Soap Note 2 Of Diabetes Mellitus ( To Rewrite)

Table of Contents

Diabetes Mellitus

free plagiarism

Save Time On Research and Writing
Hire a Pro to Write You a 100% Plagiarism-Free Paper.
Get My Paper

APA style

(Student Name)

Miami Regional University

Date of Encounter:

Save Time On Research and Writing
Hire a Pro to Write You a 100% Plagiarism-Free Paper.
Get My Paper

Preceptor/Clinical Site:

Clinical Instructor:

Soap Note # Main Diagnosis Diabetes Mellitus type 2

PATIENT INFORMATION

Name: Mr. ET

Age: 56-year-old

Gender at Birth: Female

Gender Identity: Female

Source: Patient

Allergies: Penicillins

Current Medications:

· Multi-Vitamin Centrum Silver

· Lisinopril 10 mg daily

· PMH: HTN

Diabetes mellitus type 2

Immunizations:

Preventive Care: Coloscopy 3 years ago (Negative)

Surgical History: laparoscopic cholecystectomy

Family History: Father alive

Mother-alive, 90 years old, Diabetes Mellitus, HTN

Daughter-alive, 21 years old, healthy

Social History: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, she lives alone.

Sexual Orientation: Straight

Nutrition History: Diets off and on

Subjective Data:

Chief Complaint: “I cannot stop to drink water and to pee, I need to see my labs”

Symptom analysis/HPI:

The patient is 56 years old female who complaining of she cannot stop to drink water and to pee. Patient noticed the problem started 1 month ago and sometimes it is accompanied by anxious for eat. She states that she has been under stress because her daughter for the last month. Patient denies pain, or another symptom. She makes some labs and coming to see the results.

Diabetes Mellitus

Review of Systems (ROS)

CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures.

HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.

RESPIRATORY: Patient denies shortness of breath, cough or hemoptysis.

CARDIOVASCULAR: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal

dyspnea.

GASTROINTESTINAL: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or diarrhea.

GENITOURINARY: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.

MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound.

SKIN: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.

Objective Data:

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 pain 0/10.

HbA1C 9.5 %.

Serum creatinine 1.2 mg/dl, add more

GENERAL APPREARANCE: The patient is alert and oriented x 3. No acute distress noted. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5.

HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without lesions,. Lids non-remarkable and appropriate for race.

Neck: supple without cervical lymphadenopathy, no jugular vein distention, no thyroid swelling or masses.

CARDIOVASCULAR: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary refill < 2 sec.

RESPIRATORY: No dyspnea or use of accessory muscles observed. No egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on auscultation.

GASTROINTESTINAL: No mass or hernia observed. Upon auscultation, bowel sounds present in all four quadrants, no bruits over renal and aorta arteries. Abdomen soft non-tender, no guarding, no rebound no distention or organomegaly noted on palpation

MUSKULOSKELETAL: No pain to palpation. Active and passive ROM within normal limits, no stiffness.

INTEGUMENTARY: intact, no lesions or rashes, no cyanosis or jaundice.

ASSESSMENT:

Main Diagnosis: Diabetes mellitus type 2 explain why

Obesity, HTN

Differential diagnosis: Put 3 and explain

PLAN: Metformin 500 mg one tablet daily in addition to daily style modifications. This dose can be increased to twice daily as needed or as tolerated every 1 o 2 weeks, until a maximum of 2 grams daily.

Hydrochlorothiazide (thiazide diuretic) 1 tablet daily added to the treatment for HTN to better control.

Labs and Diagnostic Test to be ordered:

· CMP

· Complete blood count (CBC)

· Lipid profile

· Liver function test (because the metformin requires routine monitoring)

· Serum creatinine

· Potassium because the ACE inhibitors requires monitoring of electrolytes

· Urinalysis with Micro

· Electrocardiogram (EKG 12 lead)

· Urine to monitor ketone and glucose

Pharmacological treatment:

· Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily.

· Lisinopril 10mg PO Daily

· Metformin tab 500 mg one tablet daily.

Non-Pharmacologic treatment:

· Weight changes must be done to manage better the Diabetes

· Healthy diet (DASH dietary pattern): Diet rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced content of saturated and trans l fat

· Reduced intake of dietary sodium: <1,500 mg/d is optimal goal but at least 1,000 mg/d reduction in most adults

· Enhanced intake of dietary potassium

· Exercises must be done at least 3 times per week like: walking, swimming or running

· Measures to release stress and effective coping mechanisms.

Education

· Provide with nutrition/dietary information.

· To avoid GI side effects, take the Metformin with foods.

· Instruction about medication intake compliance.

· Avoid drinking alcohol: Alcohol has a negative interaction with Metformin and contribute to hyperglycemia.

· Education of possible complications of Diabetes such as stroke, heart attack, and other problems.

· Educate to the importance to foot examination and to choose diabetes footwear.

Follow-ups/Referrals

· Follow up appointment 1 weeks for managing blood sugars: It is important to target levels of A1C less than 7 %, so labs will be every 3 months.

· Follow up nutritionist to…..

References(acerca de la enfermedad y el tratamiento, en alfabetico orden, en APA

Calculate the price
Make an order in advance and get the best price
Pages (550 words)
$0.00
*Price with a welcome 15% discount applied.
Pro tip: If you want to save more money and pay the lowest price, you need to set a more extended deadline.
We know how difficult it is to be a student these days. That's why our prices are one of the most affordable on the market, and there are no hidden fees.

Instead, we offer bonuses, discounts, and free services to make your experience outstanding.
How it works
Receive a 100% original paper that will pass Turnitin from a top essay writing service
step 1
Upload your instructions
Fill out the order form and provide paper details. You can even attach screenshots or add additional instructions later. If something is not clear or missing, the writer will contact you for clarification.
Pro service tips
How to get the most out of your experience with Scholary Essays
One writer throughout the entire course
If you like the writer, you can hire them again. Just copy & paste their ID on the order form ("Preferred Writer's ID" field). This way, your vocabulary will be uniform, and the writer will be aware of your needs.
The same paper from different writers
You can order essay or any other work from two different writers to choose the best one or give another version to a friend. This can be done through the add-on "Same paper from another writer."
Copy of sources used by the writer
Our college essay writers work with ScienceDirect and other databases. They can send you articles or materials used in PDF or through screenshots. Just tick the "Copy of sources" field on the order form.
Testimonials
See why 20k+ students have chosen us as their sole writing assistance provider
Check out the latest reviews and opinions submitted by real customers worldwide and make an informed decision.
Education
I love you guys, yal are the best. Thank you so much !!!
Customer 453117, September 10th, 2022
Computer science
Thank You
Customer 453099, August 28th, 2022
Professional Writing Engl-3311
Thank you
Customer 452919, March 2nd, 2023
Education
Great Job !!
Customer 453117, September 17th, 2022
Nursing
Great paper thank you so much
Customer 452667, March 19th, 2021
English 101
Great work!!
Customer 452989, November 21st, 2021
Sociology
Thank you. You all have been timely, and amazing.
Customer 452919, May 3rd, 2022
Nursing
Very good service
Customer 453075, April 27th, 2022
Other
Best service hands down.
Customer 452995, January 24th, 2022
Business Studies
The writer delivered as on time with quality work. But writteres communication could of been better and I would have been more content with choosing my own writer as per my assignment.
Customer 452679, March 24th, 2021
Business Studies
Thank you sincerely great paper and content
Customer 452793, June 22nd, 2021
English 3311- Professional Writing
Thank you, it looks good!
Customer 452919, January 28th, 2023
11,595
Customer reviews in total
96%
Current satisfaction rate
3 pages
Average paper length
37%
Customers referred by a friend
OUR GIFT TO YOU
15% OFF your first order
Use a coupon FIRST15 and enjoy expert help with any task at the most affordable price.
Claim my 15% OFF Order in Chat
Live Chat+1(978) 822-0999EmailWhatsApp

Order your essay today and save 30% with the discount code ESSAYHELP