SOAP NOTE W2
| Name: SR | Date:08/01/2019 | Time:1045 | ||
| Age:51 | Sex:Male | |||
| SUBJECTIVE | ||||
| CC: “I feel thirsty most of the time and urinate more than usual” | ||||
| HPI: A 51-year-old male patient is coming to the clinic for preventive care, he says that he feels thirsty most of the time, has lost some weight and c/o frequent urination, he wants a full checkup because his mother died due to a complication of elevated blood pressure but she also had Type 2 Diabetes Mellitus and was poor controlled, he stated that he has not been checked in years because he keeps busy all the time. Denies any other symptoms but has experienced blurred vision sometimes, he thinks this is because he needs to change his glasses soon, he already has the appointment in three weeks from now. | ||||
| Medications: None | ||||
| PMH
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Medication Intolerances: None Chronic Illnesses/Major traumas: None Hospitalizations/Surgeries: None Immunizations: Up to date including Flu vaccine received last season. Environmental hazards: None reported Safety measures: Routine measures. Exercise and leisure: None Sleep: Between 6 to 7 hours per day and he usually sleeps more on Sundays. Diet: His wife and he cook at home most of the time and go out to restaurants often. |
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| Family History: Brother (deceased) MI / Mother (deceased) Stroke. | ||||
| Social History: Family time is important for him and his wife. They participate in many sport events as possible with other family members as well. | ||||
| ROS | ||||
| General: denies fever and headache, c/o weight loss and malaise. Denies chills. | Cardiovascular: Denies chest pain, syncope, and shortness of breath. Denies palpitations, orthopnea. | |||
| Skin: Denies rashes, itching, or other skin changes. Denies nail problems, hair loss or sun sensitivity. | Respiratory: Denies cough, sputum, shortness of breath, and fatigue with exertion. | |||
| Eyes: c/o blurred vision sometimes, denies eye pain, or itching.
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Gastrointestinal: denies abdominal pain, denies nausea, vomiting, or dysphagia. Denies constipation, melena, and diarrhea. denies loss of appetite. Denies blood or mucus in stools. | |||
| Ears: Denies trouble hearing, or drainage
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Genitourinary/Gynecological:c/o polyuria and frequency, no dysuria denies hematuria, or offensive odor of urine. | |||
| Nose/Mouth/Throat: Denies swelling of nose, or loss of sense of smell. Denies sore throat, difficulty swallowing, and bleeding gums. | Musculoskeletal: Denies myalgias and weakness.
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| Breast: Deferred | Neurological: Denies memory loss, change in mental status, imbalance, or weakness. Denies muscle cramps or seizures. | |||
| Heme/Lymph/Endo: Denies bleeding tendency, bruising and transfusions. Denies cold or heat intolerance, flushing, c/o excessive thirst. | Psychiatric: No depression, anxiety or suicidal feelings. | |||
| OBJECTIVE | ||||
| Weight 185 | Temp97.6 | BP136/85 | ||
| Height 6’0’’ | Pulse86 | Resp18 | ||
| General Appearance: Well groomed. alert, calm, well-developed. No acute distress. | ||||
| Skin: No rashes, skin warm and dry, no erythematous areas | ||||
| HEENT: Pupils equal, round, reactive to light and accommodation. Extra- ocular movements intact. Moist mucous membranes in oropharynx. | ||||
| Cardiovascular: No edema, pulses 2+ bilaterally (radial, posterior tibialis, dorsalis pedis), no JVD. | ||||
| Respiratory: Chest wall motion symmetric with no accessory muscle use. Resonant to
percussion. CTA bilaterally. No wheezes or rhonchi heard. |
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| Gastrointestinal: Normal bowel sounds, abdomen soft and nontender. No hepatosplenomegaly; liver span approximately 10 cm. | ||||
| Musculoskeletal: No edema, cyanosis or clubbing. 5/5 strength, normal range of motion, no swollen or erythematous joints. | ||||
| Neurological: alert and oriented x 3, CN 2-12 grossly intact. | ||||
| Psychiatric: mood stable, appropriate affect. | ||||
| Lab Tests: Fasting Plasma Glucose: 131 mg/dl Hgb A1C: 7.2 % |
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| Diagnosis | ||||
| Primary Diagnosis
Type 2 DM: complex chronic metabolic illness characterized by abnormal insulin secretion, resistance to insulin in target tissues, and decrease in insulin receptors. Type 2 diabetes develops when the body becomes resistant to insulin or when the pancreas is unable to produce enough insulin. Exactly why this happens is unknown, although genetics and environmental factors, such as being overweight and inactive, seem to be contributing factors (Buttaro, 2017) Differential Diagnosis: Type 1 Diabetes Mellitus: Type 1 diabetes is caused by an autoimmune reaction that destroys the cells in the pancreas that make insulin, called beta cells. This process can go on for months or years before any symptoms appear. It is usually diagnosed in children, teens, and young adults, but it can develop at any age. Type 1 is less common than Type 2 Diabetes Mellitus. Type 1 diabetes symptoms can develop in just a few weeks or months. Once symptoms appear, they can be severe(Buttaro, 2017) Pheochromocytoma: is a rare tumor that can form in cells in the middle of the adrenal glands. In the case of PCC, a tumor can cause the adrenal glands to make too much of the hormones norepinephrine (noradrenaline) and epinephrine (adrenaline). Together these hormones control heart rate, metabolism, blood pressure, and the body’s stress response. It can show symptoms like headaches, sweating, palpitations, heat intolerance, anxiety and nervousness(Buttaro, 2017) Cushing Syndrome: results from an overexposure of tissues to corticosteroids from exogenous or endogenous sources. The most common cause of it is glucocorticoid excess related to excessive production of adrenocorticotropic hormone by the pituitary gland. Some of the findings are edema, moon face, weakness and fatigue, personality changes, truncal obesity and osteoporosis(Buttaro, 2017)
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| Plan/Therapeutics | ||||
| Nonpharmacologic Management: Weight Loss: primary goal for obese patients. Avoid alcohol Avoid smoking Exercise: increases insulin secretion, glucose utilization and HDL levels (Buttaro, 2017) Pharmacologic management: Metformin 500 mg BID PO (Thrasher,2017). |
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| Evaluation of patient encounter | ||||
Diabetes mellitus is a leading cause of morbidity and mortality in the United States. Type 2 diabetes mellitus is most common (90% to 95% of persons with diabetes) and affects older adults, particularly those older than 50 years of age. An estimated 16 million Americans have type 2 diabetes, and up to 800 000 new diagnoses are made each year (Gomez, 2019)
Type 2 diabetes mellitus is a risk factor for incident heart failure and increases the risk of morbidity and mortality in patients with established disease. Secular trends in the prevalence of diabetes mellitus and heart failure forecast a growing burden of disease and underscore the need for effective therapeutic strategies (Pirbaglou, 2018)
Recent clinical trials have demonstrated the shared pathophysiologydiabetes mellitus and heart failure, the synergistic effect of managing both conditions, and the potential for diabetes mellitus therapies to modulate the risk of heart failure outcomes (Gomez, 2019)
Given the markedly elevated risk for cardiovascular events in most persons with type 2 diabetes, preventing cardiovascular disease through aggressive management of cardiovascular risk factors is of utmost importance. Optimizing treatment of hypertension, smoking cessation, and lipid control provides substantial benefit, at least to the average patient with type 2 diabetes. (Pavlou, 2018)
