SOAP Note on Diabetes Patient

SOAPNote on Diabetes Patient

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SOAPNote on Diabetes Patient

Inthe past month, I examined several patients most with short-termillnesses and others with emergency needs. I, however, noted aparticular case of Miss Catherine, a twenty-five-year-old sufferingfrom diabetes. Generally, from an overview of our conversation, shehad been lean ever since her teenage years. She did admit that therewere cases of diabetes in her family and intact in the last year hergrandmother died of the same disease. She complained of constantfever and nausea and sometimes pain in the chest. As I examined her,I noted that she had some degree of confusion, especially whenexpressing herself and her skin was pale. Her reflexes were notheightened and she had problems with her breathing.

Thepatient could be suffering either from type-one diabetes. Type-onediabetes patients are lean and depend on medication to control theircondition. Type-one diabetes mellitus differential diagnosisincludes:

  • Diabetic Ketoacidosis

  • Diabetic Nephropathy

  • Diabetic Ulcers

  • Insulin Resistance

  • Lead Nephropathy

  • Type 2 Diabetes Mellitus

DiabeticKetoacidosiswas my primary diagnosis because it is an acute complication ofdiabetes and it is uncommon among type-two diabetes patients. Idecided to conduct tests on the lady to asses her vulnerabilities andstabilities. The first diagnostic was a random plasma glucose testindicated a whopping 181 mg/ dl. This test is performed as the mainone while the rest supplement it (Bakris,2011).I then measured the patient’s blood pressure. The results seemedsomewhat reasonable with a rate of 138/80 mm/Hg.&nbspBloodtests ensure a detailed analysis of the disease’s hosting medium(Kolata, 2013).I conducted visual tests where I found that the lady had a blurredvision of which she had visited the optician and obtained a beautifulframe of lenses not knowing what the problem was. I also conducted aweight analysis which showed that the patient was overweight. Afterexamining my patient further, I concluded that she was suffering fromtype-two diabetes.

Forher medication, I proposed the use of metformin. Metformin assists inreducing the amount of glucose the liver releases into the blood andboost the responsiveness of the cells to insulin(Stehouwer &amp Schaper, 2011).I advised her to observe healthy living practices such as properdieting with little animal fats and daily exercising.

Diabeteshas various categories and intensities. Luckily, for Catherine, hercondition was manageable with minimal medication and change of herlifestyle. Some patients such as those suffering from type-onediabetes require severe medication and very close follow-up(Fowler, 2011).

References

Bakris,G. (2011).&nbspContemporarydiagnosis and management of hypertension and diabetes.Newtown, Pa.: Handbooks in Health Care Co.

Fowler,M. (2011). Diagnosis, Classification, and Lifestyle Treatment ofDiabetes.&nbspClinicalDiabetes,28(2),79-86. http://dx.doi.org/10.2337/diaclin.28.2.79

Kolata,G. (2013).&nbspTheNew York Times science of the times.New York, NY: Sterling.

Stehouwer,C. &amp Schaper, N. (2011).&nbspDiabetes.Oxford: Clinical Pub.