Soap Note

Denies dysuria, hematuria, or genital lesions but reports urinary frequency.

CC:

“I have been urinating more frequently, feeling continuously thirsty, and stopped taking my diabetes medications last week. I am worried that my blood sugar levels may be off again.”

HPI:

The 46-year-old African American patient reports that "about one week ago I started urinating a lot more frequently than usual. It's been constant and I can't seem to quench my thirst, no matter how much I drink. The excessive urination and thirst haven't been localized to any particular area. It's been going on for the entire past week non-stop. The urination is frequent and feels urgent, and my thirst is severe to the point of feeling like I am constantly dehydrated no matter how much liquid I consume. Nothing makes it better or worse. The symptoms don't radiate anywhere. The only associated symptom is that last week I stopped taking my diabetes medications, which I now regret. The urinary frequency and thirst have been constant throughout the day and night. It's severe enough that I'm worried my blood sugars are out of control again, which is why I scheduled this appointment.”

PMH:

The patient has a past medical history of type 2 diabetes mellitus, diagnosed approximately one year ago at age 45. He was initially prescribed oral antidiabetic medications but stopped taking them about a week ago. He reports never being admitted to a hospital.

PSH

The patient denies any past surgical history.

FH

Paternal Grandfather: A 90-year-old with a history of hypertension, diabetes, and hyperlipidemia.

Paternal Grandmother: An 88-year-old with no reported past medical history.

Father: A 70-year-old with hypertension.

Maternal Grandfather: Deceased at the age of 78 due to diabetes.

Maternal Grandmother: An 89-year-old with no reported past medical history.

Mother: A 71-year-old with hypertension.

SH

The patient is single and is a full-time sales agent at a textile factory, working an average of 46–50 hours per week. The patient reports engaging in occasional smoking, about once a week, and maintains a social drinking habit, consuming approximately two alcoholic beverages weekly. Finding time for exercise proves challenging due to the workload, resulting in infrequent workout sessions. Regarding dietary habits, the patient follows a regular diet but favors fast food, mainly burgers. Due to the long work hours, many patients' meals are consumed at the workplace, often consisting of fast food or delivery orders to the facility.

R

Constitutional

Denies having a chill or fever. Denies experiencing weakness or losing weight.

Head

Denies headaches, dizziness, or vision changes.

Eyes

Denies eye pain, redness, vision changes, or discharge.

Ears, Nose, Mouth, and Throat

Denies ear pain, hearing problems, nasal congestion, a sore throat, or oral lesions.

Neck

Denies neck pain, stiffness, or masses.

Cardiovascular

Denies chest pain, palpitations, or edema.

Respiratory

Denies difficulty breathing, coughing, shortness of breath, or wheezing.

Gastrointestinal

Denies abdominal pain, nausea, vomiting, diarrhea, or constipation.

Genitourinary

Denies dysuria, hematuria, or genital lesions but reported urinary frequency.

Musculoskeletal

Denies muscle or joint pains, swelling, or limitations in range of motion.

Integumentary

Denies rashes, lesions, or skin changes.

Neurological

Denies headaches, dizziness, numbness, tingling, weakness or incoordination.

Psychiatric

Denies appetite changes, suicidal thoughts, loss of interest, anxiety, or sleep disturbances.

Endocrine

Reports increased thirst and excessive urination, as mentioned in HPI, likely due to uncontrolled diabetes.

Hematologic/lymphatic

Denies easy bruising, bleeding, or lymph node swelling.

Allergic/immunologic

Denies environmental or food allergies.

O: OBJECTIVE DATA

VITALS:

HR 83b/min

RR 18b/min

Ht 6’

Temp 36.8 °C

BP 129/89 mmHg

SpO2 95%

Wt. 190 lbs

BMI 25.7

AGE-SPECIFIC

FINDINGS:

The patient falls under the middle adulthood stage (ages 40 to 65 years), where Erikson's concept of "Generativity vs. Stagnation" is pertinent. Age-specific findings in this stage involve assessing the patient's engagement in activities that contribute to the well-being of others, such as mentoring or community involvement, indicative of generativity. However, the symptoms of stagnation may be demonstrated by the patient's unwillingness to work or do some activities presented by the patient who yearns to change his work. Analyzing such elements will let you understand how a person's psychosocial development is going during this period of life (Miller & Lang, 2022).

Physical Exam

General Appearance

The patient's dressing is appropriate to the weather and situation. He is well-oriented and aware of the place without distress.

Head

Upon examination, the head is atraumatic normocephalic and non-tender.

Eyes

Pupils are round, equal, and light-responsive. There is no conjunctival pallor or scleral icterus.

ENT, Mouth

Nose: The mucosa of the nares appears to be of a pink color with no demonstration of swelling, congestion, or discharge. The nasal septum, located midline, does not show any deviation from the septum's normal state of the septum straightness.

Ear: The eardrums are intact and organized in a light gray configuration, clearly visualizing proper landmarks. No sign of inflammation or discharge is detected, and the tympanic membrane has not broken down.

Mouth and Throat: The mucosa in the mouth appears pink and moist, without any visible scratch marks. Gums are red-colored and firm to the touch. There is no gingivitis or bleeding upon examination. The pharynx is clear, and all surfaces appear within the normal limits. There is no evidence of erythema, exudate, or tonsillar hypertrophy. The midline-positioned uvula is seen while the palate still looks intact. The articulation and the coherence transmit the essence of the patient's voice.

Neck

Flexible and soft, free of trauma, scars, thyromegaly, or lymphadenopathy.

Cardiovascular

S1 and S2 heart sounds are audible during auscultation, with a regular rate observed. No abnormal heart sounds are detected. Additionally, there is no swelling in the lower limbs.

Respiratory

No evidence of dyspnea or use of accessory muscles is noted. There is no egophony, whispered pectoriloquy, or tactile fremitus findings upon palpation. Clear breath sounds are bilaterally present and audible during auscultation.

GI

No masses or hernias are observed upon examination. Bowel sounds are audible in all four quadrants during auscultation, and no bruits are detected over the renal and aorta arteries. The abdomen feels soft and non-tender; no guarding or rebound tenderness was noted. Additionally, there is no evidence of distention or organomegaly upon palpation.

GU

No costovertebral angle tenderness.

Musculoskeletal

There is no pain elicited upon palpation. The active and passive ranges of motion (ROM) are within normal limits, with no observed stiffness.

Skin

The skin is warm and dry and appears intact, with no evidence of lesions, rashes, cyanosis, or jaundice.

Neurological

The patient is alert and demonstrates intact cranial nerves II to XII. They are oriented to person, place, and time. Sensation is intact in both bilateral upper and lower extremities. Bilateral upper and lower extremity strength is graded as 5/5.

Psychiatric

The patient is cooperative, and their mood is euthymic.

Endocrine

Elevated random blood glucose levels of (11.5 mmol/L) 

Hematologic/lymphatic

No lymph nodes swelling, absent lower extremities swelling.

Immunologic

No environmental, seasonal, food, or drug allergies.

Other

Blood pressure 128/89 mmHg

RBS 11.5 mmol/L.

A: ASSESSMENT AND DIAGNOSES

Prioritize

DIAGNOSIS

1

Uncontrolled Diabetes Mellitus

ICD–10 E119

The patient presents with classic symptoms of uncontrolled diabetes mellitus, including polyuria and polydipsia, exacerbated by medication non-adherence and suboptimal lifestyle habits. Objective findings reveal elevated blood glucose levels and HbA1c, along with symptoms of excessive thirst and urination (Elliott & Pfotenhauer, 2022).

2

Non-medication adherence

ICD-10 Z91.1

The patient's cessation of diabetes medications without medical advice suggests non-adherence to prescribed treatment regimens. This behavior contributes to uncontrolled diabetes and exacerbates hyperglycemia, increasing the risk of acute and chronic complications associated with poorly managed diabetes (Saraiva et al., 2020).

3

Hyperglycemia, unspecified 

ICD-10 R73. 9

The patient exhibits elevated blood glucose levels, indicating hyperglycemia. This condition is associated with uncontrolled diabetes and increases the risk of acute complications such as diabetic ketoacidosis and long-term complications associated with poorly managed diabetes. Addressing hyperglycemia is crucial to prevent complications and improve overall diabetes management (Mouri & Badireddy, 2023).

Diabetes Mellitus, Uncontrolled

Diagnostic

1. Lipid profile


2. Liver function test (because Metformin requires routine monitoring)


3. Urine to monitor ketone and glucose

Therapeutic

Metformin 500 mg, one tablet to be taken orally daily, alongside daily lifestyle modifications. The dosage can be escalated to twice daily as required or tolerated, with adjustments made every 1 to 2 weeks, up to a maximum dosage of 2 grams daily.

Hydrochlorothiazide 1 tablet daily was added to the treatment for HTN to better control it.

Patient Education

1. Take Metformin with meals to minimize gastrointestinal side effects.


2. Emphasize medication adherence for optimal effectiveness.


3. Avoid alcohol consumption due to negative interactions with Metformin and the risk of hyperglycemia.


4. Educate on potential complications of diabetes, including stroke and heart attack, and stress the importance of regular foot examinations and appropriate footwear selection.

ACTIONS

1

Diabetes Mellitus, Uncontrolled

Diagnostic

1. Lipid profile
2. Liver function test (because the Metformin requires routine monitoring)
3. Urine to monitor ketone and glucose

Therapeutic

Metformin 500 mg, one tablet to be taken orally daily, alongside daily lifestyle modifications. The dosage can be escalated to twice daily as required or tolerated, with adjustments made every 1 to 2 weeks, up to a maximum dosage of 2 grams daily.

Hydrochlorothiazide 1 tablet daily was added to the treatment for HTN to control better.

Patient Education

1. Take Metformin with meals to minimize gastrointestinal side effects.
2. Emphasize medication adherence for optimal effectiveness.
3. Avoid alcohol consumption due to negative interactions with Metformin and the risk of hyperglycemia.
4. Educate on potential complications of diabetes, including stroke and heart attack, and stress the importance of regular foot examinations and appropriate footwear selection.

2

Non-Medication Adherence:

Diagnostic

Assess reasons for medication non-adherence and address barriers.

Therapeutic

Collaborate with the patient to develop strategies for improving medication adherence, such as simplifying the regimen or providing reminders.

Patient Education

Educate the patient about the importance of consistent medication adherence in managing diabetes and preventing complications.

3

Hyperglycemia, Unspecified:

1. Diagnostic

Monitor blood glucose levels regularly to track glycemic control.

1. Therapeutic

Adjust antidiabetic medication regimen as needed to target hyperglycemia.

1. Patient Education

Educate the patient on maintaining blood glucose within target ranges and guide self-management strategies, including dietary modifications and physical activity.

PREVENTATIVE

Incorporating Guidance, Health Promotion, and Disease Prevention strategies into the programs for families, patients, and caregivers includes several essential strategies. Nutritionally, the best health advocacy is promoting a diet with a wide range of proteins, vegetables, and fruits while shunning processed foods and sugary soda as far as possible (García-Molina et al., 2019). Regular exercise (which should include cardio and resistance exercises) is the most reliable contributor to reasonable sugar control and enhanced overall health. Furthermore, it should be ensured that support for smoking cessation services is offered as stopping smoking is already associated with a decreasing risk of cardiovascular complications related to diabetes. By doing so, diabetes patients can take care of their diabetes and cut the risk of its comorbidities, leading to a better life for them (Driva et al., 2022).

FOLLOW UP

A follow-up meeting One week for blood sugar control: Since aiming for A1C values under 7% is crucial, lab tests will be conducted every three months.

PRESCRIPTIONS

-

-

-

Metformin 500mg - Take one tablet twice daily with meals. #60, 3 refills.

HCTZ 25mg - Take one daily in AM. #30, 2 refills.

Atorvastatin 20mg - Take one night with food. #30, 3 refills

CLINICAL REFLECTION

That being the case, we diagnose uncontrolled diabetes mellitus that has worsened due to the patient's failure to take the prescribed medications, as it happens to a 46-year-old African American male. Lifestyle elements, which include long working hours, occasional cigarette smoking, and adherence to a poor diet, are magnified in his case. For the treatment plan, we will include medications like Metformin to help with blood sugar control and stress the significance of adhering to medications and lifestyle changes. Our prevention program includes nutrition education and exercise as two crucial facets to help lower the risk factors. The follow-up appointments are regularly arranged to watch progress, rectify any deviation, and ensure that the patient will have the best possible healthcare result.