SOAP Note Template Essay
SOAP Note Template Essay
SOAP Note Template
Make sure that all questions are answered on the template, and the sources used have to be five years or less old; i.e., 2016-2021. APA, template will be uploaded. SOAP Note Template Essay
41 year old female came to the clinic stating that “she has not been able to control her blood sugar She has not been feeling well lately. Her fasting blood sugar was 240. Moreover, no one educated on how to manage her diabetes. Her last Hgb A1C is 11.5 three months ago.”
Her vital signs are; BP 118/65, hr 72, RR 15, Temp 98.2, and O2 Sat is 100%, and her BMI is 33.
BUY NOW A PLAGIARISM-FREE PAPER HERE
Assessment of all of her systems are unremarkable, except that her lips are dry.
She is currently taken Metformin 500 mg bid, and a low estrogen contraceptive, which she does not remember the name.
Encounter date: __2/5/2021______________________
Patient Initials: _ A.J_____ Gender: M/F/Transgender __female__ Age: __41years___ Race: ___american__ Ethnicity _white___
Reason for Seeking Health Care: ___fatigue___________________________________________
HPI: _The patient complaints of general body fatigue for unspecified duration of time. She has been unable to control her blood pressure and blood glucose. she reports that fatigue is associated with weight gain, increased appetite, and increased urine output associated with thick whitish per vaginal discharge. _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Allergies (Drug/Food/Latex/Environmental/Herbal): ___none________________________________
Current perception of Health: Excellent Good Fair Poor
The patient’s current perception to health is poor because she does not engage in physical exercise and feeding on a healthy diet. SOAP Note Template Essay
Past Medical History
- Major/Chronic Illnesses: The patient is known to have diabetes mellitus, hypertension, and hypercholesterolemia._________________________________________________
- Trauma/Injury __none_________________________________________________________
- Hospitalizations ____once due to diabetes keto acidosis______________________________________________________
Past Surgical History__No history of surgical procedure________________________________________________________
Medications: __ Currently she is on metformin 500mg bid and low estrogen contraceptive.________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Family History: __ She is the third born in a family of 5. Her siblings are alive and healthy. Her mother passed on due to coronary heart disease and her father passed on due to stroke.__________________________________________________________
Social history:
Lives: Single family House/Condo/ with stairs: she lives in a three bedroom apartment in a serene enevironemnt.___________ Marital Status:__married______ Employment Status: __she works as a call center anager____ Current/Previous occupation type: ____none_____________
Exposure to: ___Smoke_her husband smokes tobacco in the house___ ETOH ____Recreational Drug Use: __she takes gin and whisky occasionally________________
Sexual orientation: _______ Sexual Activity: _she is sexually activr___ Contraception Use: __takes low dose estrogen__________
Family Composition: Family/Mother/Father/Alone: _she stays with her husband and children. Her parents passed on due to chronic illnesses.____________________________
Health Maintenance
The patient has been attending monthly scheduled clinics due to hypertension and diabetes. She does mammogram and pap smear once a year as advised by the doctor. She has had all her immunizations as scheduled by the ministry of health. SOAP Note Template Essay
Review of Systems:
General:
HEENT: no visual loss, blurred vision, double vision or yellow sclera, no hearing loss, sneezing, congestion, runny nose, or sore throat
Neck: no neck mass or swelling
Lungs: no cough, no difficulties in breathing, and no wheezing.
Cardiovascular: the patient reports of dyspnea on exertion, no edema, no palpitations.
Breast: no breast pain and palpable mass on both breasts
GI: denies having diarrhea and constipation, abdominal discomfort and cramping, incomplete emptying of the bowel, and unexplained weight loss.
Male/female genital: thick whitish discharge
GU: the patient reports of polyuria. No dysuria,
Neuro: no tingling sensation and numbness
Musculoskeletal: no muscle pain, back pain, joint pain or stiffness.
Activity & Exercise: the patient does no engage in physical exercise.
Psychosocial: the patient is alert and well oriented. No signs of sadness and depression.
Derm: no skin rash and itchiness
Nutrition: the patient is obese. She feeds on highly processed foods and junk.
Sleep/Rest: she has a healthy sleeping pattern.
LMP: 30th April 2020
STI Hx: no history of sexually transmitted infections
Physical Exam
BP__118/65______TPR_98.2____ HR: _72____ RR: _15___Ht. _151 cm____ Wt. _70kgs_____ BMI (percentile) _33____
General: the patient is sick looking and dehydrated. No pallor, no jaundice, no cyanosis, no edema
HEENT: no sclera yellowness, eye discharge, no nasal secretion or throat swelling
Neck: no mass or neck swelling.
Pulmonary: symmetrical expansion with vesicular breath sounds and resonant percussion note.
Cardiovascular: pulse rate is present at a regular rate and rhythm. Heart sounds S1 and S2 are heard. No murmurs.
Breast: bilaterally, the nipples are everted, normal skin color, no mass, no oozing discharge, and no axillary lymphadenopathy.
GI: abdomen is moving with respiration, with tympanic note, no flank fullness, no tenderness and no organ enlargement.
Male/female genital: she has a normal external female genitalia with a thick whitish discharge. No bruises or genital warts
GU: the bladder is neither distended nor palpable
Neuro: normal nerve sensation and reflexes
Musculoskeletal: no fractures, no edema
Derm: no skin rash, hypopigmentation, and hyperpigmentation.
Psychosocial: the patient is well oriented to time place and person
BUY NOW A PLAGIARISM-FREE PAPER HERE
The patient has generalized body fatigue, obesity, dyspnea on exertion, and dehydration. She is unable to control blood pressure and blood sugar.
Plan:
Differential Diagnoses
- hyperglycemia due to the elevated fasting blood sugar
- acute metabolic syndrome because the patient is hypertensive, diabetic, and is obese
- diabetes keto acidosis because of the hyperglycemia and dyspnea
Principal Diagnoses
- diabetes keto acidosis
- hyperglycemia
Plan
Diagnosis
Diagnostic Testing: urinalysis, white blood cell count, lipid profile, renal function test
Pharmacological Treatment: insulin treatment therapy and fluid replacement
Education: engage in physical activities like waling, taking medication as prescribed, and take healthy meals.
Referrals: nutrition clinic, physician clinic, and drug adherence counseling clinic.
Follow-up: physician clinic for blood glucose and pressure monitoring. Nutrition clinic to monitor weight and feeding pattern.
Anticipatory Guidance: the patient should lose weight, engage in physical activities, and take healthy meals to avoid complications of hypertension and diabetes mellitus.
Diagnosis
Diagnostic Testing: urinalysis, white blood cell count, lipid profile, renal function test
Pharmacological Treatment: insulin treatment therapy and fluid replacement
Education: engage in physical activities like waling, taking medication as prescribed, and take healthy meals.
Referrals: nutrition clinic, physician clinic, and drug adherence counseling clinic.
Follow-up: physician clinic for blood glucose and pressure monitoring. Nutrition clinic for weight and diet monitoring.
Anticipatory Guidance: the patient should lose weight, engage in physical activities, and take healthy meals to avoid complications of hypertension and diabetes mellitus. SOAP Note Template Essay
Signature (with appropriate credentials): __________________________________________
Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________
Diabetes keto acidosis is a complication of pre-existing or newly diagnosed diabetes mellitus (Barski, et al, 2019). It presents with fatigue, weight gain or loss, polyuria, elevated blood glucose, and dyspnea. The causes of diabetes mellitus type two are physical inactivity, obesity, and unhealthy diet (Oguntibeju, O. O. 2019). Patients known to have hypertension and diabetes mellitus should regularly monitor to prevent complications such as retinopathy, neuropathy, and organ failure.
References
Barski, L., Eshkoli, T., Brandstaetter, E., & Jotkowitz, A. (2019). Euglycemic diabetic ketoacidosis. European journal of internal medicine, 63, 9-14.
Oguntibeju, O. O. (2019). Type 2 diabetes mellitus, oxidative stress and inflammation: examining the links. International journal of physiology, pathophysiology and pharmacology, 11(3), 45.
DEA#: 101010101 STU Clinic LIC# 10000000
Tel: (000) 555-1234 FAX: (000) 555-12222
Patient Name: (Initials)______________________________ Age ___________
Date: _______________
RX ______________________________________
SIG:
Dispense: ___________ Refill: _________________
No Substitution
Signature: ____________________________________________________________ SOAP Note Template Essay
