SOAP Note:
Nursing & Medical diagnosis/es formulated with correct ICD- 10 codes. Include health maintenance diagnosis per guidelines. You MUST provide at least 3 likely differential diagnoses and list R/Os if appropriate.
Include pertinent positives & negatives for the Mgt plan cost-effective, clinically correct & includes sections for medical & nursing therapeutics. Patient education should be identified as such. Organize categories in your plan: Diagnostic, Therapeutic, Pt Education, Referral, & Follow-Up. major diagnosis only.
Attach a current clinical guideline with clear reference for one of the major diagnoses. Rationale justifies EACH ASPECT of mgt plan with appropriate references. Mechanism of action of medications you change/prescribe should be cited here .
Pathophysiology discussion justifies major diagnoses addressed at visit and mgt plan. 1) You must personalize to your patient’s health status by discussing how it applies specifically to your patient. 2) No more than 2 diagnoses need to be addressed if multiple dx exist. 3) Use a CURRENT primary patho reference 4) Do not duplicate pathophysiology from prior SOAPs Health Promotion/Prevention. Include age/gender/risk specific
Recommendations as your guidelines require.
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Patient Information:
Sarah Johnson, a 58-year-old female, presents to the primary care clinic with complaints of persistent fatigue, increased thirst, and frequent urination over the past month. She has a history of hypertension and is overweight (BMI 29). Family history is significant for type 2 diabetes in her mother.
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The SOAP note based on this scenario:
Subjective:
Chief Complaint: “I’ve been feeling really tired lately, and I’m always thirsty and need to use the bathroom more often.”
History of Present Illness: Sarah Johnson, a 58-year-old female, reports experiencing increased fatigue, polydipsia, and polyuria for approximately one month. She denies any recent illnesses, changes in diet, or new medications. The patient notes that her fatigue is most pronounced in the afternoons and interferes with her daily activities.
Past Medical History: Hypertension (diagnosed 5 years ago)
Medications: Lisinopril 10 mg daily
Allergies: No known drug allergies
Family History: Mother with type 2 diabetes
Social History: Non-smoker, occasional alcohol use (1-2 drinks per week), sedentary lifestyle
Review of Systems:
General: Fatigue, denies fever or chills
HEENT: Denies vision changes, dry mouth
Cardiovascular: Denies chest pain or palpitations
Respiratory: Denies shortness of breath or cough
Gastrointestinal: Reports increased appetite, denies abdominal pain
Genitourinary: Reports polyuria, denies dysuria
Musculoskeletal: Denies joint pain or muscle weakness
Neurological: Denies numbness or tingling in extremities
Objective:
Vital Signs:
BP: 138/88 mmHg
HR: 78 bpm
RR: 16/min
Temp: 37.0°C
SpO2: 98% on room air
Weight: 82 kg
Height: 168 cm
BMI: 29 kg/m²
Physical Examination:
General: Alert and oriented, appears fatigued
HEENT: Normocephalic, atraumatic, mucous membranes slightly dry
Cardiovascular: Regular rate and rhythm, no murmurs
Respiratory: Clear to auscultation bilaterally
Abdominal: Soft, non-tender, no hepatosplenomegaly
Extremities: No edema, pulses intact
Neurological: Cranial nerves II-XII intact, sensation intact in all extremities
Laboratory Results:
Fasting Plasma Glucose: 142 mg/dL (Reference range: 70-99 mg/dL)
HbA1c: 7.2% (Reference range: <5.7%)
Serum Creatinine: 0.9 mg/dL (Reference range: 0.6-1.1 mg/dL)
eGFR: >60 mL/min/1.73m²
Lipid Panel:
Total Cholesterol: 210 mg/dL (Reference range: <200 mg/dL)
LDL: 130 mg/dL (Reference range: <100 mg/dL)
HDL: 45 mg/dL (Reference range: >50 mg/dL)
Triglycerides: 175 mg/dL (Reference range: <150 mg/dL)
Assessment:
Type 2 Diabetes Mellitus, newly diagnosed (ICD-10: E11.9)
Essential (primary) hypertension (ICD-10: I10)
Overweight (ICD-10: E66.3)
Hyperlipidemia (ICD-10: E78.5)
Differential Diagnoses:
Hypothyroidism
Anemia
Chronic kidney disease
Health Maintenance Diagnosis:
Need for screening for diabetes mellitus (ICD-10: Z13.1)
Plan:
Diagnostic:
Thyroid function tests (TSH, free T4) to rule out hypothyroidism
Complete blood count (CBC) to assess for anemia
Urinalysis to evaluate for microalbuminuria
Therapeutic:
Initiate Metformin 500 mg orally twice daily with meals
Continue Lisinopril 10 mg daily for hypertension
Recommend lifestyle modifications:
a. Diet: Referral to a registered dietitian for medical nutrition therapy
b. Exercise: Gradually increase physical activity to 150 minutes of moderate-intensity aerobic exercise per week
Patient Education:
Explain the diagnosis of type 2 diabetes and its implications
Instruct on home blood glucose monitoring:
a. Provide glucometer and testing supplies
b. Teach technique for checking blood glucose
c. Advise to check fasting and 2-hour postprandial glucose levels daily
Discuss symptoms of hyper- and hypoglycemia and appropriate management
Emphasize the importance of medication adherence, diet, and exercise in managing diabetes
Referrals:
Ophthalmology for baseline diabetic retinopathy screening
Podiatry for comprehensive foot examination
Follow-up:
Schedule follow-up appointment in 2 weeks to assess response to treatment and review home glucose monitoring results
Plan for HbA1c check in 3 months
Rationale:
The diagnosis of type 2 diabetes is based on the patient's presenting symptoms of fatigue, polydipsia, and polyuria, along with laboratory findings of elevated fasting plasma glucose (142 mg/dL) and HbA1c (7.2%). According to the American Diabetes Association (2023), diabetes is diagnosed when fasting plasma glucose is ≥126 mg/dL or HbA1c is ≥6.5%.
Metformin is initiated as the first-line pharmacological treatment for type 2 diabetes, as recommended by the American Diabetes Association (2023). Metformin works by reducing hepatic glucose production and improving insulin sensitivity in peripheral tissues (Rena et al., 2017). Starting at a low dose and titrating up helps minimize gastrointestinal side effects.
Continuation of Lisinopril for hypertension is appropriate, as ACE inhibitors are preferred in patients with diabetes due to their renoprotective effects (Whelton et al., 2018).
Lifestyle modifications, including dietary changes and increased physical activity, are crucial components of diabetes management. The recommended 150 minutes of moderate-intensity aerobic exercise per week is based on guidelines from the American Diabetes Association (2023), which have shown to improve glycemic control and reduce cardiovascular risk.
Pathophysiology:
Type 2 diabetes mellitus is characterized by insulin resistance and relative insulin deficiency. In Sarah's case, her overweight status contributes to insulin resistance in peripheral tissues, particularly skeletal muscle and adipose tissue. This leads to reduced glucose uptake and increased hepatic glucose production. Over time, the pancreatic β-cells fail to compensate for the increased insulin demand, resulting in relative insulin deficiency (DeFronzo et al., 2015).
The patient's symptoms of polydipsia and polyuria are direct consequences of hyperglycemia. As blood glucose levels rise above the renal threshold, glucose spills into the urine, causing osmotic diuresis and increased urine output. This fluid loss triggers compensatory thirst mechanisms (Kahn et al., 2014).
Sarah's concomitant hypertension and hyperlipidemia further increase her cardiovascular risk. Hypertension in type 2 diabetes is often associated with insulin resistance and hyperinsulinemia, which can lead to increased sodium retention and sympathetic nervous system activation (Lastra et al., 2014).
Health Promotion/Prevention:
Given Sarah's age and new diagnosis of type 2 diabetes, the following health promotion and prevention measures are recommended:
Annual influenza vaccination (Centers for Disease Control and Prevention, 2023)
Pneumococcal vaccination as per current guidelines (Centers for Disease Control and Prevention, 2023)
Breast cancer screening with mammography every 2 years (U.S. Preventive Services Task Force, 2023)
Colorectal cancer screening, with options including colonoscopy every 10 years or annual fecal immunochemical testing (U.S. Preventive Services Task Force, 2023)
Bone density screening for osteoporosis (U.S. Preventive Services Task Force, 2023)
These recommendations are tailored to Sarah's age, gender, and newly diagnosed diabetes, focusing on preventing complications and promoting overall health.
Keywords: Type 2 Diabetes Mellitus, Metformin, Lifestyle Modification
References:
American Diabetes Association. (2023). Standards of Medical Care in Diabetes—2023. Diabetes Care, 46(Supplement 1), S1-S2.
Centers for Disease Control and Prevention. (2023). Recommended Adult Immunization Schedule for ages 19 years or older, United States, 2023. Retrieved from https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html
DeFronzo, R. A., Ferrannini, E., Groop, L., Henry, R. R., Herman, W. H., Holst, J. J., ... & Weiss, R. (2015). Type 2 diabetes mellitus. Nature Reviews Disease Primers, 1(1), 1-22.
Kahn, S. E., Cooper, M. E., & Del Prato, S. (2014). Pathophysiology and treatment of type 2 diabetes: perspectives on the past, present, and future. The Lancet, 383(9922), 1068-1083.
Lastra, G., Syed, S., Kurukulasuriya, L. R., Manrique, C., & Sowers, J. R. (2014). Type 2 diabetes mellitus and hypertension: an update. Endocrinology and Metabolism Clinics, 43(1), 103-122.
Rena, G., Hardie, D. G., & Pearson, E. R. (2017). The mechanisms of action of metformin. Diabetologia, 60(9), 1577-1585.
U.S. Preventive Services Task Force. (2023). USPSTF A and B Recommendations. Retrieved from https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations
Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Dennison Himmelfarb, C., ... & Wright, J. T. (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology, 71(19), e127-e248.
Rastogi, S., & Bajaj, S. (2022). Comorbidities in Type 2 Diabetes Mellitus: Challenges and Opportunities. The Journal of the Association of Physicians of India, 75(1), 20-25. [jaipindia.org]
