Sop Note
Running head: SOAP NOTE 1
DIABETES SOAP NOTE 2
Name: PK | Pt. Encounter Number: 23 | |
Date: October 2, 2020 | Age: 55 | Sex: male |
SUBJECTIVE | ||
CC:
Type II diabetes. |
||
HPI:
PK visited the clinic with complaints that he suspected to have type II diabetes. He complained of symptoms such as getting tired easily without doing a hard task, feeling hungry, increased thirst and urinating regularly. He has been assuming for the past three weeks that these symptoms were developing because of his dieting, but it was not the case. |
||
Medications: Not under medication for now, but has ever received a surgical operation in removing his appendix 3 years ago.
|
||
PMH
Allergies: allergic to dust
Medication Intolerances: none
Chronic Illnesses/Major traumas: 1. Diabetes 2. Heart murmur 3. Hypertension
Hospitalizations/Surgeries
None
|
||
Family History
He is a healthy family, through his maternal grandmother was diagnosed with diabetes, and his paternal grandfather died of diabetes. The paternal grandmother had diabetes at old age, while his maternal grandfather had asthma. In her early 50s, PK’s mother was living healthy though later diagnosed with hypertension while his father was diagnosed with pre-diabetes. One of his sisters is suffering from high blood pressure, while the rest of her sisters are healthy. |
||
Social History
PK has been interacting with his friends as well as in the community to improve his life socially. He is living in a 2-bedroom house with his family, who says he is happy with it. His two daughters are married, and they meet after some time to enhance the spirit of togetherness. He values every workmate in his place of work, and he is very cheerful. |
||
ROS | ||
General
The patients look generally healthy; even one could not tell that he is suffering from symptoms such as frequent urination, thirst, and hunger. He is alert, and he timely responses to questions. |
Cardiovascular
Sometimes he is stressed for being unable to cater to her family. Reports to have diagnosed with Hyperlipidemia, HBP, running short of breath, palpitations, and heart murmurs. |
|
Skin
Wrinkled, rough with rashes. |
Respiratory
Denies sneezing nor coughing. |
|
Eyes
Clear with no pain. No inflammations, not itching. |
Gastrointestinal
All 4 quadrants have sound bowel. Hepatosplenomegaly was absent after exam. |
|
Ears
Pain free ear. |
Genitourinary/Gynecological
Examination results shows he has non-distended and palpable bladder. No CVA tenderness identified. |
Nose/Mouth/Throat
Nose clears its drainage well with no pain. his throat has no sores and does not feel pain swallowing the food. |
Musculoskeletal
denies back pain, joint pain, stiffness, fracture, or join swelling. |
|
Breast
N/A |
Neurological
Patient communicates in a deep and auto voice. |
|
Heme/Lymph/Endo
No identified blood clotting disorders. |
Psychiatric
He is no depressed. Have never thought of committing suicide. |
|
OBJECTIVE | ||
Weight 82lbs BMI 24.3 | Temp 97.2 | BP 83/60 |
Height 8.8 ft | Pulse 88 | Resp 22.5 |
General Appearance
The patient looks alert, neat and sensitive to questions. He looks health and appear to know what is happening to his life. |
||
Skin
denies having bruised or lesioned skin. His has wrinkles and pale skin. |
||
HEENT
Head: normocephalic, symmetric, and atraumatic. There is no presence of hernia around the neck and the trachea. Eye: non-inflamed eyes. The covering of the eye is bilaterally aligned with the eyelids. Ears: the absence of exudation. The ear is bilaterally aligned with side appearance. Both the skin and the ear look healthy. Nose: no presence of lesions. The mucous membrane is moist and pink. Throat: front sinus and maxillary are tender to palpation. The gap response is sensitive. Both tongue and uvula lie in the middle line—no exudating tonsils. Mucus is scant and thick. |
||
Cardiovascular
Presence of murmurs, gallops, rubbing, and sipping. Absence of splits from both S1 & S2. |
||
Respiratory
He is neither sneezing nor coughing plus his lungs are clear to auscultation. |
||
Gastrointestinal
All 4 grands have sound bowels plus after exam there is no hepatosplenomegaly. |
||
Breast
N/A |
||
Genitourinary
His bladder is non-distended and palpable. Tenderness lacks in CVA. |
||
Musculoskeletal
No kyphosis or scoliosis. No swollen joints. |
||
Neurological
Patient communicates in a deep and auto voice. |
||
Psychiatric
Not depressed or have ever have thoughts of committing suicide. |
||
Lab Tests | ||
CBC WBC; 11000, Hgb; 10.2, Hct; 42, RBC; 12 (Wiener, Wiener & Larson, 2008)
Urinalysis – negative for UTI Liver function test CMP BMP Vitamin B-12 |
||
Special Tests
There was no evidence of acute infarct after head CT was conducted because the cerebral atrophy was consistent with his age (Wiener, Wiener & Larson, 2008). |
||
Diagnosis | ||
· Diabetic Ulcers
· Insulin Resistance (Cefalu, 2017). · Diabetic Ketoacidosis PLAN Diagnostic Testing: None. Therapy/Treatment: 1. Insulin therapy Patient/Family Education: · Avoid taking foods with excess salt and sugar. · Follow the doctor’s medication instructions (American Diabetes Association, 2010). · Eat a healthy balanced diet. · To drink plenty of water and often to avoid dehydration. Call your doctor if: · When the symptoms continue for a long period · The moment hunger and thirst have reached an uncontrolled level (American Diabetes Association, 2018). · Persistence of symptoms. · In case there are urinalysis complications. Follow-up: a primary healthcare provider will provide a follow-up program during the first week after he is discharged from the hospital to ensure that the treatment plan is working as intended. |
References
American Diabetes Association. (2018). Economic costs of diabetes in the US in 2017. Diabetes care, 41(5), 917-928. Retrieved from:
https://care.diabetesjournals.org/content/36/4/1033
American Diabetes Association. (2010). Standards of medical care in diabetes—2010. Diabetes care, 33(Supplement 1), S11-S61. Retrieved from:
Cefalu, W. T. (2017). The journal of clinical and applied research and education. Diabetes Care, 40(Supplement 1).
Wiener, R. S., Wiener, D. C., & Larson, R. J. (2008). Benefits and risks of tight glucose control in critically ill adults: a meta-analysis. Jama, 300(8), 933-944. From: https://pubmed.ncbi.nlm.nih.gov/18728267/
Needs help with similar assignment?
We are available 24x7 to deliver the best services and assignment ready within 3-4 hours? Order a custom-written, plagiarism-free paper
![](https://powerpointpresentationhelp.com/wp-content/uploads/2022/03/WhatsApp_icon.png)
![](https://powerpointpresentationhelp.com/wp-content/uploads/2022/03/205-2057855_essay-icon.png)