SOAP Note: Diabetes Mellitus

Patient: S.T

Age: 60 years old

Clinical Setting: Outpatient

Subjective Data

Chief Complaint

S.T came to the hospital looking anxious. She says, “When I urinate, I feel pain. My left toe is swollen, red, painful, and blackened. I cannot even walk well.”

History of Present Illness

S.T was diagnosed with type 2 diabetes mellitus and obesity two years ago. Her general practitioner prescribed metformin and glyburide and advised doing exercise. S.T. does not remember the dosages and has not been compliant with the drugs. Two months ago, she noticed a painful wound on her left toe. She did not take any medicines apart from over the counter ibuprofen, hoping the wound would heal. Last week, the toe started to swell, became necrotized, and the pain increased. Today morning, the painful toe caused difficulty in walking. She also reports painful micturition, which has been present for two weeks.

Past Medical History

Used only metformin and glyburide. Does not remember the dosages and was not compliant. Not allergic to any drug. Immunization status is up-to-date.

Family History

Father is obese and has type II diabetes mellitus. Her two brothers are alive and well. Mother died due to lung fibrosis.

Social History

Married; works at an elementary school as a teacher. Neither smokes nor drinks. Interacts well with peers at work. Has low libido.

Review of Systems

Constitutional: Weighs 145 lbs and appears fatigued. Positive for night sweats. Denies recent trauma, injuries or falls.

Eyes: Positive for blurry vision. Denies scotomas or eye pain.

Ears, nose, mouth, and throat: Denies otalgia or vertigo. Denies sinusitis or epistaxis. Denies xerostomia or gingival ulceration. Denies pharyngitis or hoarseness.

Cardiovascular: Denies palpitations, chest pain, or edema.

Respiratory: Denies a cough, dyspnea, or orthopnea.

GI: Denies diarrhea or melena.

GU: Positive for dysuria. Denies urethral discharge or increased urinary frequency.

Musculoskeletal: Positive for joint pain on the left toe and generalized fatigue. Denies back pain.

Skin and breast: Positive for a sore on the left foot. Denies itching. Denies any lesions, pruritus, or tumors.

Neurological: Denies paresthesia or fasciculations.

Psychiatric: Positive for anxiety. Denies thought disorder or any history of major depression.

Endocrine: Positive for polyphagia, polydipsia, weight gain, and polyuria. Denies unexplained weight loss.

Hematologic/Lymphatic: Denies petechiae or purpura.

Allergic/Immunologic: Denies any allergic reactions or swelling.

Objective Data

Vital Signs

RR: 26bpm; BP: 139/90 mmHg; Temp: 102.2 F; PaO2: 97%; Pulse: 82bpm

Pain score: 10/10

Ht: 5’ 5”

Wt: 195 lbs

BMI: 32.4kg/m2

Physical Examination

Constitutional: Has body malaise; oriented.

Eyes: Conjunctiva is pink, the macula is visualized, the sclera is white. Pupils are of equal size.

ENT/ Mouth: Auditory canal is normal. No masses or tenderness. Midline nasal septum, free from epistaxis. Normal pharynx and tonsillar fossa. Tongue is pink, 32 teeth present, no infection or bleeding from the gums.

Cardiovascular: Clear S1 and S2 sounds. No murmurs or carotid bruits heard on auscultation. No edema noted.

Respiratory: Normal tactile fremitus. Does not use any accessory muscles when breathing.

GI: No masses or tenderness in upper quadrants. No liver nodularity or active bowel sounds.

GU: Inflamed urinary meatus.

Musculoskeletal: Swollen left toe with reduced ROM in the phalanges. Symmetrical upper extremities. No cyanosis petechiae noted.

Skin: Ulcerations present on the left toe. No rashes or other lesions noted.

Neurological: Intact cranial nerves. Normal hearing on rough testing; a normal tone of the motor system. Unable to extend phalanges of the left foot.

Psychiatric: Judgment is intact; patient is oriented to place and time. No depression or anxiety noted.

Hematologic/Lymphatic/Immunologic: Submental, submandibular, subscapular and pectoral axillary lymph nodes are not palpable.

Testing Results

Full hemogram leucocyte values: 14,000mcL

Urinalysis: glucose -150 mg/dL

Lipid panel: cholesterol – -250mg/dL

Assessment

Diagnoses (Centers for Medicare and Medicaid Services, n.d.)

Obesity: Z68.32

Hyperlipidemia: E78.5

Gangrene in diabetes mellitus: (R02).

Dysuria: R30.0

Blurred vision: H53.8

Polyphagia: R63.2

Polydipsia: R63.1

Polyuria: R35.8

Differential Diagnoses

Bacterial cystitis: Lee, Romih, and Zupan?i? (2014) indicate that this urinary tract infection occurs after the bacteria enter the bladder and multiplies, thus causing inflammation and pain. The patient has the symptoms of dysuria.

Thrombophlebitis: Scott, Mahdi, and Alikhan (2015) ascertain that this superficial skin condition occurs after blood clots in a given part of the body. It results in pain, darkening of the area of the skin and reddening. The patient presents with blackened painful toe.

Synergistic gangrene: Ying, Zhang, Yan, and Zhu (2013) explain that this condition occurs after due to the death of the body tissue and presents with swelling, redness, and darkening of the skin in the patient.

Plan

Medications

The most appropriate medications for this case would be antidiabetics, pain relievers, and statin therapy. The nurse should issue metformin 500mg BD and glyburide 5mg OD orally. According to Ferrannini (2014), metformin increases the sensitivity of cells to insulin, thus enabling proper sugar regulation. Additionally, Carroll and Kelley (2014) advocate for glyburide for its ability to help the body to secrete more insulin. Further, Rodriguez-Hernandez, Simental-Mendia, Rodriguez-Ramirez, and Reyes-Romero (2013) recommend lovastatin 20mg OD to reduce the lipid level. Finally, the patient should get diclofenac 75mg BD, which Dinh et al. (2016) ascertain that it reduces pain significantly. These medications can help her body system to control sugar and relieve pain both in the toe and the urethra.

Additional Diagnostic Tests

X-ray, ultrasound, culture and bone biopsy are recommended. Malhotra, Chan, and Nather (2014) argue that ultrasound and X-ray are effective in diagnosing the extent of osteomyelitis in diabetic patients. The authors explain that culture and bone biopsy can aid in choosing the most appropriate antibiotic. Therefore, the nurse should request for these tests, including urine culture to determine the necessary antibiotics and determine the need for referral.

Education

The nurse should teach S.T the importance of drug adherence since she has a history of poor compliance with medication. Alikari and Zyga (2014) attribute poor compliance with drugs to inadequate patient education. Therefore, to ensure recovery, the nurse should focus on educating the patient on compliance with not only the medication but also health advice, including exercise.

Referrals

The nurse should refer S.T to a podiatric surgeon since the foot has a necrotic tissue. Malhotra et al. (2014) argue that podiatric surgeons are competent in combining antibiotic and surgical management of osteomyelitis that has complicated from a diabetic foot. Most importantly, the nurse should accompany the referral note with the results of the additional laboratory tests to enable the surgeon to have baseline information for managing S.T.

Follow-up

Phone follow-up and a return date are needed to assess compliance with treatment and the recovery process. Aliha et al. (2013) ascertain that such follow-up is one of the most significant steps in nursing that can enhance drug compliance and promote proper health-seeking behavior. Therefore, the nurse should implement phone follow-up to prevent further diabetic complications.

SOAP Note: Peptic Ulcer Disease

SOAP Note on Bacterial Conjunctivitis