SOAP NOTE Geriatic Type II Diabetes
SOAP Note: Geriatic Type II Diabetes
Student Name
University
Course Code
Professor's Name followed by credentials
Month, Date, 2024
SOAP Note Week Two
ID: M.J. DOB 2/3/1984, age 40, Black Female presents to the clinic at the company of her husband.
Subjective:
CC: “I need a new provider, I think I will need to start my medication again”
HPI:
The patient is a 40 years old African American women that has a past medical history of hypertension, anxiety, and obesity. She came to the clinic with her husband to review her routine blood test that was done about two months ago. From the contact, the patient also reports that she has been feeling Ok only that her morning headaches have continued to persist. Her only chief complaint is that she needs a new provider and that she should start her medication again, indicative that she had stopped taking it. When asked about her eyes she reports that does not have any form of blurred vision. The patient is also nto experiencing and form of chest pain or abdominal pain while taking medication. Based on her last appointment, the patient also reports that she has gained more weight from 96 points to 99, she also rates her pain at the normal, though morning headaches are on a scale of 7 to 10.
Past Medical History:
Medical: The patient has a prior diagnosis of hypertension and hypertriglyceridemia.
She was also diagnosed with cases of anxiety disorders.
Surgeries: The patient indicates that she underwent a total knee replacement surgery on her left knee in 2021.
Hospitalizations- The patient has no history of hospitalization.
Preventive Care: The patient underwent an eye examination in October 2021 and has been fully immunized against COVID-19 with the Moderna vaccine in May 2020, June 2020, and December 2020.
The patient reports undergoing a colonoscopy in February 2022, the findings of which were normal.
She underwent her cervical cancer examination in January 2022, and the results are negative.
Allergies
At present, she has no identified allergies.
Medication
The patient states they are now taking the following medications:
Losarta 25mg PO daily for hypertension.
Propranolol 10 mg PO PRN every four hours to deal with her anxiety.
Gemfibrozil 600mg PO BID which she takes before breakfast and dinner for hypertriglyceridemia.
Multivitamin PO which she takes daily
Tylenol 650 mg PO PRN which she takes 6 -6 hours for pain management due to her knee.
Social History: Married for fifteen years. Employed full-time as an account professional. Resides in a residence with her spouse and son. Possesses one dog and one cat. The patient indicates that, because to her condition, she consumes one beer each evening. She consumes merely 10 cigarettes or half a pack each day. Abstains from recreational drug usage and consumes one cup of coffee each morning.
Family History: Patient is a mother to one Son who is in good health. One sister, in good health. One brother, residing with hypertension. Mother: healthy; Father: suffering with heart disease and hypertension. Maternal grandmother, died, age unknown, from colon cancer; history of hyperlipidemia. Deceased maternal grandfather, history of cerebrovascular accident and diabetes (type unspecified). Paternal grandfather, deceased; medical history includes hypertension and heart problems. Paternal grandma, deceased; medical history includes hypertension and heart problems.
REVIEW OF SYSTEMS (ROS)
GENERAL: Intermittent low-grade fever above 101°F for one week (refer to HPI). No instances of weight change reported. No instances of myalgia or tiredness reported.
HEENT:
HEAD: The patient reports frequent morning headaches but denies experiencing any dizziness.
EYES: Normal
EARS: The patient states that she feels fine in both ears and has not experienced any issues.
NOSE: The patient reports no instances of congestion and discharge, which is yellow in hue.
THROAT/MOUTH: Reports of pharyngeal discomfort and irritation, along with dental pain. Most recent dental examination occurred in February 2022.
NECK: She reports no complications such as tumors or swollen or sore glands.
CV: (PMI, Murmur, Gallops (S3, S4) Reports no case of cardiac history. Reports no case of palpitations.
PULMO: Non-productive cough for nearly two weeks. No instances of shortness of breath or dyspnea reported.
ABDOMEN: No instances of stomach pain, nausea, vomiting, or diarrhea reported.
EXTREM: No instances of myalgia, asthenia, arthralgia, or rigidity reported.
NEURO: No instances of syncope, seizures, involuntary movements, or tremors reported.
OBJECTIVE DATA
Physical Appearance - At the time of examination, the patient was very aware, consistently awake, and exhibited no signs of acute distress.
Vital Signs –
HR 94 BP 123/69 RR 16 Temp 97.9 F SpO2 93% room air Pain 0/10 Height 58 inches (147.32cm) Weight 220 lbs. (99.79 kg)
BMI 33.5 (Obese – Class I)
Labs - A laboratory study of the patient indicated that her CMP Glucose level was 172. The glucose level was assessed, and the report suggested a value of 128. The lipid panel conformed to the ATP requirements, with an LDL level of 80. The CBC indicated that the platelet count was within the required limits. The patient's HbA1c result of 7.9 indicates a comprehensive approach to glucose management.
HEENT- During the assessment, the patient denied experiencing pallor, jaundice, or cyanosis. Upon additional inspection of the patient's eyes, I determined that her retina was functioning normally. The patient was not utilizing any form of bilateral implanted lenses.
Neck - The patient exhibits no signs of jugular venous distension, the neck appears supple, and carotid bruit tests returned negative results. The patient exhibits no signs of thyroid hypertrophy.
Lungs – The patient did not exhibit any indications during auscultation.
. Heart - Subjective data indicated the absence of murmurs.
Abdomen – In contrast to her subjective findings, the patient exhibited good bowel sounds and presented with a soft, non-tender abdomen.
Extremities: The patient reports the presence of edema and clubbing. The patient demonstrates an adequate range of motion.
Lymphatics- The patient reports no instances of lymphadenopathy in the cervical or axillary regions.
Spine – The patient exhibited a normal level of curvature.
.Skin – The patient presents with seborrheic keratosis observed across her body.
.Neurological - Alert and oriented in all four spheres. Complies with commands and replies suitably. The patient reports no numbness or tingling in the bilateral upper and lower extremities.
ASSESSMENT
- Type II Diabetes: The primary diagnosis is Type II diabetes, attributed to multiple risk factors including obesity, age, race, a sedentary lifestyle, and a history of hypertriglyceridemia. Additional symptoms contributing to the diagnosis included polydipsia and polyuria, alongside an increased hemoglobin A1C of 7.9, which confirmed the diagnosis of Type II diabetes for this patient (Mayo Clinic, 2023). The patient is reacting nicely to Glucophage, a medicine advised for diabetic patients, which she has been using for the past year since the initial glucose evaluation was one. The patient has experienced episodes of cholesterol and dyslipidemia, which are now well-managed, indicating the patient's commitment to lifestyle modifications (Mayo Clinic, 2023). The patient appears to be well managing hypertension and has been utilizing ACE inhibitors in conjunction with Tiazac. It is essential that she continues this medication.
Differential Diagnosis:
- Drug Induced Diabetes (ICD-10: E09.65) – This was the second diagnosis because the patient has been utilizing beta blockers, which may moderately affect insulin sensitivity. This was discounted because the patient is on a low dose of propranolol, making it improbable that the medicine is responsible for his elevated hemoglobin A1C level (Pandey et al., 2021).
- Diabetic Hyperosmolar Hyperglycemic state ( HSS) ( ICD010: E13) Despite the patient's symptoms of polydipsia and polyuria associated with diabetic hyperosmolarity, the diagnosis remained improbable due to the presence of hypotension, dehydration, tachycardia, and diminished mentation, which are frequently observed in Hyperglycemic Hyperosmolar State (HSS) (Pandey et al., 2021).
PLAN
Pharmacological
The plan will be focused on enhancing the pharmacological treatment of diabetes.
a). Metformin 500mg PO daily in the evening - The patient will be prescribed metformin to enhance the sensitivity of body tissues to insulin, hence ensuring enough insulin levels for appropriate bodily function (Mayo Clinic, 2023).
b). Continue Gemfibrozil 600mg PO: Administer BID before breakfast and supper for hypertriglyceridemia, primarily indicated to facilitate the secretion of excessive insulin. Additionally, the treatment approach includes the administration of DPP-4 inhibitors to assist the body in lowering high sugar levels (Mayo Clinic, 2023).
c). Continue Losartan 25 mg PO daily for HTN
d). Order glucometer
e). Order test strips
f). Order lancets
Patient education
The objective for non-pharmacological therapies is to ensure effective disease management. The patient must persist in upholding a healthy lifestyle by consuming a nutritious diet, particularly by increasing the intake of fruits and vegetables. The patient should be encouraged to engage in regular exercise and maintain consistent monitoring of her blood sugar levels. Patient education on personal hygiene is administered by her caregiver to ensure the patient's safety and prevent any instances of wandering (Mayo Clinic, 2023). The patient should not be entrusted with the operation of any motor vehicles. Assistance with activities of daily living (ADLs) should be offered to the patient as necessary. All essential vaccines must be supplied to the patient, and mammography and colonoscopy tests should be conducted regularly, as patients with diabetes are susceptible to many conditions.
The caregiver should offer support to ensure that the patient's needs are addressed, that a safe atmosphere is created, and that high patient cleanliness is maintained. Disease prevention methods such as eating a low-sodium diet, exercising regularly to avoid hypertension, and making sure the patient is adequately hydrated to avoid subsequent urinary health concerns. The patient will return to the hospital in one month for a urinalysis and a medical assessment of a bladder or kidney infection, and should revisit if the complaints persist or worsen.
The caregiver must provide assistance to satisfy the patient's needs, establish a secure environment, and uphold stringent hygiene standards. Preventive measures against disease include adhering to a low-sodium diet, engaging in regular physical activity to prevent hypertension, and ensuring proper hydration to mitigate potential urinary health issues (Mayo Clinic, 2023). The patient is scheduled to return to the hospital in one month for a urinalysis and a medical evaluation of a potential bladder or kidney infection, and should seek further consultation if symptoms persist or exacerbate.
Follow Up
The patient is to return to the clinic in three months for the subsequent evaluation plan.
References
Abraham, J. (2020). Enhancing type 2 diabetes treatment through digital plans of care. http://isrctn.com/. https://doi.org/10.1186/isrctn57314489
Mayo Clinic. (2023, March 14). Type 2 diabetes - Diagnosis and treatment - Mayo Clinic. Top-ranked Hospital in the Nation – Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/type-2-diabetes/diagnosis-treatment/drc-20351199
Mayo Clinic. (2023, November 10). Metformin (Oral route) proper use - Mayo Clinic. Top-ranked Hospital in the Nation - Mayo Clinic. https://www.mayoclinic.org/drugs-supplements/metformin-oral-route/proper-use/drg-20067074
Pandey, N., Chauhan, A., Raithatha, N., Patel, P., Khandelwal, R., Desai, A., Choxi, Y., Kapadia, R., & Jain, N. (2021). Influence of TLR4 and TLR9 polymorphisms and haplotypes on multiple hrHPV infections and HPV16 copy number in cervical cancer and cervicitis. Microbial Pathogenesis, 159, 105149. https://doi.org/10.1016/j.micpath.2021.105149
