Minimum 5 pages according to template 2)¨******APA norms Dont copy and pase the questions. Answer the question objectively, do not make introductions to your answers, answer it when you start the paragraph 4) Minimum 5 references not older than 5 years create soap note for patient with Diabetes. Create a clinical case of a patient diagnosed with Diabetes. Based on the case you created, complete the Template.

Patient Information:

Name: John Smith
Age: 50
Gender: Male
Chief Complaint: Increased thirst and frequent urination

Subjective:

HPI: John Smith, a 50-year-old male, presents to the clinic with a chief complaint of increased thirst and frequent urination for the past two weeks. He reports feeling fatigued and has lost 5 pounds unintentionally. John also complains of blurred vision occasionally. No fever or sweating noted. He denies any chest pain, shortness of breath, or any other significant symptoms.

PMH: John has a past medical history of hypertension and dyslipidemia. He takes medications for both conditions and claims good adherence. No previous history of diabetes.

Surgical history: John underwent laparoscopic cholecystectomy five years ago.

Allergies: NKDA

Family history: John’s mother has type 2 diabetes.

Social history: John is married and works as an accountant. He is a non-smoker and denies any illicit drug use. He consumes alcohol occasionally.

Objective:

Vitals:
– Temperature: 98.6°F
– Blood pressure: 136/82 mmHg
– Heart rate: 78 bpm
– Respiratory rate: 16 bpm
– BMI: 29 kg/m^2

General:
John appears well-nourished, in no acute distress. He is alert, oriented, and cooperative.

HEENT:
– Head: Normocephalic, atraumatic
– Eyes: Pupils are equal, round, reactive to light, and accommodation (PEARL).
– Ears: External ears appear normal.
– Nose: No flaring or discharge.
– Throat: Oropharynx is moist, no erythema or exudates.

Chest/Lungs:
Symmetrical chest expansion. No respiratory distress observed. Lungs clear to auscultation bilaterally. No wheezes, rales, or rhonchi.

Cardiovascular:
Regular rate and rhythm, normal S1 and S2. No murmurs, rubs, or gallops. Peripheral pulses are palpable and equal bilaterally.

Abdomen:
Soft, non-tender, and non-distended. No hepatosplenomegaly or masses palpated. No rebound tenderness or guarding. Bowel sounds present in all four quadrants.

Extremities:
No clubbing, cyanosis, or edema noted. Capillary refill less than 2 seconds.

Neurological:
Cranial nerves II-XII intact. Strength 5/5 in all extremities. No focal neurological deficits noted. Reflexes are equal and symmetrical throughout.

Assessment:

Based on the subjective and objective findings, it is likely that John Smith has developed diabetes mellitus. His presentation with increased thirst, frequent urination, unexplained weight loss, and fatigue are classic symptoms of hyperglycemia. His family history of type 2 diabetes and his age also increase his risk for developing this condition. The absence of chest pain, shortness of breath, or other concerning symptoms suggests that John’s diabetes may be in the early stages and not yet associated with complications.

Plan:

1. Confirm the diagnosis:
– Order fasting blood glucose level to determine if it is within the diabetic range.
– Consider ordering a hemoglobin A1c (HbA1c) test to assess long-term control of blood glucose levels.

2. Educate the patient about diabetes:
– Discuss the importance of lifestyle modifications, such as a healthy diet, regular physical activity, and weight management.
– Explain the need for monitoring blood glucose levels and the potential use of medications to control blood sugar.
– Provide information about potential complications of diabetes and the importance of regular follow-up appointments.

3. Initiate treatment:
– If fasting blood glucose level and HbA1c confirm the diagnosis of diabetes, begin pharmacologic therapy.
– Consider prescribing metformin as first-line therapy unless contraindicated (e.g., renal impairment).
– Start with a low dose and titrate gradually to reduce side effects.

4. Monitor and follow-up:
– Schedule a follow-up appointment in 2-4 weeks to assess treatment response and adjust therapy if necessary.
– Consider referring the patient to a diabetes educator for ongoing education and support.

5. Address comorbid conditions and risk factors:
– Continue management of hypertension and dyslipidemia with appropriate medications and lifestyle modifications.
– Advise the patient about smoking cessation and the importance of alcohol moderation.

Conclusion:

John Smith, a 50-year-old male, presents with symptoms suggestive of diabetes mellitus. Further diagnostic tests, such as fasting blood glucose and HbA1c, are necessary to confirm the diagnosis. Initial treatment will focus on patient education, lifestyle modifications, and pharmacologic management if indicated. Regular monitoring and follow-up appointments will be vital to ensure adequate glycemic control and reduce the risk of complications. Addressing associated comorbid conditions and risk factors will also be important for John’s overall health and well-being.