but reports episodic heart palpitations

Endocrine: Reports an increase in appetite and thirst.

Musculoskeletal: Denies having joint pain, muscle pain, or swelling.

Genitourinary: Denies discomforts when urination. Reports an increase in urination more often during the night.

Neuro: Denies tremors, headaches, or dizziness.

Psychiatric: Denies sleep disturbances or ideas of hurting himself, such as suicidal thoughts. Denies depression and anxiety

 

Objective

Vital Signs:

Blood Pressure 138/89, Resp: 18, Heart rate: 88, Temperature 98.6 F, SpO2 100

Height 5’3″ Weight 158lbs BMI 28.2.

Physical Exam:

General appearance: The patient is a nice looking 50-year-old Caucasian man who is

conscious, oriented, and well-groomed

Head: normocephalic, symmetric, atraumatic

Ears: T.M. intact and pearly gray with the cone of light bilat. Pinna clean, no exudate noted.

Eyes: Normal PERRLA findings. Anicteric sclera.

Nose: No maxillary sinuses, lesions, or bleeding. The mucous membrane is moist.

Throat: No lesions, exudate, or inflammation.

Skin: Soft, warm, supple, and dry. There are no rashes, bruising, or changes in skin color.

Cardiovascular: Normal S1 and S2 sounds. Irregular heartbeat.

Gastrointestinal: No palpable masses. Soft, non-distended, and non-tender abdomen.

Respiratory: Lung auscultation indicates no abnormalities. No wheezes

Musculoskeletal: No joints or muscles that are inflamed or stiff.

Extremities: No discernible edema.

Neurological: Gait is normal, and balance is stable. Clear communication with a clear tone of

voice.

Psychiatric: He is cooperative, alert, and has a pleasant disposition and conduct.

Assessment

Differential Diagnoses

Type 2 diabetes– (ICD-10-E11.65) This illness is characterized by a reduction in beta cells in the pancreas of the patient, which leads to high blood glucose (CDC, 2022b). The condition typically manifests following the start of type I diabetes. The primary signs and symptoms are blurred vision, excessive thirst, weight loss, headaches, excessive urination, poor wound healing, and numbness (CDC, 2022b). The patient’s symptoms, which include increased thirst, weariness, increase in urination, and a family history of diabetes, make the possibility that this diagnosis is the most likely.

Urinary tract infection (UTI) – (ICD-10-N39.0) This is an infection that constitutes the kidneys, bladder, ureters, or urethra (Cleveland Clinic, n.d.). These are the parts of the body that urine goes through before leaving the body. Early symptoms and indicators of a UTI are typically straightforward to spot and mostly involve pain, irritation, or burning when urinating (Cleveland Clinic, n.d.). This can be accompanied by an urgent need to urinate, known as urinary urgency, or the need to urinate frequently, known as urine frequency. Even though the urge to urinate is strong, one may only pass a small volume of urine. The urine may appear crimson or cloudy (Cleveland Clinic, n.d.). As the patient reported frequent urination, we deemed this a likely diagnosis. However, since no discharge or pain has been reported, we rule out this possibility.

Nephrogenic diabetes insipidus (NDI) – (ICD-10-N25.1) Patients with Nephrogenic Diabetes Insipidus are affected by an imbalance in their water intake and output (Hoffman, 2020). The body generally maintains a balance between fluid intake and urine output. Patients with NDI produce increased thirst due to polyuria (polydipsia) (Hoffman, 2020). Afflicted persons might become dehydrated rapidly if they do not consume enough water, especially during hot weather or while they are ill. NDI can be inherited or acquired. There are some medicines and chronic disorders that might cause the acquired form, and it can happen at any time in life (Hoffman, 2020). Since the patient reports symptoms of frequent urination, we consider NID a plausible diagnosis; nevertheless, we deemed it less likely due to the absence of family history that could have indicated that the disease was inherited.

Plan

Diagnostic Tests

Hemoglobin A1C tests – are recommend in aid to confirm a diagnosis of diabetes. The test can also be used to monitor diabetes patients’ blood sugar levels (Mayo Clinic, n.d.). A1C test results show the average blood glucose level over the previous 2 to 3 months (Mayo Clinic, n.d.). Particularly, the A1C test evaluates the amount of sugar-coated hemoglobin proteins in the blood. Hemoglobin is a protein that moves oxygen around in red blood cells (Mayo Clinic, n.d.). The greater the A1C score, the worse the blood sugar management and the greater the chance of developing diabetic complications. A test result of 6.5% or greater on two different occasions implies diabetes (Mayo Clinic, n.d.). In this case, the HbA1C level is 8.7%, and the 269 mg/dL blood sugar level.

A urinalysis – Urinalysis is a urine examination. It is used to evaluate a variety of conditions, including urinary tract infections or diabetes (Cleveland Clinic, n.d.). A urinalysis examines the color, concentration, and composition of urine. For example, if someone has an infection in the urinary tract, the urine might appear cloudy instead of clear. Elevated protein levels in the urine can imply renal dysfunction (Cleveland Clinic, n.d.). Lab findings reveal negative results for ketones, 1+ protein

Final diagnosis Diabetes type II (ICD-10-E11.65) Elevated A1C and family history of diabetes.

Treatment

Metformin is commonly used as the initial treatment for type 2 diabetes. Primarily, it reduces glucose synthesis in the liver and increases insulin sensitivity, allowing the body to utilize insulin more efficiently (Lv & Guo, 2020).

The patient is prescribed to take metformin 500 mg twice a day with meals.

Continue with his prescribed Lisinopril 10 mg orally once daily for the treatment of high blood pressure.

Patient Education

Stop drinking alcohol. Depending on the amount of alcohol consumed and whether or not the food was consumed at the same time, the effects of alcohol on blood sugar can range from normal to dangerously high. Diabetic patients are recommended to reduce their intake of alcohol or stop drinking alcohol (Mayo Clinic, 2022).

Take responsibility for diabetes management. The patient is educated to be sure to include healthy food and exercise in every aspect of life. Start exercise plan of walking at least 3 times a week and gradually increase as tolerated to 30 mins. Exercise should be avoided if fasting blood sugar is more than 250 mg/gl. Keep the weight in a good range. Keep an eye on the blood sugar levels and keep a record of daily fasting sugar for the next visit. Follow the healthcare provider’s advice on how to keep them in check. Take the medication as prescribed, review hyperglycemic/hypoglycemic signs and symptoms and advice on what to do (Mayo Clinic, 2022).

Referral – Referred to a diabetic educator and dietitian who will guide on the best nutrition plan for diabetic control.

Follow up – After 30 days, the patient is recommended to come back for a check-up visit, which will assist evaluate his signs and symptoms, the effect of the treatment, blood pressure, and glucose levels.

 

References

CDC. (2022a). Diabetes risk factors. Centers for Disease Control and Prevention. https://www.cdc.gov/diabetes/basics/risk-factors.html

CDC. (2022b, March 2). What is diabetes? Centers for Disease Control and Prevention. https://www.cdc.gov/diabetes/basics/diabetes.html

Cleveland Clinic. (n.d.). Urinalysis: What It Is, Purpose, Types & Results. https://my.clevelandclinic.org/health/diagnostics/17893-urinalysis

Hoffman, M. (2020). An Overview of Nephrogenic Diabetes Insipidus. WebMD. https://www.webmd.com/diabetes/nephrogenic-diabetes-insipidus-symptoms-causes-and-treatments

Lv, Z., & Guo, Y. (2020). Metformin and its benefits for various diseases. Frontiers in Endocrinology, 11, 191. https://doi.org/10.3389/fendo.2020.00191

Mayo Clinic. (n.d.). A1C test. Mayoclinic.Org. https://www.mayoclinic.org/tests-procedures/a1c-test/about/pac-20384643

Mayo Clinic. (2022). Diabetes care: 10 ways to avoid complications. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/diabetes/in-depth/diabetes-management/art-20045803

WebMD. (n.d.). Lisinopril oral: Uses, side effects, interactions, pictures, warnings & dosing – WebMD. Webmd.Com. https://www.webmd.com/drugs/2/drug-6873-1785/lisinopril-oral/lisinopril-solution-oral/details