SOAP NOTE COMPETED

 

SOAP NOTE COMPETED

Name:   A. K  Pt. Encounter Number: 368/2018
Date:  01/05/2018 Age:  56 years old Sex:  Female
SUBJECTIVE
CC: 

“I have experienced increased thirst, dramatic loss of weight, increased amount and frequency of urination. In other cases, I also experience episodes of blurred vision as well as tingling sensation in the extremities.”

 

HPI: 

The patient illustrated that the symptoms have existed for about two months and are usually on in mild levels. She has ever been admitted for the same presentations and was discharged home on medication of which the condition seemed to be stabilized prior to the remission. The symptoms increases after meals but stabilizes their after.

Medications:

Since the resolution of the last episode of the condition, the patient reported no use of drugs for any reason.

PMH

Allergies:   No known food or drug allergies.

Medication Intolerances: None.

Chronic Illnesses/Major traumas: None.

Hospitalizations/Surgeries

The patient had been hospitalized two months ago where she presented with similar symptoms and was treated and discharged. The condition resolved shortly when she was on medication but remitted later on.

Family History

Her mother passed away after suffering from hypertension and diabetes while the father died in an accident. Her elder sister is 60 years old with no medical history. The husband is 62 years old suffering from osteoarthritis. The patient has two daughters with no medical history.

Social History

The patient is a business lady while the husband is a tutor in a training institute. The couple stays together in an apartment along with their daughters and a house-help. She does not smoke cigarette nor drinks alcohol. The patient and other family members observes safety measures while playing at home and when using cares.

ROS
General

The patient reports reduced energy and marked weight loss.

Cardiovascular

These exists mild edema on the extremities. The patient denies chest pain or palpitations. She reports tingling sensation in the extremities.

Skin

The skin is clean and dry. The patient reports no bruises, lesions or rashes.

Respiratory

No episodes of coughs or wheezing. Their exists no difficulty in breathing and no history of tuberculosis.

Eyes

Patient reported episodes of blurred vision. Denies use of corrective lenses.

Gastrointestinal

No instances of constipation or diarrhea, no abdominal pain, diarrhea, nausea and vomiting.

Ears

No discharge or pain reported from the ears. The patient however reports mild episodes of ringing in the years.

Genitourinary/Gynecological

The patient denied presence of vaginal discharge. She is sexually active. The patient reports instances of increased frequency and amount of urine passed in a day.

 

 

   
Nose/Mouth/Throat

Patient reported no swollen or bleeding gums. No discharge or bleeding from the nose. No hoarseness of voice.

Musculoskeletal

No muscle pain, no history of fracture or dislocation, no joint stiffness.

Breast

She knows and carries out self breast examination. No lumbs on the breasts.

Neurological

No history of seizures or headaches.

Heme/Lymph/Endo

She is HIV negative in reference to test done in March 2018. She has no history of either blood transfusion or donation. No lymphadenopathy.

Psychiatric

Denies instances of difficulty in maintaining sleep, anxiety and suicidal ideations.

OBJECTIVE
Weight : 59 Temp  98.4 BP  125/82
Height   : 5.7’’ Pulse  : 80 Resp  21
General Appearance

Healthy looking adult female with no distress though displays to be fatigued. She is well groomed and alert throughout the period of assessment. She also communicates appropriately.

Skin

She has clean, dry and warm skin. No lesions, rashes or lesions.

HEENT

The head is normocephalic. There is no discharge from the eyes with pupils being equal and reactive to light. In relation to the ears, the patient is able to hear well, has a normal pinna with the canals being patent. The tympanic membranes are grey and otoscopy shows no bleeding or discharge from the canal. No nasal flaring. Full range of motion by the neck with no swollen lymph nodes. No halitosis from the mouth. No bleeding gums with all the teeth present.

 

Cardiovascular

S1 and S2 can be heard from auscultation.. Regular rhythm and rate of the heart beat. No facial edema but mild edema on the extremities. Capillary refill of 2 seconds. There is tingling sensation in the extremities.

Respiratory

Symmetrical chest movement, no difficulty in breathing with the respiration being regular.

Gastrointestinal

Increased thirst. The bowel sounds are heard in all the four quadrants. No obvious organomegally.

Breast

There are no lumbs on the breasts.

Genitourinary

Not explored.

Musculoskeletal

Full range of motion of the four limbs was evident throughout the time of assessment.

Neurological

Her speech is clear. She has a stable balance and a normal gait.

Psychiatric

She is fully oriented. She is well groomed and maintained eye contact during interrogation. She responds to questions appropriately.

Lab Tests
Glycated hemoglobin (A1C) test—pending

Random blood sugar test—20mmol/L

 

Special Tests

Oral glucose tolerance test.

 

 Diagnosis
Uncontrolled diabetes

Refers to an undiagnosed condition where the control of blood sugars is impaired concerning insulin production and usage. The patient presents with polyphagia, polyuria, polydipsia, weight loss, blood vision and tingling sensations in the extremities (Bizet et al., 2014). These signs indicate hyperglycemia this causing the fluid shift.

Metabolic syndrome

It encompasses a group of risk factors that are linked to insulin resistance. It has the potential of existing among individuals with normal glucose intolerance, prediabetes, and diabetes (Kaur, 2014). The patient presents with fasting sugars of 100mg/dl and above, abdominal obesity, elevated blood pressures and elevated triglyceride levels.

Hyperthyroidism

Refers to increased activity of the thyroid gland due to increased levels of thyroxine (Ross et al., 2016). The patient presents with weight loss, fatigue, insomnia, muscle weakness, tachycardia and excessive sweating.

Final Diagnosis

The primary diagnosis, in this case, is uncontrolled diabetes based on the history and existence of symptoms such as increased frequency and amount of urine passed every day, feeling thirsty, weight loss and feeling of tingling sensations in the extremities. This diagnosis is confirmed with the high blood sugars of 20 mmol/L.

PLAN

Further testing

The patient to undergo oral glucose tolerance test as well as fasting blood sugar tests.

Medication

Administration of insulin 10IU in an infusion of Normal saline

Aspirin 75mg once a day

Education

Patient to be educated on dietary restriction (Nautiyal & Nautiyal, 2014). This will allow for proper management of the blood sugars. The patient is also to be taught how to inject herself with insulin in preparation for self-management upon discharge.

Follow-up

The patient to join the diabetes support groups. Upon stability, the patient will be discharged and reviewed after two weeks to evaluate the progress and adherence to medication.

 

 

 

References

Bizet, J., Cooper, C. J., Quansah, R., Rodriguez, E., Teleb, M., & Hernandez, G. T. (2014). Chorea, Hyperglycemia, Basal Ganglia Syndrome (CH-BG) in an uncontrolled diabetic patient with normal glucose levels on presentation. The American journal of case reports15, 143.

Kaur, J. (2014). A comprehensive review on metabolic syndrome. Cardiology research and practice2014.

Nautiyal, R., & Nautiyal, V. (2014). Management of Diabetes Mellitus. Global Journal of Multidisciplinary Studies3(6).

Ross, D. S., Burch, H. B., Cooper, D. S., Greenlee, M. C., Laurberg, P., Maia, A. L., … & Walter, M. A. (2016). 2016 American Thyroid Association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis. Thyroid26(10), 1343-1421.

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