Soap note on diabetes
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Diabetes SOAP Note
United State University
Diabetes SOAP Note
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.
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
Mother, age 78, has diabetes
Father, age 80, diseased, with history of hypertension
Brother, age 60, has diabetes
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.
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
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
Blood Pressure 138/89, Resp: 18, Heart rate: 88, Temperature 98.6 F, SpO2 100
Height 5’3″ Weight 158lbs BMI 28.2.
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
Psychiatric: He is cooperative, alert, and has a pleasant disposition and conduct.
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.
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.
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.
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.
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
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