Complete a focused SOAP note for the case study as noted below and address the additional discussion questions. For the SOAP note section, you do not need to use complete sentences and must use approved nursing/medical abbreviations. For the discussion sections you must use Harvard format, using correct sentence structure and spelling. Include a properly written cover sheet. Be succinct on both sections of the paper. The rubric is attached at the end of this document, be sure to review the rubric as you are writing so that you will have a well written paper.

Case Scenario 

CC: “I am here for my diabetic check-up”

65-year-old Saudi woman presents for her yearly diabetic checkup. She was diagnosed with Type 2 diabetes mellitus 15 years ago. Currently she is prescribed Metformin 1000 mg by mouth twice daily with meals and empagliflozin 10 mg by mouth every morning. Medical history includes hypertension, diagnosed 20 years ago, for which she takes losartan 100 mg and hydrochlorothiazide 25 mg by mouth each morning, dyslipidemia for which she takes Atorvastatin 40 mg by mouth at bedtime, and frequent tension headaches for which she takes paracetamol 500 mg once for each headache episode for good relief. She reports that she takes all medication as ordered and experiences no side effects. She eats a standard Saudi diet except that she and her husband go out to eat at least 4-3 times each week for dinner and travel to Dubai at least 2 times each year where they eat 3 meals per day in restaurants. When she eats in restaurants, she doesn’t follow a diabetic diet. She walks 2-3 miles 4 times each week at the mall. She is married with 3 healthy grown children. She lives in her owned home with her husband and youngest daughter. She is comfortable in her home and has a happy relationship with her husband, children, and 4 grandchildren. She denies any symptoms of depression. Both her mother and father had T2DM. Her mother died at age 75 from an MI and her father died at age 55 from an MI and renal failure. She has 3 siblings, all of whom have T2DM. Her youngest brother had an MI at age 58 but is doing well post stent placement 2 years ago. Headaches occur about once monthly and are not related to anything that she can tell. Denies other pain except for some numbness and tingling in her toes, with pain at 4/10.  Denies any recent foot ulcers. Denies nausea/vomiting/diarrhea/constipation/black/bloody stools. Denies reflux/heartburn. Denies shortness of breath, cough or wheezing, dizziness, difficulties with balance, or falls. Denies chest pain or palpitations. Denies joint pain, stiffness, or swelling. Denies rashes but does note she has very dry skin that improves with twice daily application of moisturizers. Had a UTI 6 weeks ago for which she was given TMP-SMX 960 mg twice daily for 2 days which resolved the UTI. She has not been sexually active with her husband for the past 2 years as neither have any desire for conjugal intimacy. She c/o burning with voiding and urgency for the past 3 days but denies chills, incontinence, or CVP pain. She sees the ophthalmologist for yearly eye exam, last exam was 6 months ago and was normal, per patient report. She has declined PAP, pelvic exam, mammography, colonoscopy but did have a bone density last month.

Appears well groomed and is oriented to person, place, and time. Skin is warm and notably dry with minor flaking, no open lesions. Scattered actinic keratoses on neck and trunk. Conjunctivae white, moist, without drainage.  Red reflex present. Optic disc round, well defined bilaterally. Macula is without visible lesions. No A-V nicking noted. Oropharynx is pink, moist without lesions, dentition is in good repair. Trachea is midline, thyroid is palpable and within expected limits, no nodules palpated. Lungs clear to auscultation bilaterally, anterior and posterior, without adventitious sounds. Heart with regular rate and rhythm, no murmurs, gallops, or rubs. Abdomen soft, bowel sounds active x 4. Suprapubic tenderness 5/10 with palpation. No CVP pain on percussion bilaterally. MSK not examined. LOPS (loss of protective sensation) 6/10 bilaterally including plantar surface distal 1/3 of foot and 10 toes, PS (protective sensation) 4/10 for remainder of foot by microfilament examination. Previous HgA1c 7.9% 3 months ago and 7.7% 6 months ago.

Vital signs: Weight 90.7 kg, Ht. 1.7m, BMI 31.3, B/P 128/82, HR 89, RR 18, Temp 36.7 C, PO2 97% on room air.

Bone density results: T score: -1.5 (Reference range: Normal T-score > -1, Osteopenia between -1 and -2.5; Osteoporosis below -2.5)

Laboratory Results

These results were obtained fasting 2 days prior to this appointment:

Test	Result	Adult Reference Range
Glucose	205	Fasting: 70 - 110 mg/dL
Calcium	9.1	8.2 - 10.6 mg/dL
Albumin	4.5	3.5 - 5.0 gm/dL
Total Protein	7.1	6.0 - 8.4 gm/dL
Sodium	139	133 - 146 mEq/L
Potassium	4.8	3.5 - 5.4 mEq/L
CO2	34	23 to 29 mEq/L
Chloride	102	98 - 106 mEq/L
BUN	16	7 - 18 mg/dL
Creatinine	1.3	0.6 - 1.2 mg/dL
GFR	47	> 60 mL/min/1.73m2
ALP	87	44 to 147 IU/L
ALT	18	1 - 21 units/L
AST	22	7 - 27 units/L
Total Bilirubin	0.6	Up to 1.0 mg/dL
HgA1c	8.6	5.7 %

 

Thyroid Panel
Test	Patient results	Adult Reference Ranges
TSH	0.30	0.27 – 4.20 μIU/mL
T4	10.2	4.5-11.7 μg/dL
T3	180	80-200 ng/dL
Antithyroglobulin Antibody	50	<115
Antithyroid Peroxidase Antibody (Anti-TPO)	22	<34

 

 

Test	Result	Adult reference Range
Red blood cell count	5.1	4.2 - 6.9 million/µL/cu mm
Hematocrit	40%	Female: 37 - 48%
Platelet count	280,000	150,000 - 350,000/mL
Hemoglobin	13	Male: 13 - 18 gm/dL Female: 12 - 16 gm/dL
WBC	8	4.3-10.8 × 103/mm3

 

Cholesterol panel: all within normal limits for age and gender.

This was checked today in the office lab:

Test	Results	Reference Standards
Color	Dark yellow	Yellow
Appearance	hazy	Clear
Specific Gravity	1.020	1.005 -1.030
pH	5.7	5.5 - 7.5
Protein	negative	Negative
Glucose	negative	Negative
Ketones	negative	Negative
WBC/HPF	20	0 – 5/HPF
RBC/HPF	3	0 – 5/HPF
Epithelial cells	few	None-few/LPF
Casts/LPF	2	Hyaline 0-3
Bacteria	many	None-few/HPF
Leukocyte esterase	positive	Negative
Nitrite	positive	Negative
HPF = high power field, LPF = low power field                 ML McGary 2019

Discussion: These will be graded as part of the plan section. Answer the following questions:

1. Based on your plan, what is your rationale for changing or not changing the diabetic medications? Include a discussion of either a or b, based on your plan.
1. If you changed the medications and /or dosages, what is your rational for choosing the drug(s) and doses you chose?
2. If you chose not to change the medications and/or dosages, what is your rationale for continuing the same medication regimen?
2.  What should this patient’s blood pressure, weight, and HgA1c goals be? Give the rational for each goal, specific to this patient.

 

 

Category	Exceptional                       3	Satisfactory                  2	Needs Improvement      1	Possibly Harmful                          0	Score
Subjective	Information is accurate and complete and is organized and concise. The documentation is comprehensive to include all CC, HPI, PMH, SH, FH, Allergies, Meds, ROS etc.	Accurate information provided (as in exceptional column), but could be more organized and succinct	Minor incorrect information and / or information placed in the incorrect location; omissions such as allergies, medications	Major incorrect information and / or major omissions that make it unlikely another provider would come to the same A and P; major omissions such as HPI, ROS, PMH etc.
Objective	Accurate information is organized and precise and does not include any major or minor omission.	Accurate information is provided, but could be more organized and succinct	Incorrect information, or contains minor, but important information, or incorrect placement of information is evident	Incorrect information (major) or omissions that make it unlikely another provider would come to the same A and P (such as lab results)
Assessment	Accurate information provided: complete and concise description to include the diagnosis, supported logically by subjective and objective data; cites guidelines as appropriate	Accurate information provided but could be more organized	Incorrect information (minor) provided such as drug therapy inconsistent with established guidelines; contains problem not discussed in S and O sections or information from P section	Incorrect information (major) included that could result in wrongly identified drug therapy which may result in patient harm
Plan	Complete and appropriate in every detail to include education, further investigation, follow up, referral (if indicated) etc.	Appropriate information (same as exceptional column), but with minor omissions	Missing or inconsistent information or using guidelines that are not appropriate; major omissions where another practitioner is unlikely to come up with the same plan	Contains errors that could result in patient harm; fails to address correct therapy; has missing or incorrect key educational points (e.g. drug side effects), follow up / referral)
Overall grammar / medical terminology / references	Appropriate word choice and terminology; no grammatical errors; appropriate up to date scientific references used, for instance textbooks, clinical practice guidelines	Few errors with word choice and terminology; fewer than 2 grammatical errors; up to date and appropriate sources used	Incorrect or inappropriate word choice or terminology (minor); greater than 3 grammatical errors; some sources are scientific / or up to date	Incorrect or inappropriate word choice or terminology (major); greater than 5 grammatical errors; few or no sources are up to date, inappropriate scientific references
Total (out of a possible 15)