Soap Note # ____ Main Diagnosis ______________
PATIENT INFORMATION
Name:
Age:
Gender at Birth:
Gender Identity:
Source:
Allergies:
Current Medications:
•
PMH:
Immunizations:
Preventive Care:
Surgical History:
Family History:
Social History:
Sexual Orientation:
Nutrition History:
Subjective Data:
Chief Complaint:
Symptom analysis/HPI:
The patient is …
Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )
CONSTITUTIONAL:
NEUROLOGIC:
HEENT:
RESPIRATORY:
CARDIOVASCULAR:
GASTROINTESTINAL:
GENITOURINARY:
MUSCULOSKELETAL:
SKIN:
Objective Data:
VITAL SIGNS:
GENERAL APPREARANCE:
NEUROLOGIC:
HEENT:
CARDIOVASCULAR:
RESPIRATORY:
GASTROINTESTINAL:
MUSKULOSKELETAL:
INTEGUMENTARY:
ASSESSMENT:
(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data)
Example : “Pt came in to our clinic c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and that etc.)
Main Diagnosis
(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 7th Edition.
Differential diagnosis (minimum 4)
–
–
PLAN:
Labs and Diagnostic Test to be ordered (if applicable)
• –
• –
Pharmacological treatment:
–
Non-Pharmacologic treatment:
Education (provide the most relevant ones tailored to your patient)
Follow-ups/Referrals
References (in APA Style)
Discussion Topic: Soap Note 4 “Diabetes Mellitus”
___________________
SOAP Note #4: Diabetes Mellitus
PATIENT INFORMATION:
Name: John Doe
Age: 45
Gender at Birth: Male
Gender Identity: Male
Source: Self-referred
Allergies: None
Current Medications: None
PMH: Hypertension, Hyperlipidemia
Immunizations: Up-to-date
Preventive Care: Last physical exam 6 months ago
Surgical History: Appendectomy
Family History: Father with Type 2 diabetes
Social History: Non-smoker, social alcohol use
Sexual Orientation: Heterosexual
Nutrition History: High-calorie, high-fat diet, fast food consumption, limited exercise
SUBJECTIVE DATA:
Chief Complaint: “I have been feeling very thirsty and urinating frequently. I also feel tired all the time.”
Symptom analysis/HPI: John reports a 3-month history of increased thirst, increased urination, and fatigue. He also noticed a 10-pound weight loss during this period. He denies any fever, chills, or night sweats.
REVIEW OF SYSTEMS (ROS):
CONSTITUTIONAL: Reports fatigue
NEUROLOGIC: Denies headache, dizziness, or syncope
HEENT: Denies visual changes, hearing loss, or tinnitus
RESPIRATORY: Denies cough, shortness of breath, or chest pain
CARDIOVASCULAR: Denies chest pain, palpitations, or leg swelling
GASTROINTESTINAL: Reports occasional heartburn
GENITOURINARY: Reports increased frequency of urination
MUSCULOSKELETAL: Denies joint pain or stiffness
SKIN: Reports no rashes or skin changes
OBJECTIVE DATA:
VITAL SIGNS: Blood pressure 138/90 mmHg, heart rate 86 bpm, respiratory rate 18 breaths/min, temperature 98.6°F, oxygen saturation 98% on room air
GENERAL APPEARANCE: Alert and oriented, no acute distress
NEUROLOGIC: Cranial nerves intact, normal sensation and reflexes, no focal deficits
HEENT: Pupils equal, round, and reactive to light, normal extraocular movements, no nystagmus, normal tympanic membranes
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops, distal pulses palpable
RESPIRATORY: Clear to auscultation bilaterally, no wheezes, rhonchi, or crackles
GASTROINTESTINAL: Soft, non-tender, non-distended abdomen, no hepatosplenomegaly, no masses or tenderness
MUSKULOSKELETAL: No edema or deformity noted
INTEGUMENTARY: No rashes or skin lesions noted
ASSESSMENT:
John presents with a 3-month history of increased thirst, increased urination, and fatigue, along with a 10-pound weight loss. Based on these symptoms and his medical history, the most likely diagnosis is Type 2 Diabetes Mellitus (ICD10 E11.9) (American Diabetes Association [ADA], 2021). Differential diagnoses include Type 1 Diabetes, Hyperthyroidism, Cushing’s Syndrome, and Polycystic Ovary Syndrome (PCOS).
PLAN:
Labs and Diagnostic Test to be ordered:
Fasting Plasma Glucose (FPG) test to confirm the diagnosis of Diabetes Mellitus (ADA, 2021).
Hemoglobin A1c (HbA1c) test to assess long-term glycemic control (ADA, 2021).
Lipid profile to assess cardiovascular risk factors (ADA, 202 • Blood pressure measurement to assess hypertension (ADA, 2021).
Pharmacological treatment:
Metformin 500mg orally twice daily to improve insulin sensitivity and decrease hepatic glucose production (ADA, 2021).
Insulin therapy may be considered based on the FPG and HbA1c levels (ADA, 2021).
Non-Pharmacologic treatment:
Diet and exercise counseling to promote weight loss and improve glycemic control (ADA, 2021).
Patient education on monitoring blood glucose levels and identifying signs and symptoms of hypoglycemia (ADA, 2021).
Education:
Importance of maintaining a healthy diet and regular exercise routine.
Proper technique for monitoring blood glucose levels.
Identification of symptoms of hyperglycemia and hypoglycemia.
Importance of medication adherence and regular follow-up appointments with healthcare provider.
Follow-ups/Referrals:
Patient to return in 2 weeks for follow-up FPG and HbA1c testing.
Referral to a registered dietitian for dietary counseling.
References:
American Diabetes Association (ADA). (2021). Standards of medical care in diabetes – 2021. Diabetes Care, 44(Suppl. 1), S1-S232.
