SOAP Note On Type II Diabetes Assignment

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SOAP Note On Type II Diabetes Assignment

Introduction

The patient is a 65-year-old male who has Type II Diabetes Mellitus (managed), idiopathic gout, morbid obesity, hypertension, and hyperlipidemia. His usual follow-up visit focused on diabetes and health management. He takes Levemir, Metformin, Amlodipine, Atorvastatin, Glipizide, Hydroxyzine, Omeprazole, Tramadol, Hydrochlorothiazide, and Vitamin D2. Recent test results show inadequate diabetes management with an 8.5% HbA1c and 269 mg/dL glucose. SOAP Note On Type II Diabetes Assignment

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Subjective A. Chief Complaint (CC)

The patient reports for diabetes control and gout joint pain follow-up.

History of Present Illness (HPI)

Recent blood sugar tests show hyperglycemia in the patient. He denies hypoglycemic symptoms. Fatigue, diminished mobility, and difficulties following a low-carbohydrate diet impair the patient’s diabetes management. Gout-related joint discomfort restricts his physical activities.

Past Medical History (PMH)

  • Type II Diabetes Mellitus: Diagnosed 15 years ago; previously controlled with HbA1c below 7%, but the current level is 8.5%.
  • Idiopathic Gout: Diagnosed 10 years ago, with periodic flares, currently experiencing more frequent attacks.
  • Morbid Obesity: 42 kg/m² BMI, significant weight gain over the past decade.
  • Hypertension: Diagnosed 20 years ago, treated with Amlodipine and Hydrochlorothiazide. Blood pressure is suboptimally controlled.
  • Hyperlipidemia: Treated with Atorvastatin; recent lipid panel shows elevated LDL and low HDL. SOAP Note On Type II Diabetes Assignment

Medications

  • Diabetes Management: Levemir (insulin), Metformin, Glipizide.
  • Hypertension: Amlodipine, Hydrochlorothiazide.
  • Hyperlipidemia: Atorvastatin.
  • Other: Hydroxyzine for anxiety, Omeprazole for GERD, Tramadol for pain, Vitamin D2 for deficiency.
  • The patient has been adherent to his medication regimen but has reported side effects, including occasional dizziness from Amlodipine.

Family History (FH)

Positive family history of Type II Diabetes (mother) and cardiovascular disease (father).

Social History (SH)

The patient does not smoke and consumes 2–3 beers each week. He struggles to follow a diet since his food is strong in carbs. Obesity and joint discomfort keep him idle.

  1. Review of Systems (ROS)
  • General: Reports fatigue and recent weight gain.
  • Cardiovascular: No chest pain but reports occasional palpitations.
  • Endocrine: Increased thirst, polyuria.
  • Musculoskeletal: Joint pain due to gout.
  • Gastrointestinal: Occasional heartburn, managed with Omeprazole.

III. Objective A. Vital Signs

  • Blood Pressure: 152/92 mmHg
  • Heart Rate: 78 beats per minute
  • Respiratory Rate: 16 breaths per minute
  • BMI: 42 kg/m² (indicative of morbid obesity) SOAP Note On Type II Diabetes Assignment
  1. Physical Examination Findings
  • General: Obese male, appears fatigued.
  • Cardiovascular: Regular heart rate and rhythm, no murmurs.
  • Endocrine: Signs of acanthosis nigricans in the neck, indicating insulin resistance.
  • Musculoskeletal: Swelling and tenderness in the right big toe joint suggestive of a gout flare.
  1. Laboratory Results
  • HbA1c: 8.5% (indicates poor diabetes control).
  • Glucose: 269 mg/dL (elevated).
  • Lipid Panel: Elevated LDL, low HDL.
  • Kidney Function: Elevated creatinine (1.4 mg/dL), indicating possible early nephropathy.
  • Uric Acid: Elevated, consistent with gout.
  1. Diagnostic Tests
  • Electrocardiogram (EKG): Normal sinus rhythm.
  • Foot Examination: Reduced sensation in bilateral feet, indicating peripheral neuropathy.
  1. Assessment A. Review of Systems (ROS)
  • Detailed examination reveals signs of poorly controlled diabetes, hypertension, and gout.
  1. Differential Diagnoses
  1. Type II Diabetes Mellitus – Uncontrolled
    • Evidence: HbA1c of 8.5%, elevated fasting glucose levels.
  2. Hypertension – Suboptimally Controlled
    • Evidence: Elevated blood pressure (152/92 mmHg).
  3. Gout
    • Evidence: History of joint pain and elevated uric acid levels.
  1. Primary Diagnosis
  • Type II Diabetes Mellitus – Uncontrolled: Elevated HbA1c and symptoms consistent with hyperglycemia indicate poor control (American Diabetes Association, 2022)​SOAP Note On Type II Diabetes Assignment.

Treatment Plan

This patient receives comprehensive therapy for various chronic illnesses, focusing on medication optimization, lifestyle changes, and frequent follow-up. Given the 8.5% HbA1c, the diabetes care approach involves increasing the Metformin dose or adding a GLP-1 receptor agonist to improve glycemic control. Levemir will be kept, and Glipizide may be modified. To treat diabetes, the patient will be directed to a nutritionist for help eating a low-carbohydrate diet and checking blood glucose regularly (American Diabetes Association, 2022).

The Amlodipine dose will be reassessed to better regulate blood pressure, and an ACE inhibitor will be added. Salt restriction and moderate exercise like walking are advised to reduce blood pressure and promote cardiovascular health (National Guideline Centre, 2019). Prophylactic Allopurinol will be begun to maintain normal uric acid levels, and Tramadol will be maintained to address acute pain during flares.

Multidisciplinary obesity treatment will include dietician referrals for tailored nutritional counseling and pharmaceutical weight reduction medicines if necessary (Cornier, 2022)SOAP Note On Type II Diabetes Assignment. With physical therapy help, the patient will be encouraged to do low-impact activities like walking or swimming. The atorvastatin dose may be changed to attain target lipid levels for hyperlipidemia, and the patient may be instructed to exercise and modify their diet to lower cholesterol.

Patient education is essential to the strategy. The patient will learn the necessity of taking diabetic medicines and monitoring glucose levels. Patients with hypertension should minimize salt intake and exercise regularly. Alcohol and purine-rich meals should be avoided for gout. Additionally, the patient will be urged to undertake healthy lifestyle modifications and control weight.

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The patient will be retested for diabetes and hypertension after three months. HbA1c, lipid panel, and renal function tests will be repeated to evaluate intervention efficacy. Specialized nutrition and exercise assistance will be provided by dietitians and physical therapists. The patient will also be sent to an endocrinologist for diabetes treatment if glucose control continues to be poor and to physical therapy to enhance mobility and encourage an active lifestyle.

Reflection Notes

If I managed this patient again, I would use motivational interviewing to improve lifestyle modifications. Evidence-based motivational interviewing may help patients overcome ambivalence about diet and exercise changes, improving engagement and results. Since the patient has unsatisfactory glycemic control, I suggest starting insulin medication sooner if the visit changes do not improve glucose levels. Hyperglycemia problems may be avoided by early treatment intensification. Follow-up will need monitoring of blood glucose trends and patient adherence to the new food plan to determine intervention success. Medication modifications may be needed to meet glycemic objectives depending on patient response.

References

American Diabetes Association Professional Practice Committee, & American Diabetes Association Professional Practice Committee:. (2022). 7. Diabetes technology: standards of medical care in diabetes—2022. Diabetes Care, 45(Supplement_1), S97-S112.

Cornier, M. A. (2022). A review of current guidelines for the treatment of obesity. American Journal of Managed Care, 28.

Grundy, S. M., Stone, N. J., Bailey, A. L., Beam, C., Birtcher, K. K., Blumenthal, R. S., Braun, L. T., De Ferranti, S., Faiella-Tommasino, J., Forman, D. E., Goldberg, R., Heidenreich, P. A., Hlatky, M. A., Jones, D. W., Lloyd-Jones, D., Lopez-Pajares, N., Ndumele, C. E., Orringer, C. E., Peralta, C. A., . . . Yeboah, J. (2018). 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APHA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: Executive Summary. Journal of the American College of Cardiology, 73(24), 3168–3209. https://doi.org/10.1016/j.jacc.2018.11.002 SOAP Note On Type II Diabetes Assignment

National Guideline Centre. (2019). Hypertension in adults: Diagnosis and management. Cost-effectiveness analysis: Treatment initiation threshold for people with stage 1 hypertension (NICE guideline NG136). Economic analysis report. National Institute for Health and Care Excellence (NICE). https://www.nice.org.uk/guidance/ng136

Yip, R. M., Cheung, T. T., So, H., Chan, J. P., Ho, C. T., Tsang, H. H., Yu, C. K., & Wong, P. C. (2023). The Hong Kong Society of Rheumatology consensus recommendations for the management of gout. Clinical Rheumatology, 42(8), 2013–2027. https://doi.org/10.1007/s10067-023-06578-9

MALE PATIENT 65 YEARS OLD SEEN IN CLINIC. PT HAS HISTORY OF TYPE II DIABETES MELLITUS CONTROLLED, IDOPATHIC GOUT, MORBID OBESITY, HYPERTENSION, AND HYPERLIPIDEMIA. LABS: A1C 8.5, GLUCOSE 269. PT MEDICATIONS: LEVEMIR, METFORMIN, AMLODIPINE, ATOVASTATIN, GLIPIZIDE, HYDROXYZINE, OMPERAZOLE, TRAMADOL, HYDROCHLOROTHIAZIDE, VITAMIN D2.**ADD OTHER INFORMATION TO SOAP NOTE.**

Description
Complete a SOAP note on a patient from your current clinical experience.

The patient must be an adult patient between the ages of 60-100 years old.

Select a patient presenting with a CHRONIC MEDICAL PROBLEM and utilize the rubric above to document a well-prepared SOAP note on this patient.

Utilize and ensure you provide citations for all references. Ensure you use two scholarly articles, including any of the required textbooks, to support your documentation. Ensure you utilize the rubric stated above to maximize your points fully.

To Prepare SOAP Note On Type II Diabetes Assignment
Select a client that presents topics covered within the module assigned.
Create a Focused SOAP Note on this patient.
Review the Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.
Include at least three scholarly resources to support your assessment, diagnosis, and treatment planning.
SOAP Note Exemplar
Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
Objective: What observations did you make during the assessment?
Assessment: Discuss their review of systems (ROS)SOAP Note On Type II Diabetes Assignment. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with Clinical Practice Guidelines.
Plan: In your presentation of the SOAP note, describe your treatment plan using clinical practice guidelines supported by evidence-based practice. Include a discussion on your chosen pharmacotherapeutic agents if prescribed or recommended. Include alternative treatments available and supported by valid research. All treatment choices must have a discussion of your rationale for the choice supported by valid research. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this treatment session?

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Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow-up, discuss what your next intervention would be. SOAP Note On Type II Diabetes Assignment