SOAP Note Diabetes PDF

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SOAP Note Diabetes...

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Diabetes Management Discussion Prompt Scenario: You are seeing a 64-year-old Hispanic male for his diabetes management. He reports that his morning capillary blood sugar readings are ranging in the 150 to 190 range.          

Last month his Hgb A1C was 7.4 He is on Metformin 1000mg twice a day and Glipizide 5mg daily. He walks a couple miles three to five times a week. A dietary review reveals that his daily total carbohydrate intake is in the range of 75 to 100 grams. Last eye exam did not reveal any problems. He wears reading glasses when needed. He does report some intermittent burning sensation in his feet. Ht 6’2”, Wt 200 lbs, BP 118/72, P 72, R 17 Heart regular rhythm, without murmur or gallop Lungs clear Monifilament testing does not reveal any decreased sensation in the feet

Please develop a discussion that responds to each of the following prompts. Where appropriate your discussion needs to be supported by scholarly resources. Be sure to include in-text citations in the context of the discussion and provide a full reference citation at the end of the discussion. Initial post Utilize the information provided in the scenario to create your discussion post. Construct your response as an abbreviated SOAP note (Subjective Objective Assessment Plan). Structure your ‘P’ in the following format: [NOTE: if any of the 3 categories is not applicable to your plan please use the ‘heading’ and after the ‘:’ input N/A] Therapeutics: pharmacologic interventions, if any – new or revisions to existing; include considerations for OTC agents (pharmacologic and nonpharmacologic/alternative); [optional - any other therapies in lieu of pharmacologic intervention] Educational: health information clients need in order to address their presenting problem(s); health information in support of any of the

‘therapeutics’ identified above; information about follow-up care where appropriate; provision of anticipatory guidance and counseling during the context of the office visit Consultation/Collaboration: if appropriate - collaborative ‘Advanced Care Planning’ with the patient/patient’s care giver; if appropriate -placing the patient in a Transitional Care Model for appropriate pharmacologic and nonpharmacologic care; if appropriate – consult with or referral to another provider while the patient is still in the office; Identification of any future referral you would consider making.

Subjective (S): The patient is a 64-year old Hispanic male. He has come in for a scheduled office visit for his diabetes medication management. He takes his daily medications, but blood sugars in the mornings are in the range of 150-190. The patient leads an active lifestyle and walks a couple of miles 3 to 5 days a week. The patient keeps his carbohydrate intake between 75 to 100 grams a day. The patient takes 1000 mg of Metformin BID and 5 mg of Glipizide once daily. The patient states this his last eye exam was routine, and he wears reading glasses when needed. He does report some intermittent burning sensations in his feet. Objective (O): Patients HgB A1C 7.4 when checked last month. Ht. 6’2”. Wt. 200 pounds. BP 118/72. Pulse 72. RR 17. During the assessment, patients’ lungs are clear and has a regular heart rhythm, no murmur or gallop noted. Monifilament testing does not reveal any decreased sensations in his feet. Assessment (A): Based on the patients’ morning blood sugars, his diabetes is not well managed due to his elevated A1C and blood sugar levels. Based on the patients’ symptoms of burning sensations that he has diabetic neuropathy. Therapeutics: Is seems that his current daily medication is not working very well to control his blood sugar levels. Metformin can be administered at 500 or 850 mg to be taken once or twice a day and can be increased every few weeks to a maximum dose of 2,550 milligrams a day. (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Metformin should be increased to 1,500 milligrams BID and to come back for a follow-up and recheck his A1C and HgB in 2 weeks. The continual effects are reached about 24 to 48 hours. (Arcangelo et al., 2017). Neuropathic pain conditions do not react to analgesic medications since peripheral and central triggers cause it. (Arcangelo et al., 2017). Gabapentin or pregabalin can be useful in controlling the discomfort from neuropathy. (Arcangelo et al., 2017). Some studies show that antidepressants, medications for seizures, and antiarrhythmic medications may also help with neuropathic discomfort. (Arcangelo et al., 2017).

Consultation: After the next follow-up appointment, if some improvements are not noted after the changes in the dosage of the Metformin and the addition of gabapentin, I would recommend this patient see an endocrinologist for management of his diabetes and complications from his diabetes. I would encourage the patient to continue his exercise routine and to continue monitoring his carbohydrate and sugar intake. Reference: Arcangelo, V. P., Peterson, A. M., Wilbur, V., Reinhold, J. A. (20161108). Pharmacotherapeutics for Advanced Practice, 4th Edition [VitalSource Bookshelf version]. Retrieved from vbk://9781496374066...