Soap note-diabetes Mellitus Essay

Soap Note-Diabetes Mellitus

Subjective Data

Chief complaint: “ I have increased urine frequency for three weeks.”

History of presenting of illness: E.W is a 56years old female who presented at the ER with increased urinary frequency for three weeks. It was of gradual onset, worse at night with no aggravating and relieving factors. The patient reports that increased urinary frequency is associated with polydipsia, polyphagia, blurring of vision, and numbness of extremities. She reports significant weight loss for three months. Soap note-diabetes Mellitus Essay

Current medication: HCTZ 25mg PO OD and atorvastatin 20mg PO OD

Past medical history: recurrent urinary tract infection, hypertension, and hyperlipidemia.

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Past surgical history: none

Allergies: she denies, food, drug, environmental, and latex allergies.

Immunization history: childhood immunization is up to date.

Reproductive history: her menarche was at the age of 16years with a regular 28days cycle. She is six years into menopause. Her last menstrual period was at the age of 49years. She has three children all grown. They were born via spontaneous vertex delivery. She denies antenatal and post-partum complications.

Social history: she is married and lives with her husband. She is a retired teacher. She enjoys watching and singing. She drinks alcohol occasionally and smokes at least two sticks of cigarettes with her husband. She prefers taking fast foods to healthy meals. She does not engage in physical exercise. She rarely goes to the hospital for a check-up.

Family history: she is the only child in the family. Her mother passed on three years ago due to stroke, she had diabetes mellitus, hypertension, and hyperlipidemia. Her father is alive living with diabetes mellitus and chronic obstructive pulmonary disease.

Review Of System

General: she denies fever and night sweats

HEENT: she denies headache, eye ache, ear pain, throat pain, and runny nose.

Respiratory: she denies cough, chest pain, tachypnea, and shortness of breath

Cardiovascular system: she denies palpitations, tachycardia, syncope, and lower limb swelling.

Musculoskeletal system: she denies joint pain, muscle spasms, and joint stiffness.

Neurological system: she denies facial droop, tremors, and tingling sensation.

Objective Data

General: she is calm and alert without pallor, jaundice, cyanosis, and lymphadenopathy.

Vitals: blood pressure 168/99mmHg, Pulse rate of 76beats per minute, BMI 29kg/m2, temperature at 36.7 degrees Celcius, and oxygen saturation 95% room air.

HEENT: the head is cephalic and atraumatic. She has a cataract in the right eye. She has no runny nose, post nasal drip, otorrhea, and tearing of the eyes.

Respiratory system: the chest has symmetrical expansion with resonant percussion notes and vesicular breath sounds.

Cardiovascular system: the heart sounds are present without murmurs and gallop.

Abdominal examination: the abdomen is round without flank fullness. The bowel sounds are present. There is a tympanic note, no dullness, and no fluid thrills. There is no tenderness and organ enlargement. The external genitalia has a normal size and hair distribution. There is no vaginal discharge and tenderness.

Diagnostic tests: laboratory tests appropriate for this patient are random blood sugar, and hemoglobin A1C to check the sugar control for three months. Urinalysis to check for infection, glucose, and ketone levels. Complete blood count to rule out infections.

Assessment

The primary diagnosis is Type two diabetes mellitus E11.9. Type two diabetes mellitus is a metabolic disease characterized by hyperglycemia because the body cells are resistant to insulin or there is insufficient production of insulin in the body (McCance, K. L., & Huether, S. E. 2019). The symptom of diabetes is increased thirst, fatigue, blurring of vision, polyuria, weight loss,  recurrent infections, numbness, and tingling sensation. The risk factors for diabetes mellitus are hypercholesterolemia, obesity, family history of diabetes mellitus, gestational hypertension, polycystic ovarian syndrome, smoking, sedentary lifestyle, and old age above 45years. The patient is 56years old in her menopause years. Menopause reduces metabolism and increases the risk for insulin resistance. she has hypertension, leads a sedentary lifestyle, and has a family history of diabetes mellitus. Soap note-diabetes Mellitus Essay

Plan

Pharmacological

1. Losartan 50mg PO daily
2. HCTZ 25mg PO daily
3. Amlodipine 10mg PO daily
4. Sitagliptin-metformin 1tablet PO daily
5. Aspirin 81mg PO daily
6. Atorvastatin 80mg PO daily

The patient’s blood pressure is not well controlled despite being on medication. Moreover, she has a higher risk for cardiovascular events because she is obese and has hyperlipidemia. The American heart association recommends combination of three drugs to reduce the risk of heart disease (Woo, T. M. & Robinson M.V. 2020). Additionally, aspirin would help reduce the risk of stroke and atorvastatin to lower the cholesterol levels.

Non-pharmacological

1. Nutritional counseling to achieve a healthy diet regime to control blood pressure, glucose, and cholesterol levels.
2. Physical exercise to burn excess calories
3. Physician follow-up monitor the complications.
4. Patient education for lifestyle modification like stop smoking and taking alcohol.

References

McCance, K. L., & Huether, S. E. (2019). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). St. Louis: Mosby. ISBN: 978-0-323-40281-1

Woo, T. M. & Robinson M.V. (2020). Pharmacotherapeutics for Advanced Practice NursePrescribers (5th ed.). Philadelphia, PA: F.A. Davis. ISBN-13: 978-0-8036-6926-0

Independent Case Study

Print

Students will choose a clinical case they have encountered in their clinical areas, gather relevant clinical data associated with the pathophysiology, document the information in a SOAP note format, and relate the clinical data to the pathophysiological process.

References utilized should be from reliable sources.

Independent case studies should be in APA student paper format.

Use the Independent Case Study Template provide for this assignment.

• SOAP Note Guidelines

Patient demographics:  initials, age, gender (Patient information must be de-identified.)

Source of information:  Patient/spouse/parent/child/guardian/witness/institutional chart review – institution name; reliability: poor/fair/good historian, questionable reliability, unreliable historian

PCP

Subjective information obtained from the patient/caretaker.

History

Chief complain (in quotations):

History of Present Illness (HPI)

In the history of present illness or the chief complaint, we want to ascertain the history of their complaint.  This is the symptom analysis.  Typical mnemonics that help with symptom assessment are NOPQRSTU (my preference), OLD CARTS, or SOCRATES.

PMHx (include year of diagnosis)

PSHx (include year)

Trauma/Accidents (include year, treatment)

MenHlthHx

Diagnosis, prior psychiatric admissions, h/o suicidal attempts, self-injurious behavior

Consider the depression scale “Patient Health Questionnaire-2 (PHQ-2) Depression Screening Tool

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OB/GYN

LMP, menarche/menopause, GPTPAL, BC

Medications

Prescribed (reason)/OTC/Herbal

Dose, frequency, route

Allergies

Drug (NKDA), Food (NKFA), Latex, Environmental (dust/pollen/seasonal), Animal dander

Reactions in parenthesis after each; example:  penicillin (hives)

SocHx

Single/married/divorced/widowed; housing/undomiciled; education level; occupation

For the purpose of the case study, we can leave out some of the pertinent social history information that we normally gather.  However, information such as place of birth and occupation may be relevant to the case presentation.

Nicotine/ETOH/substance use

• • • Nicotine:  smoked, vaped, chewed, gum, patch; age started, type, frequency – packs per day, number of years
    • ETOH: frequency, amount, age started. If excessive drinking consider asking about when drinking frequency and amount increased, h/o binging, h/o blackouts, withdrawal symptoms, and/or detox/rehab for ETOH

• • • • For example, a case study regarding alcohol induced pancreatitis would be lost if information regarding alcohol (ETOH) use, preference (wine/beer/liquor), the size of the glass, frequency, history of blackouts, detoxification and/or withdrawal symptoms.

• • • Substance: cannabis blunts/day, pipes/day, edibles/day; cocaine snort/IV; crack; heroin sniff/IV; LSD; MDMA; street BDZ/Percocet/Adderall; KS.  Ask about each substance when started, frequency of use, route of use.  If excessive substance use consider asking about when increased frequency/amount occurred, h/o binging, h/o withdrawal symptoms and/or detox/rehab for each substance.

• • • • Another thought is legally medicinal use of some substances.  If a patient is using medicinal cannabis, it belongs under the “Medications” header and not under substance use.

Preferred gender; sexual preference; sexually active –  M/F/Both; use of barrier protection; number of lifetime partners; h/o STIs – When? Treated? For clients entering into detox/rehab units, must ask about h/o or exposure to: Syphilis, HIV, HCV, HBV, and TB.

• Again, this information may or may not be applicable to the case presentation.  For example, a case study regarding syphilis would be lost if the sex (male/female), gender, sexuality, number of partners, birth control/sex protection (barrier/non-barrier methods), history of sexually transmitted infections (STIs) year and treatment information was not provided.

FamHx

Grandparents, aunts/uncles, parents, siblings, children.  Always consider 1^st generation

Alive/deceased; health status/diagnoses; ages; age and cause of death

ROS (Review of Systems)

The ROS is the way to evaluate if other body systems are involved.

If comprehensive history is required, must review all body systems include health promotion and health maintenance questions.

Otherwise, consider the chief complaint and relevant systems.

Must always consider the patient’s past history in relation to the present complaint.

Objective information obtained during a physical exam or diagnostics completed prior to the exam.

Physical Exam

Vital signs

Constitutional

HEENT

Thorax

Neuro

Abdomen

Musculoskeletal

Integumentary (typically this is covered with each system assessment; however, if specifically related to chief complaint – for example cellulitis, can separate out.)

Diagnostics: (if applicable, include relevant diagnostic results in this section)

Assessment (or Diagnosis)

Name the pathophysiological condition. Place your diagnosis in this section.

Your patient may have multiple diagnoses. Highlight the one you choose to explore in the assignment.

If co-morbid conditions exist, students must discuss the interaction of these pathophysiological processes.

Plan – For NURS 681, the “P” will stand for Pathophysiology.

Pathophysiology:

• • Students will thoroughly discuss the pathophysiology from cellular to tissue to system to whole being effects.
  • Relationship between the pathophysiological symptoms and signs/diagnostic results presented in the subjective and objective sections, respectively, are thoroughly discussed.
  • If co-morbid conditions exist, students must discuss the interaction of these pathophysiological processes.
  • Use the questions below to guide the discussion.

• • Symptom Analysis for History of Present Illness (HPI)

To refresh your memory, a symptom analysis gathers background information of the symptoms to guide the clinician to the diagnosis.  Consider any one of these mnemonics to help you gather your symptom analysis data for your history of present illness (HPI) section.

Old Carts

• • • O – Onset
    • L – Location
    • D – Duration
    • C – Character
    • A – Alleviating and Aggravating factors
    • R – Radiation
    • T – Treatments
    • S – Severity

Socrates

• • • S – Site
    • O – Onset
    • C – Character
    • R – Radiation
    • A – Associated symptoms
    • T – Time span/duration
    • E – Exacerbating & relieving factors
    • S – Severity

NOPQRSTU

• • • N – New patient or New symptom
    • O – Onset
    • P – Palliative/Provocative factors
    • Q – Quality/Quantity (can use pain scale here)
    • R – Region & Radiation
    • S – Severity (how does it impact their daily activities)
    • T – Time (onset, frequency, crescendo/decrescendo [it gets worse/then better])
    • U – Understanding (patient’s)

• Pathophysiological Questions for Independent Case Study

Questions to answer for the Pathophysiology Section

As with our case studies in class, these may be bulleted.  However, be sure to clearly link the information to the pathophysiology.

• 1. Describe the pathophysiology.

• Consider cellular, tissue, organ, system, whole being responses. (Etiology)

• 1. What is the incidence and prevalence of this pathophysiology?

• Prevalence is a statistical concept referring to the number of cases of a disease that are present in a particular population at a given time.
• Incidence refers to the number of new cases that develop in a given period of time.

• 1. How do the symptoms, signs, and diagnostic studies of this specific case relate to the pathophysiology of the diagnosis indicated in the Assessment section?

• Not all cases of a given pathophysiology present in an identical manner. When discussing symptoms and signs of your patient, be sure to explain how the symptoms or signs occur given the specific pathophysiology.
• When discussing diagnostics, clearly link the diagnostic to the pathophysiology. Explain the diagnostic, what the results mean, and its relationship to the specific pathophysiology.

• 1. Are there any nonpharmacological interventions that may assist with the pathophysiological condition?

• If so, describe how the intervention would benefit the patient with this specific pathophysiology.

• 1. Are there any additional diagnostics that could be performed for the diagnosis?

• If so, describe the diagnostic(s) and how it would provide additional relevant information for the specific pathophysiology. Soap note-diabetes Mellitus Essay