Sample soap note for diabetes

(Student Name)

Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor:

Soap Note # Main Diagnosis Diabetes Mellitus type 2

PATIENT INFORMATION

Name: Mr. ET

Age: 56-year-old

Gender at Birth: Female

Gender Identity: Female

Source: Patient

Allergies: Penicillins

Current Medications:

· Multi-Vitamin Centrum Silver

· Lisinopril 10 mg daily

· PMH: HTN

Diabetes mellitus type 2

Immunizations:

Preventive Care: Coloscopy 3 years ago (Negative)

Surgical History: laparoscopic cholecystectomy

Family History: Father alive

Mother-alive, 90 years old, Diabetes Mellitus, HTN

Daughter-alive, 21 years old, healthy

Social History: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, she lives alone.

Sexual Orientation: Straight

Nutrition History: Diets off and on

Subjective Data:

Chief Complaint: “I cannot stop to drink water and to pee, I need to see my labs”

Symptom analysis/HPI:

The patient is 56 years old female who complaining of she cannot stop to drink water and to pee. Patient noticed the problem started 1 month ago and sometimes it is accompanied by anxious for eat. She states that she has been under stress because her daughter for the last month. Patient denies pain, or another symptom. She makes some labs and coming to see the results.

Review of Systems (ROS)

CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures.

HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.

RESPIRATORY: Patient denies shortness of breath, cough or hemoptysis.

CARDIOVASCULAR: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal

dyspnea.

GASTROINTESTINAL: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or diarrhea.

GENITOURINARY: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.

MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound.

SKIN: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.

Objective Data:

VITAL SIGNS and Lab valuesTemperature: 97.5 °F, Pulse: 84, BP: 142/82 mmhg, RR 20, PO2-98% on room air, Ht- fill, Wt fill lb, BMI 37.2. No report pain 0/10.

HbA1C 9.5 %.

Serum creatinine 1.2 mg/dl, add more

GENERAL APPREARANCE: The patient is alert and oriented x 3. No acute distress noted. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5.

HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without lesions,. Lids non-remarkable and appropriate for race.

Neck: supple without cervical lymphadenopathy, no jugular vein distention, no thyroid swelling or masses.

CARDIOVASCULAR: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary refill < 2 sec.

RESPIRATORY: No dyspnea or use of accessory muscles observed. No egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on auscultation.

GASTROINTESTINAL: No mass or hernia observed. Upon auscultation, bowel sounds present in all four quadrants, no bruits over renal and aorta arteries. Abdomen soft non-tender, no guarding, no rebound no distention or organomegaly noted on palpation

MUSKULOSKELETAL: No pain to palpation. Active and passive ROM within normal limits, no stiffness.

INTEGUMENTARY: intact, no lesions or rashes, no cyanosis or jaundice.

ASSESSMENT:

Main Diagnosis: Diabetes mellitus type 2 explain why

Obesity, HTN

Differential diagnosis: Put 3 and explain

PLAN: Metformin 500 mg one tablet daily in addition to daily style modifications. This dose can be increased to twice daily as needed or as tolerated every 1 o 2 weeks, until a maximum of 2 grams daily.

Hydrochlorothiazide (thiazide diuretic) 1 tablet daily added to the treatment for HTN to better control.

Labs and Diagnostic Test to be ordered:

· CMP

· Complete blood count (CBC)

· Lipid profile

· Liver function test (because the metformin requires routine monitoring)

· Serum creatinine

· Potassium because the ACE inhibitors requires monitoring of electrolytes

· Urinalysis with Micro

· Electrocardiogram (EKG 12 lead)

· Urine to monitor ketone and glucose

Pharmacological treatment:

· Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily.

· Lisinopril 10mg PO Daily

· Metformin tab 500 mg one tablet daily.

Non-Pharmacologic treatment:

· Weight changes must be done to manage better the Diabetes

· Healthy diet (DASH dietary pattern): Diet rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced content of saturated and trans l fat

· Reduced intake of dietary sodium: <1,500 mg/d is optimal goal but at least 1,000 mg/d reduction in most adults

· Enhanced intake of dietary potassium

· Exercises must be done at least 3 times per week like: walking, swimming or running

· Measures to release stress and effective coping mechanisms.

Education

· Provide with nutrition/dietary information.

· To avoid GI side effects, take the Metformin with foods.

· Instruction about medication intake compliance.

· Avoid drinking alcohol: Alcohol has a negative interaction with Metformin and contribute to hyperglycemia.

· Education of possible complications of Diabetes such as stroke, heart attack, and other problems.

· Educate to the importance to foot examination and to choose diabetes footwear.

Follow-ups/Referrals

· Follow up appointment 1 weeks for managing blood sugars: It is important to target levels of A1C less than 7 %, so labs will be every 3 months.

· Follow up nutritionist to…..

References(acerca de la enfermedad y el tratamiento, en alfabetico orden, en APA

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