Main Diagnosis Diabetes Mellitus Type 2 (Case Study Sample)

Soap Note # Main Diagnosis Diabetes Mellitus Type 2
Patient Information
Name: Judith Ashley
Age: 57 years
Gender at Birth: Female
Gender Identity: Female
Source: The patient
Allergies: Pollen energy, mold allergy and penicillin

Current Medications: She is under medication of Fortamet, corticosteroids, Glumetza, and antihistamines.
PMH: Ashley has suffered from hypertension for the last three years. According to their most recent clinical visit, the patient's blood triglyceride levels were above 170 milligrams per deciliter. In addition, the test reveals that the patient has an issue with low concentrations of good cholesterol. Prediabetes is a condition characterized by elevated blood sugar levels, but the individual is not yet diabetic.
Immunizations: Vaxchora, pertussis (DTaP-IPV), adenovirus, HPV9, PCV 13 (Prevnar13), MMR (M-M-R II), and HepB, TaP-IPV/Hib.
Preventive Care: Counseling about eating healthfully, weight loss, and quitting drinking and smoking. Additionally, the patient got testing for diabetes, blood pressure, and cholesterol.
Surgical History: Ashley had knee surgery about six years prior to the visit.
Family History: There is no family history of diabetes. The patient's mother died of high blood pressure, whereas the patient's father died from a heart attack. Ashley’s two siblings are also on medications for high blood pressure (HBP).
Social History: Ashley filed a lawsuit for excessive drinking in her twenties and thirties. She smoked cigarettes until recently.
Sexual Orientation: The patient is straight.
Nutrition History: The patient consumes four meals every day, including cobb salad twice and nachos, rice, Philly cheesesteak, nachos, and barbecue ribs on the other occasions. She is currently not on a diet.
Subjective Data
Chief Complaint: It is difficult to stop drinking water and urinating, but I eagerly await the results.
Symptom Analysis/HPI: She has been reporting that she cannot drink water and simultaneously has difficulty urinating. Upon learning that the condition is accompanied by a desire to eat more, the 57-year-old patient explains that her son has been the source of her illness for the past month. She claims she is not experiencing any discomfort or symptoms. The patient complains of blurred vision and has sores on the left foot that heal slowly. Ashley reports an increase in appetite and urinary frequency. However, tests have been conducted, and Ashley is here to hear the outcomes.
Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states…..)
Constitutional: Ashley reports experiencing rapid weight loss over the last several months. The patient denies having a fever. The patient reports experiencing fatigue.
Neurologic: Ashley denies having regular headaches, walking balance issues, unconsciousness, and altered sensations. The patient reports that she has been suffering hazy vision and spells of visual loss in recent months.
HEENT: Head: No head injuries and no changes in LOC status. Eyes: Ashley claims to have clear eyesight. Ear: Drainage and hearing are also typical. Nose: She reports that her nose has no congestion or obstruction. Throat: Ashley also states that she does not feel any discomfort in her throat and neck and swallows normally.
Respiratory: The patient denied breathing problems, reported regular night sweats, refuted persistent wheezing and coughing, denied a history of TB, and denied vomiting blood.
Cardiovascular: The patient denied having abnormal heartbeats, reported no sinus issues, denied having chest discomfort, and indicated that she had been suffering intermittent foot swelling and walking difficulties.
Gastrointestinal: The patient denied having acid heartburn and indicated she was intolerant to particular meals, particularly sugary drinks and foods. The patient reported having diarrhea. Additionally, the patient denied vomiting, claimed constipation, and denied wetness and blood in the stool.
Genitourinary: The patient reported frequent urinating but denied experiencing impotence or discomfort during urination.
Musculoskeletal: The patient-reported shoulder and joint discomfort. The patient reported experiencing backache. The patient denied saying that she had joint deformities and edema.
Skin: The patient disputed hair loss and described a recurrent rash and skin blemishes. No itching was recorded, and the patient also started to notice skin changes.
Objective Data
Vital Signs: The patient's temperature was imbalanced. The blood pressure was 134/86 mmHg. The patient's heart rate was regular.
General Appearance: The patient seemed thin, and his eyes were scarlet.
Neurologic: The patient's mental condition was normal. There were no infections of the meninges, and the sensory exam was regular.
HEENT: A vision test found that the client could not see clearly, although the patient's hearing and mouth were normal.
Cardiovascular: Normal breathing indicated there was no congestive heart failure, and no cyanosis was observed,
Respiratory: It is easy to breathe, and there are no breathing difficulties; therefore, it is clear.
Gastrointestinal: Detection of gastroparesis at a preliminary phase.
Musculoskeletal: The patient's joints on both hands were swollen, and most were rigid.
Integumentary: Intact, no rashes or lesions, no jaundice or cyanosis.
Assessment
After attending a party one week before, the patient complained of joint discomfort and frequent urination that had begun a week earlier. The patient denies having chest discomfort and headaches. She also disputed difficulty eating and abnormal heartbeat