2 SOAP NOTE 2 CP 2 SOAP Note Form Clinical Practice 2 S/ Identifying Information: (initials, age/DOB, gender, reliability) Name: L. H. Age: 56 (04/24/1963) Gender: Male Reliability: Seems reliable Chief Complaint/RFE: “Metformin is not working anymore for my diabetes, my blood sugars stay high.” Family Hx: Father: deceased; history of asthma and heart disease. Mother: decreased, history of malignant neoplasm of unspecified site. Grandparents: deceased, medical history unknown. Brother: alive; healthy. Personal/Social Hx: This is a pleasant 56-year-old male who has never been married and has one child, is currently living with his girlfriend. Patient has never smoked cigarettes, drinks alcohol only on occasion, and denies illicit drug use. Patient does admit to chewing tobacco 1 can per week. Alcohol screen (CAGE) 0 points. Reports that he thinks his diet has been better, however he admits to foods such as double cheeseburgers being a staple. Does not currently participate in regular physical activity, although as a truck driver he tries to park farther away from rest stops so he has to walk a longer distance. Hx Present Illness: (7 Variables) This 56-year-old male came to the clinic today because he missed a previous appointment with his primary care nurse practitioner, and then she left the practice. He denies any pain. The patient’s diabetes started at least one year ago, it was diagnosed on routine lab work. Patient unaware of what the HgbA1c was on diagnosis. He has never been hospitalized for his diabetes. As far as he knows he doesn’t have any problems related to his diabetes, and denies any depression. He does not remember when he last saw a dentist. Patient reports he ran out of strips for his glucometer and hasn’t been checking his blood glucose level in 2 weeks. He reports his blood sugars being in the 200’s when he was checking them. He has been feeling fatigued with intermittent blurred vision during this past month. Currently he is taking Metformin HCL 500mg 1 tablet by mouth once a day, which was prescribed by the previous provider. CURRENT HEALTH Medications: Allopurinol 100mg 1 tablet orally twice a day Action: Prevents the production of uric acid by hindering the action of xanthine oxidase, which lowers uric acid levels in the body. Typical Dose: For gout prophylaxis start 100mg by mouth daily, and increase 100mg a day every week until uric acid level is less than 6mg/dL; max daily dose 800mg. Side Effects: hypotension, hypertension, flushing, rash, drowsiness, diarrhea. Education: Discontinue immediately if a rash occurs while taking. During an acute gout attack a gout reliever may be indicated since gout does not relieve an acute attack. (Vallerand, Sanoski, & Deglin, 2017) Pravastatin Sodium 40mg 1 tablet orally once a day Action: Blocks enzyme HMG-CoA reductase which influences cholesterol in the early phases. Typical Dose: 10-40 mg by mouth once at bedtime may adjust dose every 4 weeks. 3 SOAP NOTE 2 CP 2 Side Effects: abdominal cramps, constipation, diarrhea, flatus, heartburn, arthralgia, hyperglycemia, weakness. Education: Do not drink more than 200 ml per day of grapefruit juice. Notify healthcare provider if unexplained muscle pain is present. This medication should be used with diet, exercise, and cessation of tobacco. (Vallerand et al., 2017) Lasix 40mg 1 tablet orally once a day Action: Prevents sodium and chloride from reabsorbing in the loop of Henle and distal renal tubule. Helps to increase water, sodium, chloride, magnesium, potassium, and calcium excretion. Typical Dose: 20mg-80mg by mouth every 6-8hours. Increase by 20-40mg every 6-8 hours for desired response. Side Effects: Electrolyte imbalance, blurred vision, dizziness, Steven Johnson syndrome, dehydration, muscle cramps. Education: Eat a diet high in potassium unless there is kidney dysfunction, change positions slowly when standing up, notify a healthcare provider immediately if a rash, muscle weakness, cramps, nausea, or dizziness occurs. (Vallerand, et al., 2017) Losartan Potassium 100mg 1 tablet orally once a day Action: Blocks receptor sites that coincide with angiotensin 2 and aldosterone including vascular smooth muscle, and adrenal glands, causing lower blood pressure. Typical Dose: 50mg once daily initially. Range is 25mg-100mg as a single dose or in 2 divided doses. Side Effects: dizziness, hypotension, angioedema, fatigue, headache, abdominal pain. Education: Avoid salt substitutes that contain potassium or sodium. Avoids sudden position changes. Notify healthcare professional if swelling of the face, eyes, lips, or tongue, or difficulty with swallowing or breathing occurs. (Vallerand, et al., 2017) Metformin HCL 500mg 1 tablet with a meal orally once a day Action: Decreases liver glucose production, and intestinal glucose production, increases insulin sensitivity. Typical Dose: ER – 500mg-2000mg/day, IR- 850-1000mg/day Side Effects: Diarrhea, flatulence, indigestion, metallic taste, lactic acidosis, hepatotoxicity. Education: Hold 48 hours before and after IV contrast. Check GFR at least annually, and periodically check vitamin B12. (Vallerand, et al., 2017) Allergies: No known drug allergies, no known food allergies. Last PE & Screenings: Last annual wellness exam unknown. Last HgbA1c was 6.1 on 4/12/2019. Diabetic eye exam- not done. Last diabetic foot exam today- normal. Last lipid panel 4/12/2019; HDL 35, otherwise normal. Last microalbumin/creat ratio on 2/13/19 -normal. 4 SOAP NOTE 2 CP 2 Immunization Status:  Tdap 3/2019  Influenza vaccine 10/2018 For a 56-year-old diabetic male I would look for up to date: influenza, PPSV23, Tdap, MMR, and Zoster vaccinations. LMP & Birth Control (if applicable): Not applicable PMH Illnesses & Trauma: Essential hypertension, Diverticulosis of the large intestine, morbid obesity, mixed hyperlipidemia, type 2 diabetes mellitus, gout. Hospitalizations/Surgeries: Colon resection 3/2019. OB Hx/Sexual Hx: Patient has a girlfriend; sexually activity and use of protection unknown. Emotional/Psy Hx: PHQ-2 Screening for depression- negative. REVIEW OF SYSTEMS General: Positive for fatigue. Sleeps about 6 hours a night. Denies any sudden weight gain, weight loss, fevers, chills or pains, tremors or weakness. Nutrition: States “I eat much better that I was eating, but my blood sugar will not stay down.” Admits that he likes to eat cheeseburgers, meats, some vegetables, and portable gas station foods. Skin/Hair/Nails: Denies any dry skin, hair loss, rash, or sores that don’t heal. HEENT: Denies any hearing loss, sore throat, or difficulty swallowing. Positive for blurred vision on and off for the past month, reports no other visual changes. Breasts: Deferred Respiratory: Denies any cough, shortness of breath, wheezing. CV/peripheral vascular: Denies any chest pain, palpitations, irregular heart-beat, swelling in the legs, leg cramps or pain in the extremities. GI: Denies any nausea, vomiting, constipation, diarrhea, abdominal pain. GU: Denies burning, urgency or frequency during urination. MSK: Denies painful joints, weakness, decreased range of motion. Psych: Negative for memory loss, confusion, anxiety, depression, or substance abuse Neuro: Negative for numbness, dizziness, headache, or parasthesias. Lymph/Heme/Endocrine: Denies for polydipsia, polyphagia, swollen glands, easy bruising. O/ Physical Exam: T: 98.5 F P: 69 R: 18 BP: 142/80 HT: 71 inches WT: 359 lbs. BMI: 50 Oxygen sat: 98% General: Pleasant, alert and oriented to person, place, and time, makes good eye contact. Cooperative with questions, normal affect, insight, and judgement. Diabetic foot exam done today; feet dry and flaky. Monofilament testing done; no neuropathy present. Skin: Skin warm, turgor elastic, dry and intact. Nail beds pink, firmly attached, no clubbing or cyanosis. Positive for dry skin on arms, legs, and feet. Head: Normocephalic, atraumatic, hair well distributed. EENT: Eyes: No sign of cataracts, retinopathy, or retinal hemorrhage, sclera white, conjunctiva pink. Nose: nasal turbinate’s pink, throat: no posterior exudate or tonsillar hypertrophy. Oral cavity: carious teeth, evidence of chewing tobacco between teeth, halitosis present. 5 SOAP NOTE 2 CP 2 Neck: Neck supple, thyroid symmetric and nontender, full range of motion, no cervical lymphadenopathy. Breasts/Chest: Deferred Lungs: Effort and pattern regular, lungs clear to auscultation bilaterally. Heart/ perip vascular: Regular rate and rhythm, no murmurs. S1 is normal, S2 is normal, S3/S4 is not present. Dorsalis pedis pulses +2/+4 bilaterally. Abdomen: Obese, soft, non-distended, no masses, pain, or tenderness, bowel sounds present in all four quadrants. Genitalia/Rectum: Urinalysis obtained- normal Lymph: Cervical lymph nodes non-tender, non-palpable. MSK: Full range of motion in all extremities, normal gait and posture. Neuro: Motor strength normal in upper and lower extremities, sensory intact in all extremities. Medical Dx: (2max)   Type 2 diabetes mellitus without complications, without long-term current use of insulin (E11.9) Essential Hypertension (I10) Pertinent Positives:(1DX)       Hyperglycemia Obesity Fatigue Blurred vision BMI of 50 Sedentary lifestyle (Reed, & Jessup, 2018) Rule Outs (only if applicable): Not applicable Health Profile: age/gender/racial risks:  Obesity  Hypertension  Lipid disorder  Diabetes personal/family:  Asthma  Heart disease  Malignant neoplasm screening needs: Recommended wellness and prevention for diabetics: HgbA1c, Lipid panel, CBC, CMP, TSH today. Next colonoscopy 10/4/19. Pertinent Negatives:         Recent steroid use Fatty deposits (moon face) Purple stretch marks Thinning skin that bruises easily Enlarged hands and feet Enlarged facial features Coarse, oily skin Heavy sweating counseling needs: Weight loss plan to include necessary exercise and diabetic diet, focus to reduce BMI. Chewing tobacco cessation. 6 SOAP NOTE 2 CP 2   Tremors Rapid heart beat Immunization/chemo needs: Annual influenza vaccine when available this year. (Reed, & Jessup, 2018) Differential DX:(3-5)     Cushing’s syndrome Corticosteroid use Acromegaly Pheochromocytoma Alteration in Health Prevention R/T: Screening deficits: Annual dilated eye exam-never done. Wellness exam overdue. Counseling deficits: Diabetic diet. Chewing tobacco cessation education to be done next visit. (Reed, & Jessup, 2018) Nursing Dx: Unstable blood glucose related to deficient knowledge of diabetes management as evidenced by lack of exercise, not following a diabetic diet, and a blood glucose level of 480. Immunization/chemo deficits: PPSV23. Shingrix vaccine. I. PLAN: Do separate sections in the plan to include: Max 1-2 pages Diagnostics:  Labs today: CBC, CMP, Thyroid panel with TSH, Free T3, HgbA1c, Lipid panel, Testosterone free and total, Vitamin B12 and Folate, Vitamin D 25-Hydroxy  PHQ-2 Screening for depression  Urinalysis in house  Capillary blood glucose in house: 480  Annual diabetic foot exam today Medications/Treatments:    Start Ozempic 1mg/dose 0.5 subcutaneous once a week Start Metformin HCL 1000mg 1 tablet with a meal orally twice a day Start ReliOn blood glucose test as directed in vitro 3 times a day Education:      Exercise at least 20 minutes a day five days a week, even a brisk walk to get the heart rate up. Hand-outs provided on exercise tips; the goal is to get closer to a normal BMI. Log book given to patient; log all foods everyday including dressings. Log all blood sugars twice a day; first thing in the morning, and one other time during the day. Encouraged to go to free diabetic education classes offered by in house diabetes educators on Thursday evenings. Inspect feet regularly and take care when trimming nails; see a podiatrist if needed. Follow-up: In 4 weeks to recheck blood glucose level, go over labs, and evaluate blood glucose and food log books. Referrals: Diabetic educator (free service due to grant money) Prevention Plan: 7 SOAP NOTE 2 CP 2     Exercise tips provided to patient. Diet plan already discussed with in office diabetic educator, this plan was reinforced. Annual diabetic foot exam performed today. Try to obtain blood pressure readings at home at least once a day. II. Rationale: ( Include rationale in the plan with citations) Diagnostics: Labs: CBC, CMP, HgbA1c, Lipid panel, and TSH are indicated at a regular basis for diabetic patients to determine any complications from diabetes, such as decreased renal function (“American Diabetes Association,” 2019).  Screening for depression, diabetes, and eating disorders are part of the comprehensive diabetes evaluation (“American Diabetes Association,” 2019).  Complications with kidneys are closely related to unmanaged diabetes, it is indicated to check for proteinuria.  Annual diabetic foot exams with skin inspection, pulse and capillary refill check, and monofilament testing are important to check the integrity of a highly vulnerable area on a diabetic patient, and to check for neuropathy (“American Diabetes Association,” 2019). Medications/Treatments:  Ozempic is in the medication class GLP-1 and is indicated for this patient to help with A1c reduction, weight loss, and prevention of hyperglycemia by action of increased insulin release from beta cells during glucose elevation (Vallerand et al., 2017).  Metformin is usually well tolerated after an initial GI upset. It may help with weight loss and lipids, and usually doesn’t contribute to hypoglycemia. It improves insulin sensitivity, and works on glucose in the liver and intestine. Maximum daily dose of 2000mg, blood glucose levels should be monitored frequently so the lowest effective dose is used (Reed, & Jessup, 2018). Education: Diet and exercise are necessary to help control blood glucose levels, and weight loss can help increase insulin sensitivity. Logging foods and blood sugars help the patient become accountable for their health, and allow the provider to assess accurately how the patient is managing their health, and how well a medication regimen is working. Follow up: A four week follow up is necessary to evaluate patient’s response to medication changes, and to see how the patient has been managing their diabetes with all of the new information given. Referrals: Cardiology, nephrology, and podiatry may be needed in the future. As of now the goal is to prevent complications by consulting a certified diabetes educator, especially since this is at no cost to the patient, and they are located in the office. Prevention Plan:  Regular mild to moderate exercise can improve outcomes related to diabetes, and cardiovascular health (“American Diabetes Association,” 2019).  Learn to count carbohydrates, eating protein with every meal, and watching total calorie intake; calorie and carbohydrate restriction helps with weight loss and decreased blood glucose level.  Heart disease correlates with diabetes. Blood pressure goal for diabetics: less than or equal to 130/80, Triglycerides should be less than 200mg/dL. LDL should be less than 100mg/dL. HDL should be greater than 45 mg/dL (“American Diabetes Association,” 2019). 8 SOAP NOTE 2 CP 2 III. Patho: (Max 1-2 paragraphs) Type 2 diabetes mellitus occurs from genetic, environmental or a combination of factors. Risk factors heavily related to type 2 diabetes include: “age, obesity, hypertension, physical inactivity, and family history” (Brashers, Jones, & Huether, 2014). Individuals diagnosed with metabolic syndrome or polycystic ovary syndrome have a much higher chance of developing type 2 diabetes mellitus due to increase in insulin resistance (Brashers et al., 2014). Genetically, only individuals who have a beta cell dysfunction in the pancreas will develop type 2 diabetes; environmental risk factors make it a higher probability (Brashers et al., 2014). The pancreas consists of beta cells which make a hormone called insulin. Insulin binds to cells allowing glucose to enter cells for energy (Brashers et al., 2014). Beta-cell dysfunction is caused by many different factors. High levels of glucose, inflammatory cytokines, elevated free fatty acids, and adipokines promote beta cell death, thus causing type 2 diabetes (Brashers et al., 2014). Insulin resistance is a strong indicator of type 2 diabetes. Insulin resistance is also genetic, and increases the risk of an individual developing diabetes through the action of adipocytes; leptin, adiponectin, resistin, and tumor necrosis factor-alpha. These substances are pro-inflammatory and contribute to beta cell dysfunction (Brashers et al., 2014). 9 SOAP NOTE 2 CP 2 IV. Reflection Upon evaluating this patient, it seems that he was probably an undiagnosed diabetic for quite some time, as many diabetics start out. The preceptor I am with took over this patient since another provider was let go. This gentleman in my opinion should have been watched better, it looks as if he was on one Metformin once a day for quite some time. With patients like him, it’s very common to have to increase to 1000mg twice a day. I chose this patient because diabetes is rapidly becoming a common diagnosis, and it has such scary consequences. There are many patients out there that need a great deal of help with managing their diabetes. As a future provider I want to be highly educated, and helpful to my patients in prevention of diabetes, and diabetes complications. My preceptor’s husband is a certified diabetes educator, and he has given me great material as far as managing diabetes, and implementing a diabetic diet. Diabetes also recently hit home for me. My mother was just diagnosed with diabetes, and my paternal grandmother was a diabetic. I now have personal reasons to become knowledgeable with this disease. I think in patients with diabetes it is important to check their mental health status. Depression can be a common finding in this population. It is possible that depression can be the cause of the lack of physical activity, and inadequate diet, or that the burden of diabetes caused the depression. Mental health problems have a high correlation with diabetes (“American Diabetes Association,” 2019). The “American Diabetes Association” (2019) state that lifestyle and psychosocial care are the most important aspects to proper diabetic management. Providers are responsible for keeping track of proper monitoring and screenings that go along with managing a diabetic patient.