Soap Note Of Diabetes Mellitus
Social Historical past: No smoking historical past or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, she lives alone.
Sexual Orientation: Straight
Vitamin Historical past: Diets on and off
Subjective Knowledge:
Chief Criticism: “I can not cease to drink water and to pee, I have to see my labs”
Symptom Assessment/HPI:
The affected person is 56 years previous feminine who complaining of she can not cease to drink water and to pee. Affected person observed the issue began 1 month in the past and generally it’s accompanied by anxious for eat. She states that she has been below stress as a result of her daughter for the final month. Affected person denies ache, or one other symptom. She makes some labs and coming to see the outcomes. Soap Note Of Diabetes Mellitus
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Evaluate of Programs (ROS)
CONSTITUTIONAL: Denies fever or chills. Denies weak point or weight reduction. NEUROLOGIC: Headache and dizziness as describe above. Denies adjustments in LOC. Denies historical past of tremors or seizures.
HEENT: HEAD: Denies any head damage, or change in LOC. Eyes: Denies any adjustments in imaginative and prescient, diplopia or blurred imaginative and prescient. Ear: Denies ache within the ears. Denies lack of listening to or drainage. Nostril: Denies nasal drainage, congestion. THROAT: Denies throat or neck ache, hoarseness, issue swallowing.
RESPIRATORY: Affected person denies shortness of breath, cough or hemoptysis.
CARDIOVASCULAR: No chest ache, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
GASTROINTESTINAL: Denies belly ache or discomfort. Denies flatulence, nausea, vomiting or diarrhea.
GENITOURINARY: Denies hematuria, dysuria or change in urinary frequency. Denies issue beginning/stopping stream of urine or incontinence.
MUSCULOSKELETAL: Denies falls or ache. Denies listening to a clicking or snapping sound.
SKIN: No change of coloration similar to cyanosis or jaundice, no rashes or pruritus. Soap Note Of Diabetes Mellitus
Goal Knowledge:
VITAL SIGNS and Lab valuesTemperature: 97.5 °F, Pulse: 84, BP: 142/82 mmhg, RR 20, PO2-98% on room air, Ht- fill, Wt fill lb, BMI 37.2. No report ache zero/10.
HbA1C 9.5 %.
Serum creatinine 1.2 mg/dl, add extra
GENERAL APPREARANCE: The affected person is alert and oriented x three. No acute misery famous. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to particular person, place, and time. Sensation intact to bilateral higher and decrease extremities. Bilateral UE/LE energy 5/5.
HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visible acuity and extraocular eye actions intact. No nystagmus famous. Ears: Bilateral canals patent with out erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly grey with sharp cone of sunshine. Maxillary sinuses no tenderness. Nasal mucosa moist with out bleeding. Oral mucosa moist with out lesions,. Lids non-remarkable and acceptable for race. Soap Note Of Diabetes Mellitus
Neck: supple with out cervical lymphadenopathy, no jugular vein distention, no thyroid swelling or plenty.
CARDIOVASCULAR: S1S2, common price and rhythm, no murmur or gallop famous. Capillary refill < 2 sec.
RESPIRATORY: No dyspnea or use of accent muscle groups noticed. No egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on auscultation.
GASTROINTESTINAL: No mass or hernia noticed. Upon auscultation, bowel sounds current in all 4 quadrants, no bruits over renal and aorta arteries. Stomach mushy non-tender, no guarding, no rebound no distention or organomegaly famous on palpation
MUSKULOSKELETAL: No ache to palpation. Energetic and passive ROM inside regular limits, no stiffness.
INTEGUMENTARY: intact, no lesions or rashes, no cyanosis or jaundice.
ASSESSMENT:
Major Analysis: Diabetes mellitus sort 2 clarify why
Weight problems, HTN
Differential analysis: Put three and clarify
PLAN: Metformin 500 mg one pill every day along with every day type modifications. This dose might be elevated to twice every day as wanted or as tolerated each 1 o 2 weeks, till a most of two grams every day.
Hydrochlorothiazide (thiazide diuretic) 1 pill every day added to the remedy for HTN to raised management. Soap Note Of Diabetes Mellitus
Labs and Diagnostic Take a look at to be ordered:
• CMP
• Full blood rely (CBC)
• Lipid profile
• Liver operate check (as a result of the metformin requires routine monitoring)
• Serum creatinine
• Potassium as a result of the ACE inhibitors requires monitoring of electrolytes
• Urinalysis with Micro
• Electrocardiogram (EKG 12 lead)
• Urine to watch ketone and glucose
Pharmacological remedy:
• Hydrochlorothiazide tab 25 mg, Preliminary dose: 25 mg orally as soon as every day.
• Lisinopril 10mg PO Day by day
• Metformin tab 500 mg one pill every day.
Non-Pharmacologic remedy:
• Weight adjustments should be accomplished to handle higher the Diabetes
• Nutritious diet (DASH dietary sample): Weight loss plan wealthy in fruits, greens, entire grains, and low-fat dairy merchandise with decreased content material of saturated and trans l fats
• Lowered consumption of dietary sodium: <1,500 mg/d is perfect objective however not less than 1,000 mg/d discount in most adults
• Enhanced consumption of dietary potassium
• Workout routines should be accomplished not less than three occasions per week like: strolling, swimming or operating
• Measures to launch stress and efficient coping mechanisms. Soap Note Of Diabetes Mellitus
Schooling
• Present with diet/dietary data.
• To keep away from GI unwanted side effects, take the Metformin with meals.
• Instruction about remedy consumption compliance.
• Keep away from ingesting alcohol: Alcohol has a unfavourable interplay with Metformin and contribute to hyperglycemia.
• Schooling of potential problems of Diabetes similar to stroke, coronary heart assault, and different issues.
• Educate to the significance to foot examination and to decide on diabetes footwear.
Comply with-ups/Referrals
• Comply with up appointment 1 weeks for managing blood sugars: It is very important goal ranges of A1C lower than 7 %, so labs might be each three months. Soap Note Of Diabetes Mellitus
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Diabetes Mellitus Soap Note
Social Historical past: No historical past of smoking or illicit drug utilization, excluding occasional alcoholic beverage consumption at social gatherings. She is a widow who’s retired and lives alone.
Straight sexual orientation
Diets on and off have been part of my diet historical past.
Subjective Data:
“I am unable to cease ingesting water and peeing; I have to see my labs,” is the chief criticism.
Symptom Assessment/HPI:
The affected person is 56 years previous feminine who complaining of she can not cease to drink water and to pee. Affected person observed the issue began 1 month in the past and generally it’s accompanied by anxious for eat. She states that she has been below stress as a result of her daughter for the final month. Affected person denies ache, or one other symptom. She makes some labs and coming to see the outcomes. Soap Note
