Comprehensive SOAP Note Template Essay Paper
SUBJECTIVE DATA:
Chief Complaint (CC):
“I’m here for my diabetes”
History of Present Illness (HPI): GD is a 49-year old male who presents to the ED seeking to follow up on his diabetes. A while ago, he was evaluated for an untreatable headache, and it was discovered that he had hyperglycemia, with an A1C level of 18. He states that he had an upsurge in both his thirst and his need to urinate, but that both of these symptoms have subsided after he began taking metformin. He denies the presence of symptoms such as vomiting, nausea, weakness, palpitations, dizziness, chest pain, or shortness of breath Comprehensive SOAP Note Template Essay Paper.
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Medications:
Lipitor 20 mg daily, metformin 1000 mg BID
Allergies:
Denies medication, food, seasonal, or environmental allergies.
Past Medical History (PMH):
History of diabetes. Denies history of hospitalizations or risky sexual behaviors.
Past Surgical History (PSH): Comprehensive SOAP Note Template Essay Paper
No surgical history.
Personal/Social History: Reports drinking 56 beers and 3-5 shots of whisky per week. Reports drinking 6 nips of powerball weekly, but stopped 3 weeks ago.
Reports he can go days without drinking. Denies ever having withdrawal symptoms. States that his meals usually consist of:
- Breakfast: orange juice with sugar with fried turnover.
- Lunch: Rice beans and meat
- Dinner: Rice beans and meat
Immunization History:
Tdap 7/7/2022, PCV20 7/7/2022.
Significant Family History:
Mother- deceased, history of diabetes, hypertension.
Father- alcohol abuse
Brother- good health
Sister- good health
Maternal grandmother: diabetes.
Paternal grandfather: prostate cancer, former smoker: quit 2012.
Lifestyle:
Denies any safety issues. Does not mention any cultural or economic factors.
Review of Systems:
General: Denies recent weight changes, weakness, fatigue, or fever.
HEENT: Denies history of head trauma or injury. Denies eye pain or visual problems. Denies ear pain, discharge, or hearing problems. Denies nasal issues or loss of sense of smell. Denies sore throat or difficulty swallowing.
Neck: Denies swollen lymph nodes
Breasts: Denies breast pain, soreness, lumps, or discharge.
Respiratory: denies shortness of breath, cough, or wheezing.
Cardiovascular/Peripheral Vascular: Denies chest pain, pressure or tightness. Denies edema or palpitations.
Gastrointestinal: Denies abdominal pain, nausea, vomiting, diarrhea or constipation.
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Genitourinary: Denies increased frequency in urination or pain on urination.
Musculoskeletal: Denies muscle pain or injury. Denies joint pain, stiffness, or back pain.
Psychiatric: Denies history of depression or anxiety.
Neurological: Denies headache, dizziness, vertigo, syncope, or sense of disequilibrium.
Skin: Denies rashes, lumps, sores, itching, or lesions.
Hematologic: Denies bleeding or history of anemia.
Endocrine: Denies cold or heat intolerance, night sweats, or poydipsia.
Allergic/Immunologic: Denies rash or hives Comprehensive SOAP Note Template Essay Paper
OBJECTIVE DATA:
Physical Exam:
Vital signs: BP 121/68 Pulse 75 Temp 98.1 °F Wt 175 lb SpO2 97% BMI 26.61
General: Pleasant male, in no acute distress. Well-dressed, well-groomed, and well-nourished, with steady gait. Clear and coherent speech with appropriate facial expressions. Cooperative and aware of what is happening in his surroundings.
HEENT: Head: norm cephalic and atraumatic, no abnormalities. Eyes: moist and pink conjunctiva, white sclera. Ears: No drainage from ear canals. Nose: moist and pink mucus membranes. No discharge from ear canals. Throat: Moist and pink oral mucosa, no swelling.
Neck: no deformities, signs of trauma, or external skin changes.
Chest/Lungs: Symmetric chest. Unlabored breathing. Lungs clear to auscultation bilaterally.
Heart/Peripheral Vascular: S1, S2 noted no murmurs, gallops, or rubs. No edema in the extremities. Strong and regular pulses bilaterally. Capillary refill less than 3 seconds.
Abdomen: symmetric, soft, round abdomen, no tenderness or abnormalities. Tympany noted in all areas. Normoactive bowel sounds in all quadrants.
Genital/Rectal: No hemorrhoids or bleeding from the rectum noted
Musculoskeletal: legs and arms are symmetrical, no swelling. No tenderness, joint stiffness, or swelling. Full range of motion in lower and upper extremities.
Neurological: Alert and oriented X 4, with normal speech. Intact sensation bilaterally. No motor déficits, 5/5 muscle strength bilaterally.
Skin: No tenting, cyanosis, or rash noted.
ASSESSMENT:
Differential Diagnosis
Diabetes (Primary diagnosis): Diabetes is a chronic condition that manifests itself either when the pancreas fails to secrete an adequate amount of insulin or when the body is unable to make proper use of the insulin it does generate. A major side effect of untreated diabetes is hyperglycemia, often known as high blood sugar. Over time, hyperglycemia causes catastrophic destruction to several of the body’s functions, most notably the neurons and blood vessels. The diagnosis and management of diabetes include doing a blood test to determine the patient’s sugar level. The fasting glucose test, A1c test, and the random glucose test are the three different tests that may assess the amount of sugar in the blood. A solid sign of diabetes is a HbA1c level of 6.5 percent or above (Matoori et al., 2020)Comprehensive SOAP Note Template Essay Paper.
Obesity: Obesity is a complicated condition that is caused by having an excessive quantity of fat in the body. The issue of obesity is more than simply one of appearance. Obesity is often caused by a combination of genetic, physiological, and environmental variables, as well as decisions about nutrition, level of physical activity, and exercise (Fruh, 2017). The body mass index (BMI) is a common tool for diagnosing obesity; a BMI of 25 or more indicates that a person is obese. Glycation of hemoglobin may be increased regardless of glucose levels if obesity is present due to the systemic oxidative stress that comes along with it. Therefore, A1c values in obese individuals may be disproportionately high for a particular glycemic concentration.
Hyperglycemia: When there is an abnormally high level of sugar in the blood, a condition known as hyperglycemia may develop. This occurs either because the body does not have enough insulin or because the body is unable to make good use of the insulin that it does have. Diabetes mellitus is the co-morbidity that is seen most often with this condition. Blood tests such as the fructosamine test, A1C test, or fasting plasma glucose (FPG) may be used to diagnose hyperglycemia (Mouri & Badireddy, 2021).
Prehypertension: When a person’s blood pressure is higher than normal but not quite high enough to be diagnosed as high blood pressure, the individual is said to have prehypertension. It may be the first step in developing hypertension. It indicates that the person has a greater risk of developing hypertension. Because of this, they have a higher risk of illnesses that might potentially take their lives, including a heart attack or a stroke (Han et al., 2018). A systolic pressure from 120–139 mmHg or a diastolic pressure from 80–89 mmHg indicates prehypertension.
PLAN:
Treatment Plan: A combination of pharmacological and nonpharmacological approaches is required for the treatment of diabetes. In terms of the patient’s pharmacological treatment, the patient should continue taking metformin at a dosage of 1000 milligrams twice daily. Metformin is an oral medication that, when taken as directed, may enhance the way in which the body makes use of insulin, which, in turn, can bring about a reduction in overall blood sugar levels (Lv & Guo, 2020). Diets low in calories, along with frequent rigorous exercise and weight reduction constitute nonpharmacological strategies.
Health Promotion: The patient should be taught on the need of fostering healthy living by promoting healthy eating, physical exercise, and mental well-being. Emotional distress may be brought on by diabetes, in addition to the physical symptoms and difficulties it brings. A person who has diabetes is required to make several modifications to their lifestyle, some of which include modifying their exercise and diet patterns, consistently using medications, performing self-monitoring, establishing coping mechanisms, rearranging meal times, and modifying family routines and social activities (Tynan, 2020)Comprehensive SOAP Note Template Essay Paper.
Disease Prevention: The development of diabetes may be prevented or delayed by making very little adjustments to one’s lifestyle, which have been demonstrated to be beneficial. People should do the following things to help avoid diabetes and the issues that come with it: eating a healthy diet, being physically active, maintaining a healthy body weight, and avoiding tobacco use. Additionally, the American Diabetes Association (2021) suggests that all persons who are 45 years of age or older undergo regular screening with diagnostic testing to check for diabetes.
REFLECTION: What I learned from this experience is that treatment of diabetes should focus on achieving blood glucose levels that are as near to normal as may be achieved without jeopardizing patient safety. Treatment for diabetes must also include steps to bring under control the patient’s blood pressure and cholesterol levels because diabetes is associated with a significantly increased risk of cardiovascular disease and peripheral artery disease. There is nothing I would do differently since every intervention recommended is evidence-based. I agree with my preceptor on the diagnosis and the choice of the treatment regimen.
References
American Diabetes Association. (2021). 2. Classification and diagnosis of diabetes: standards of medical care in diabetes—2021. Diabetes care, 44(Supplement 1), S15-S33. https://doi.org/10.2337/dc21-s002 Comprehensive SOAP Note Template Essay Paper
Fruh, S. M. (2017). Obesity. Journal of the American Association of Nurse Practitioners, 29(S1), S3-S14. https://doi.org/10.1002/2327-6924.12510
Han, M., Li, Q., Liu, L., Zhang, D., Ren, Y., Zhao, Y., Liu, D., Liu, F., Chen, X., Cheng, C., Guo, C., Zhou, Q., Tian, G., Qie, R., Huang, S., Wu, X., Liu, Y., Li, H., Sun, X., … Hu, D. (2019). Prehypertension and risk of cardiovascular diseases. Journal of Hypertension, 37(12), 2325-2332. https://doi.org/10.1097/hjh.0000000000002191
Lv, Z., & Guo, Y. (2020). Metformin and its benefits for various diseases. Frontiers in Endocrinology, 11. https://doi.org/10.3389/fendo.2020.00191
Matoori, S. (2022). Diabetes and its Complications. ACS Pharmacology & Translational Science.
Mouri, M., & Badireddy, M. (2021). Hyperglycemia. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430900/
Tynan, A. (2020). Supporting positive lifestyle changes among patients with diabetes mellitus type 2. https://doi.org/10.33015/dominican.edu/2020.nurs.st.14
Patient Initials: _GD______ Age: _____49__ Gender___M____
Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.
O = Onset of symptom (acute/gradual)
L= Location
D= Duration (recent/chronic)
C= Character
A= Associated symptoms/aggravating factors
R= Relieving factors
T= Treatments previously tried—response? Why discontinued?
S= Severity
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC):
“I’m here for my diabetes”
History of Present Illness (HPI):
This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (i.e., 34-year-old AA male). You must include the seven attributes of each principal symptom: Comprehensive SOAP Note Template Essay Paper
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- Location
- Quality
- Quantity or severity
- Timing, including onset, duration, and frequency
- Setting in which it occurs
- Factors that have aggravated or relieved the symptom
- Associated manifestations
Medications:
Include over-the-counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.
Allergies:
Include specific reactions to medications, foods, insects, and environmental factors.
Past Medical History (PMH):
Include illnesses (also childhood illnesses), hospitalizations, and risky sexual behaviors.
Past Surgical History (PSH):
Include dates, indications, and types of operations.
Sexual/Reproductive History: If applicable,
include obstetric history, menstrual history, methods of contraception, and sexual function.
Personal/Social History:
Include tobacco use, alcohol use, drug use, patient’s interests, ADLs and IADLs if applicable, and exercise and eating habits.
Immunization History:
Include last Tdap, flu, pneumonia, etc.
Significant Family History:
Include history of parents, grandparents, siblings, and children.
Lifestyle:
Include cultural factors, economic factors, safety, and support systems.
Review of Systems: From head to toe, include each system that covers the chief complaint, history of present illness, and history (this includes the systems that address any previous diagnoses). Remember that the information you include in this section is based on what the patient tells you. You do not need to do them all unless you are doing a total H&P.
General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here. Comprehensive SOAP Note Template Essay Paper
HEENT:
Neck:
Breasts:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Psychiatric:
Neurological:
Skin: Include rashes, lumps, sores, itching, dryness, changes, etc.
Hematologic:
Endocrine:
Allergic/Immunologic:
OBJECTIVE DATA: From head to toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and history if you are doing a total H&P. Do not use WNL or normal. You must describe what you see.
Physical Exam:
Vital signs:
Include vital signs, height, weight, and BMI.
General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of conscience, affect, and reactions to people and things.
HEENT:
Neck:
Chest/Lungs: Always include this in your PE.
Heart/Peripheral Vascular: Always include the heart in your PE.
Abdomen:
Genital/Rectal:
Musculoskeletal:
Neurological:
Skin:
ASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least three differential diagnoses, each of which must be supported with evidence and guidelines. Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled. These should also be included in your treatment plan Comprehensive SOAP Note Template Essay Paper.
PLAN:
Treatment Plan: If applicable, include both pharmacological and nonpharmacological strategies, alternative therapies, follow-up recommendations, referrals, consultations, and any additional labs, X-rays, or other diagnostics. Support the treatment plan with evidence and guidelines.
Health Promotion: Include exercise, diet, and safety recommendations, as well as any other health promotion strategies for the patient/family. Support the health promotion recommendations and strategies with evidence and guidelines.
Disease Prevention: As appropriate for the patient’s age, include disease prevention recommendations and strategies, such as fasting lipid profile, mammography, colonoscopy, immunizations, etc. Support the disease prevention recommendations and strategies with evidence and guidelines.
REFLECTION: Reflect on your clinical experience and consider the following questions: What did you learn from this experience? What would you do differently? Do you agree with your preceptor based on the evidence? Comprehensive SOAP Note Template Essay Paper