Pick any Chronic Disease: use Diabetes Follow the Soap Note Rubric as a guide Use APA format and must include minimum of 2 Scholarly Citations. Copy paste from websites or textbooks will not be accepted or tolerated. The use of templates is ok with regards of Turn it in, but the Patient History, CC, HPI, The Assessment and Plan should be of your own work and individualized to your made up patient.

SOAP Note for a Patient with Diabetes

Subjective:

Patient Information:
Name: John Doe
Age: 45
Gender: Male
Chief Complaint (CC): “I have been experiencing increased thirst and frequent urination.”

History of Present Illness (HPI):
The patient presents with a chief complaint of increased thirst and frequent urination. He reports that these symptoms have been present for the past three weeks and have been progressively worsening. The patient denies any visual changes, chest pain, shortness of breath, or difficulty breathing. He states that he has been feeling fatigued and has noticed a recent unintentional weight loss of approximately 5 pounds over the past month. He has no history of trauma or fever.

Past Medical History (PMH):
The patient has a history of Type 2 Diabetes mellitus, diagnosed 5 years ago. He reports compliance with his prescribed oral medication and regular exercise regimen. He denies any previous complications related to diabetes such as diabetic retinopathy, neuropathy, or nephropathy. The patient has not undergone any surgeries in the past.

Family History (FH):
The patient’s father has a history of Type 2 Diabetes mellitus and his mother has a history of hypertension. There is no family history of cardiovascular disease, stroke, or coronary artery disease.

Social History (SH):
The patient is married and works as an accountant. He reports a history of smoking cigarettes, but quit 10 years ago. The patient consumes alcohol occasionally on social gatherings.

Allergies:
The patient has no known drug allergies.

Current Medications:
Metformin 500mg twice daily

Objective:

General Appearance:
The patient appears well-nourished and in no acute distress. He is alert and oriented to person, place, and time. Vital signs are within normal limits: blood pressure 120/80 mmHg, pulse 72 beats per minute, respiratory rate 14 breaths per minute, temperature 98.6°F, and oxygen saturation of 98% on room air.

System Review:
Cardiovascular: Regular rate and rhythm with no murmurs, rubs, or gallops.
Pulmonary: Clear to auscultation bilaterally, no wheezes or crackles.
Musculoskeletal: No deformities, full range of motion in all extremities.
Neurological: Cranial nerves II-XII intact, no focal deficits.
Gastrointestinal: Abdomen soft and non-tender, no hepatosplenomegaly.
Skin: No rashes, lesions, or discolorations noted.

Assessment:

Diagnosis:
Type 2 Diabetes mellitus with uncontrolled blood glucose levels.

Differential Diagnosis:
1. Diabetic ketoacidosis (DKA)
2. Hyperosmolar hyperglycemic state (HHS)
3. Diabetic nephropathy

Plan:

1. Lifestyle modifications:
Advise the patient to maintain a healthy diet and regular exercise regimen to improve glycemic control. Emphasize the importance of a balanced diet with reduced carbohydrate intake and increased intake of fruits, vegetables, and lean proteins. Recommend at least 30 minutes of moderate-intensity exercise, such as brisk walking, five days a week.

2. Medication adjustments:
Increase the patient’s current dosage of metformin to 1000mg twice daily to improve glycemic control. Educate the patient on the importance of medication adherence and potential side effects. Provide instructions on proper administration and storage of medications.

3. Blood glucose monitoring:
Instruct the patient to monitor his blood glucose levels at home using a glucometer. Advise him to record his readings and bring them to follow-up appointments for review.

4. Annual eye exam:
Refer the patient to an ophthalmologist for an annual dilated eye examination to screen for signs of diabetic retinopathy.

5. Blood pressure management:
Monitor the patient’s blood pressure at each visit and aim for a target of less than 130/80 mmHg. If blood pressure remains elevated, consider initiating or adjusting antihypertensive medication.

6. Education and self-management:
Provide the patient with educational materials and resources on diabetes self-care, including healthy eating, exercise, medication adherence, and glucose monitoring. Offer referrals to diabetes education classes or support groups.

7. Follow-up:
Schedule a follow-up appointment in two weeks to assess the patient’s response to medication adjustments and review glucose monitoring records.

References:

American Diabetes Association. (2020). Standards of medical care in diabetes. Diabetes Care, 43(Supplement 1), S14-S31.

Inzucchi, S. E., Bergenstal, R. M., Buse, J. B., Diamant, M., Ferrannini, E., Nauck, M., … & Matthews, D. R. (2015). Management of hyperglycemia in type 2 diabetes, 2015: a patient-centered approach: update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care, 38(1), 140-149.