DIABETES SOAP NOTE 2 Name: PK Pt. Encounter Number: 23 ✓ Solved

Subjective:

Chief Complaint: Type II diabetes.

History of Present Illness: 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.

Past Medical History: Allergies - allergic to dust. No medication intolerances. Chronic illnesses include Diabetes, Heart murmur, and Hypertension.

Hospitalizations/Surgeries: None.

Family History: PK has a generally healthy family, although his maternal grandmother was diagnosed with diabetes, and his paternal grandfather died from the disease. His maternal grandfather had asthma, and his mother was later diagnosed with hypertension. PK’s father has pre-diabetes. One sister suffers from high blood pressure, while the rest are healthy.

Social History: PK interacts positively with his friends and community, living in a two-bedroom house with his family. He describes himself as happy. His two daughters are married, and they hold family gatherings to maintain togetherness.

Review of Systems:

General: The patient appears generally healthy. Symptoms of frequent urination, thirst, and hunger are present but not outwardly visible. He is alert and responsive.

Cardiovascular: Occasionally stressed about family finances. Reports hyperlipidemia, high blood pressure, shortness of breath, palpitations, and heart murmurs.

Skin: Shows signs of wrinkles, roughness, and rashes.

Respiratory: Denies cough or sneezing, with clear lungs upon examination.

Eyes: Clear and without pain or inflammation.

Gastrointestinal: Normal bowel sounds with no hepatosplenomegaly detected.

Ears: Pain-free with no abnormalities.

Genitourinary: Non-distended, palpable bladder, no CVA tenderness.

Musculoskeletal: Denies pain, stiffness, or swelling.

Neurological: Communicates clearly; no depressive thoughts reported.

Objective:

Weight: 82 lbs; BMI: 24.3; Temp: 97.2°F; BP: 83/60; Height: 5'8"; Pulse: 88; Resp: 22.5.

General Appearance: Patient is alert, neat, and responsive.

Skin: No lesions; wrinkle and pale skin noted.

HEENT: Normocephalic, symmetric, atraumatic. No hernias or lesions observed. Eye alignment and condition normal.

Cardiovascular: Presence of murmurs, but absence of splits from S1 & S2.

Respiratory: Lungs clear to auscultation.

Gastrointestinal: Clear bowel sounds, no signs of abnormalities.

Genitourinary: Bladder condition normal; no tenderness noted.

Musculoskeletal: No deformities or joint issues observed.

Lab Tests:

CBC results include WBC: 11,000; Hgb: 10.2; Hct: 42; RBC: 12 (Wiener, Wiener & Larson, 2008).

Urinalysis was negative for urinary tract infection. Liver function tests and additional metabolic panels were normal. Head CT showed cerebral atrophy consistent with age (Wiener, Wiener & Larson, 2008).

Diagnosis:

  • Diabetic Ulcers

  • Insulin Resistance (Cefalu, 2017)

  • Diabetic Ketoacidosis

Plan:

Diagnostic Testing: None required at this time.

Therapy/Treatment: Initiation of insulin therapy.

Patient/Family Education:

  • Avoid foods high in salt and sugar.

  • Follow prescribed medication instructions (American Diabetes Association, 2010).

  • Maintain a balanced diet.

  • Stay hydrated to prevent dehydration.

Patients are advised to contact their doctor if symptoms persist or worsen, or if complications arise during urinalysis (American Diabetes Association, 2018).

Follow-Up: A primary healthcare provider will arrange follow-up care within the first week after discharge to assess the effectiveness of the proposed treatment plan.

Paper For Above Instructions

Diabetes is a chronic condition that requires careful monitoring and management. The SOAP note outlined above for patient PK provides insights into his medical history, presenting symptoms, and response to treatment. Recognizing key aspects of diabetes care, through personalized management, dietary modifications, and understanding family history, can enhance treatment outcomes.

PK's symptomatology includes classic signs of diabetes, such as fatigue, excessive thirst, and frequent urination, which warrant further discussion. Besides insulin resistance, the presence of diabetic ulcers indicates complications that require multidisciplinary management. Regular blood glucose monitoring is essential for timely intervention to prevent serious complications.

Family history is a crucial factor in the management of diabetes. As PK’s maternal grandmother suffered from diabetes, an understanding of potential genetic predisposition should influence lifestyle recommendations and screening protocols. Furthermore, with an account of hypertension and hyperlipidemia in his family, a comprehensive approach towards managing cardiovascular risks can aid in holistic care.

Careful attention to social determinants of health also affects PK’s diabetes management. His active role in community engagement and family support systems may enhance adherence to dietary recommendations and treatment plans. Addressing psychosocial factors can cultivate an environment conducive to effective diabetes management.

Patient education is paramount; thus, informing PK to consume a balanced diet low in refined sugars and to remain physically active could aid in managing diabetes. Regular consultations with healthcare providers should solidify understanding and implementation of treatment strategies (American Diabetes Association, 2010).

Moreover, PK’s emotional well-being is linked to his health status, as stress from managing chronic conditions can exacerbate symptoms. It is crucial to address any mental health issues proactively. Encouraging PK to engage with mental health resources could foster resilience and adaptation to living with diabetes.

Utilizing a collaborative approach, the healthcare team should frequently evaluate PK's progression, adjusting treatments and setting realistic goals. Family involvement in care discussions may also empower him to manage his condition better.

References

References

  • American Diabetes Association. (2010). Standards of medical care in diabetes—2010. Diabetes Care, 33(Supplement 1), S11-S61.

  • American Diabetes Association. (2018). Economic costs of diabetes in the US in 2017. Diabetes Care, 41(5).

  • 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).