Type 2 diabetes
You will be required to write two SOAP notes during the course. Both should address the management of an acute problem in an adult or older adult individual who has a chronic disease. For example, an acute onset of respiratory symptoms in a patient with diabetes. You could also address an acute exacerbation of a chronic problem. For example, a patient with chronic depression presents with an exacerbation or recurrence of depressive symptoms. Another example would be a patient with a history of chronic back pain s/p surgery presents with worsening pain and radicular symptoms. \”Thanks Again!\”
Solution
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Acute Respiratory Symptoms and Diabetes
SOAP Note
Patient Initials: K. S. Age: 72 years old Race: Korean Gender: Male
SUBJECTIVE DATA:
Chief Complaint (CC): “I have a sore throat, persistent cough, a mild headache, and a runny nose. I also have a small ulcer on my big toe of the right foot.”
History of Present Illness (HPI): K. S. is a 72-year old Korean male who has visited the clinic unaccompanied. As reported by K. S., he has been experiencing sore throat, runny nose, persistent cough, a mild headache, and a runny nose. Besides, K. S. has a small ulcer on the big toe of his right foot. Additional symptoms include mild fever and sneezing. These symptoms began 2 days ago and they seem to be getting worse. The patient experiences stuffy nose when in cold weather. This changes to a severely runny nose when he is in hot weather.
Sore throat, fever, cough, headache, and sneezing also worsen in cold weather. K. S. further indicates that he was diagnosed with type 2 diabetes at the age of 52 and he has been using metformin for the past 20 years to manage the condition. Before developing the named problematic symptoms, K. S. reports that he has been feeling extreme thirst and he urinates a lot. These other symptoms have persisted for the past one month even when he continues to use metformin. The patient’s symptoms can be summarized using the following attributes;
Location: Nose, throat, head, overall body (fever), urinary system, and toe.
Onset: 2 days ago for respiratory symptoms and 1 month for extreme thirst, frequent urination, and ulcer on his toe.
Characteristic/Quality: A sore throat, persistent cough, a mild headache, a runny nose, and an ulcer on the toe of his right foot.
Associated symptoms: Fever, sneezing, extreme thirst, and frequent urination.
Timing: Symptoms are more severe in the morning and in the evening than during the day.
Exacerbating or relieving factors: Cold weather exacerbates symptoms while severity reduces during hot weather.
Severity or quantity: 4/10 on the pain scale (headache).
Medications: K. S. is using metformin to manage his diabetes.
Allergies: No known drug or food allergies reported.
Past Medical History (PMH): Reports a positive diagnosis of multiple health problems during his lifetime. In several instances, he has been diagnosed and treated of malaria, common cold, and general body weakness. These conditions were successfully managed without hospitalization. K. S. was diagnosed with type 2 diabetes at the age of 52 years, a condition he is still managing using metformin.
Past Surgical History (PSH): Denies surgical history.
Sexual/Reproductive History: K. S. is sexually active and he is happily married with three children. He states that he is faithful to his wife.
Personal/Social History: K.S. is a retired teacher and he is currently on pension. He is a farmer with a large plantation where he grows crops for consumption and for sale. Due to diminished physical mobility, he has employed laborers to help with farm activities. K. S. denies cigarette and alcohol use. He is a Christian who also serves as a church elder. K. S. denies engaging in physical activities in the community. His diet mainly comprises of vegetables and milk. He does not eat meat and reports limiting carbohydrate intake following the doctor’s advice after he was diagnosed with type-2 diabetes.
Immunization History: K. S. received all immunizations at the recommended ages as per his medical records.
Significant Family History: The patient’s father died 20 years ago at the age of 82 years from hypertension and stroke complications. His mother had diabetes and she died 15 years ago at the age of 76 years. K. S.’s children and wife have not been diagnosed with any serious condition.
Review of Systems:
General: K. S. has recorded a slight reduction in body weight with about 2 kg in the past one month. He feels slightly tired when the sun is hot. Reports fever.
HEENT:
Head: Denies physical head injury. Reports a mild headache.
Eyes: Reports a blurry vision during hot weather.
Ears: Denies ear and hearing problems.
Nose: Has a runny nose that gets stuffy in cold weather. He reports frequent sneezing when the weather is cold. Reports nasal congestion.
Throat: Reports a sore throat.
Neck: Denies pain or swelling in the neck region.
Respiratory: Reports breathing difficulties when nasal congestion is experienced. Reports persistent cough.
Cardiovascular/Peripheral Vascular: Denies tightness of the chest.
Gastrointestinal: Denies stomachache, constipation, or abdominal pain.
Genitourinary: Reports frequent urination, especially at night even with minimal fluid intake.
Musculoskeletal: Denies joint pain. Reports an ulcer on the toe of his right foot.
Psychiatric: Denies changes in mood, depression, anxiety, or memory loss.
Skin: Denies skin itchiness, rashes, or redness.
Hematologic: Denies a history of blood-related disorders.
Endocrine: Denies abnormal night sweats. Reports excessive thirst, frequent urination, and fatigue.
OBJECTIVE DATA:
Physical Exam:
Vital signs: Body temperature: 37 degrees Celcius, weight=95.7 lb., Height=51 inches, respiratory rate=20.
General: K. S. is well-groomed, attentive, and maintain eye contact. He responds appropriately to questions.
HEENT:
Head: Normocephalic with no evidence of physical injury. Hair evenly distributed all over the scalp.
Eyes: Vision is blurry when there is excess sunlight. Conjunctiva is moist and pink.
Ears: Ear canal is clear. Both ears are sensitive to sound waves.
Nose: Nasal mucosa is hairy and pink. Mucus flowing out of the nose.
Throat: Signs of redness in the throat. Buccal mucosa is moist and pink. K. S. coughs persistently on observation.
Neck: Upright with no evidence of swelling.
Lungs: Trouble with inhalation and exhalation of gases. Struggles with breathing. No wheezing.
Heart: No murmurs, no gallop.
Abdomen: No bowel sounds, no stomach distension, no evidence of pain on palpation.
Musculoskeletal: No evidence of joint pain on palpation. No problem with balance. Evidence of an ulcer on his big toe of the right foot.
Neurological: No evidence of numbness.
Skin: Skin appears dry, no rashes, no redness.
Lab tests, x-rays, and other procedures: Perform an x-ray of the chest to rule out the possibility of other respiratory conditions. Perform throat culture to find other possible microorganisms that might be causing the cough (Mayo Clinic, 2021). Culture specimen obtained from the foot ulcer to identify the micro-organisms involved based on the colonies. Perform A1C test to evaluate the average blood sugar level. Perform complete blood count test (CBC) to assess the concentrations of blood cells (Sullivan, 2019; Dains et al., 2016).
ASSESSMENT:
Differential diagnoses: Type 2 diabetes that co-occurs with common cold (Primary diagnosis).
: Acute sinusitis and type 2 diabetes
: Acute bronchitis and type 2 diabetes.
Rationale
The patient’s symptoms match those of type 2 diabetes that co-occurs with common cold. Symptoms of type 2 diabetes that are present in the patient include fatigue, extreme thirst, frequent urination, elevated blood sugar levels, and diabetic foot (Goyal & Jialal, 2021). Symptoms that match those of common cold include a sore throat, persistent cough, a mild headache, a runny nose, sneezing, and fever (Pappas, 2018).
Although the patient presents with nasal obstruction and nasal drainage, it is unlikely that he has acute sinusitis due to the absence of facial pain which is a common symptom for the disease (DeBoer & Kwon, 2021). Besides, acute bronchitis is unlikely because no wheezing was evidenced in the chest and the patient does not present with malaise despite the fact that he presents with a persistent cough and difficulty breathing (Singh et al., 2021).
PLAN:
Diagnostics:
- Repeat A1C test and conduct fasting blood sugar test, random blood sugar test, and glucose tolerance test to establish the severity of type 2 diabetes (Goyal & Jialal, 2021).
- Observe the patient further and make a conclusion regarding the severity of common cold (Mayo Clinic, 2021).
Therapeutics:
Pharmacological treatment:
- Prescribe clindamycin to treat diabetic foot ulcer. Advise the patient to continue using metformin as prescribed (Goyal & Jialal, 2021).
- Prescribe Tylenol to relieve headache.
- Prescribe decongestants to relieve nasal congestion and sneezing (Mayo Clinic, 2021).
- Prescribe dextromethorphan to relieve acute cough (Pappas, 2018).
Non-pharmacological intervention:
- Remove dead tissue from the ulcer (debridement) and clean the area (American Podiatric Medical Association, 2021).
- Encourage the patient to take warm water to relieve nasal congestion (Mayo Clinic, 2021).
Patient education, health promotion, referrals, and follow-ups:
- Educate the patient about the risk factors of diabetes type 2 and the causes of common cold.
- Educate the patient on drug adherence and its benefits (Edelman et al., 2017).
- Involve family members in the care of the patient.
- Advice the patient to dress warmly at all times, avoid walking bare foot, and to maintain cleanliness at all times, especially on the ulcerated area (American Podiatric Medical Association, 2021).
- Emphasize on the importance of avoiding excessive carbohydrates and eating more fruits, milk, and vegetables (Goyal & Jialal, 2021).
- Refer the patient to a physiotherapist who can offer guidance on age-appropriate physical activities.
- Ask the patient to contact the clinic in case problematic symptoms occur. He should also visit the facility in two weeks for follow-up and evaluation (Treas et al., 2018).
References
American Podiatric Medical Association. (2021). Diabetic wound care. https://www.apma.org/diabeticwoundcare
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
DeBoer, D. L., & Kwon, E. (2021). Acute sinusitis. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK547701/
Edelman, C., Mandle, C., & Kudzma, E. (2017). Health promotion throughout the life span. 9th ed. Elsevier Health Sciences. ISBN: 0323416748, 9780323416740
Goyal, R., & Jialal, I. (2021). Diabetes Mellitus Type 2. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK513253/
Mayo Clinic. (2021). Common cold. https://www.mayoclinic.org/diseases-conditions/common-cold/diagnosis-treatment/drc-20351611
Pappas D. E. (2018). The common cold. Principles and Practice of Pediatric Infectious Diseases, 199–202.e1. https://doi.org/10.1016/B978-0-323-40181-4.00026-8
Singh, A., Avula, A, & Zahn, E. (2021). Acute bronchitis. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK448067/
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia