Complete a focused SOAP note for the case study as noted below and address the additional discussion questions. For the SOAP note section, you do not need to use complete sentences and must use approved nursing/medical abbreviations. For the discussion sections you must use Harvard format, using correct sentence structure and spelling. Include a properly written cover sheet. Be succinct on both sections of the paper. The rubric is attached at the end of this document, be sure to review the rubric as you are writing so that you will have a well written paper.

Case Scenario 

CC: “I am here for my diabetic check-up”

65-year-old Saudi woman presents for her yearly diabetic checkup. She was diagnosed with Type 2 diabetes mellitus 15 years ago. Currently she is prescribed Metformin 1000 mg by mouth twice daily with meals and empagliflozin 10 mg by mouth every morning. Medical history includes hypertension, diagnosed 20 years ago, for which she takes losartan 100 mg and hydrochlorothiazide 25 mg by mouth each morning, dyslipidemia for which she takes Atorvastatin 40 mg by mouth at bedtime, and frequent tension headaches for which she takes paracetamol 500 mg once for each headache episode for good relief. She reports that she takes all medication as ordered and experiences no side effects. She eats a standard Saudi diet except that she and her husband go out to eat at least 4-3 times each week for dinner and travel to Dubai at least 2 times each year where they eat 3 meals per day in restaurants. When she eats in restaurants, she doesn’t follow a diabetic diet. She walks 2-3 miles 4 times each week at the mall. She is married with 3 healthy grown children. She lives in her owned home with her husband and youngest daughter. She is comfortable in her home and has a happy relationship with her husband, children, and 4 grandchildren. She denies any symptoms of depression. Both her mother and father had T2DM. Her mother died at age 75 from an MI and her father died at age 55 from an MI and renal failure. She has 3 siblings, all of whom have T2DM. Her youngest brother had an MI at age 58 but is doing well post stent placement 2 years ago. Headaches occur about once monthly and are not related to anything that she can tell. Denies other pain except for some numbness and tingling in her toes, with pain at 4/10.  Denies any recent foot ulcers. Denies nausea/vomiting/diarrhea/constipation/black/bloody stools. Denies reflux/heartburn. Denies shortness of breath, cough or wheezing, dizziness, difficulties with balance, or falls. Denies chest pain or palpitations. Denies joint pain, stiffness, or swelling. Denies rashes but does note she has very dry skin that improves with twice daily application of moisturizers. Had a UTI 6 weeks ago for which she was given TMP-SMX 960 mg twice daily for 2 days which resolved the UTI. She has not been sexually active with her husband for the past 2 years as neither have any desire for conjugal intimacy. She c/o burning with voiding and urgency for the past 3 days but denies chills, incontinence, or CVP pain. She sees the ophthalmologist for yearly eye exam, last exam was 6 months ago and was normal, per patient report. She has declined PAP, pelvic exam, mammography, colonoscopy but did have a bone density last month.

Appears well groomed and is oriented to person, place, and time. Skin is warm and notably dry with minor flaking, no open lesions. Scattered actinic keratoses on neck and trunk. Conjunctivae white, moist, without drainage.  Red reflex present. Optic disc round, well defined bilaterally. Macula is without visible lesions. No A-V nicking noted. Oropharynx is pink, moist without lesions, dentition is in good repair. Trachea is midline, thyroid is palpable and within expected limits, no nodules palpated. Lungs clear to auscultation bilaterally, anterior and posterior, without adventitious sounds. Heart with regular rate and rhythm, no murmurs, gallops, or rubs. Abdomen soft, bowel sounds active x 4. Suprapubic tenderness 5/10 with palpation. No CVP pain on percussion bilaterally. MSK not examined. LOPS (loss of protective sensation) 6/10 bilaterally including plantar surface distal 1/3 of foot and 10 toes, PS (protective sensation) 4/10 for remainder of foot by microfilament examination. Previous HgA1c 7.9% 3 months ago and 7.7% 6 months ago.

Vital signs: Weight 90.7 kg, Ht. 1.7m, BMI 31.3, B/P 128/82, HR 89, RR 18, Temp 36.7 C, PO2 97% on room air.

Bone density results: T score: -1.5 (Reference range: Normal T-score > -1, Osteopenia between -1 and -2.5; Osteoporosis below -2.5)

Laboratory Results

These results were obtained fasting 2 days prior to this appointment:

Cholesterol panel: all within normal limits for age and gender.

This was checked today in the office lab:

Discussion: These will be graded as part of the plan section. Answer the following questions:

1. Based on your plan, what is your rationale for changing or not changing the diabetic medications? Include a discussion of either a or b, based on your plan.
1. If you changed the medications and /or dosages, what is your rational for choosing the drug(s) and doses you chose?
2. If you chose not to change the medications and/or dosages, what is your rationale for continuing the same medication regimen?
2.  What should this patient’s blood pressure, weight, and HgA1c goals be? Give the rational for each goal, specific to this patient.