1 Diabetes SOAP Note Name xxxx United State University Course ::xxxx Professor xxxx Date xxxx Diabetes SOAP Note ID: Client's Initial: N.L. Age: 50; Race: Caucasian; Gender: Male; Date of Birth: Jan 1, 1972. He is unaccompanied and seems to be a reliable historian. Subjective CC: "I have been experiencing frequent urination, and fatigue" HPI: Patient is a 50-year-old man who arrives at the clinic complaining of frequent urination. Aside from the increased frequency of urination, other symptoms include thirst, hunger, and tiredness. He reports that the symptoms have been going on for about two months. He has a past medical history of hypertension, which was diagnosed last year 2021. He reports he has not had any other long-term illnesses or allergies. He also reports that he has not taken any medication that have made his condition worse or helped. He reports drinking alcohol occasionally about 2 bottles of beer in a week. He denies any burning or pain while urinating, denies fever or chills. Past Medical History: · Medical Problem: Hypertension · Surgeries: none · Allergies: No known allergies · Immunization: Fully immunized · Current Medications: Lisinopril 10 mg po daily for Blood pressure Family History: Mother, age 78, has diabetes Father, age 80, diseased, with history of hypertension Brother, age 60, has diabetes Social History Living situation: He lives with his wife and 3 grandchildren in a safe environment. Occupation: He is a high school teacher Tobacco or marijuana use: Denies Alcohol use: Drinks 5 bottles of beer in a week. Diet: Vegan Exercise: Rare physical activity Review of System Constitutional: The patient reports fatigue. Denies chills or fever. Skin: Denies skin rashes, bruises, color changes, or lesions. HEENT: Head: No previous head injury reported. Eyes: Denies use of corrective lenses. No eye irritation, color blindness, dryness, or copious tears were reported. Ear: Denies experiencing hearing difficulties, ear pain, ear ringing, discharges, or hearing loss. Nose: No nosebleed, loss of smell, nasal congestion, or pain reported. Months/ throat: No bleeding gums or mouth wounds were reported. No sore throat and hoarseness were reported. Respiratory: Denies difficulties in breathing, wheezing, or coughing. Cardio: Denies chest pains but reports episodic heart palpitations Endocrine: Reports an increase in appetite and thirst. Musculoskeletal: Denies having joint pain, muscle pain, or swelling. Genitourinary: Denies discomforts when urination. Reports an increase in urination more often during the night. Neuro: Denies tremors, headaches, or dizziness. Psychiatric: Denies sleep disturbances or ideas of hurting himself, such as suicidal thoughts. Denies depression and anxiety Objective Vital Signs: Blood Pressure 138/89, Resp: 18, Heart rate: 88, Temperature 98.6 F, SpO2 100 Height 5'3" Weight 158lbs BMI 28.2. Physical Exam: General appearance: The patient is a nice looking 50-year-old Caucasian man who is ...

1. 1
Diabetes SOAP Note
Name xxxx
United State University
Course ::xxxx
Professor xxxx
Date xxxx
Diabetes SOAP Note
ID:
Client's Initial: N.L. Age: 50; Race: Caucasian; Gender: Male;
Date of Birth: Jan 1, 1972. He is unaccompanied and seems to
be a reliable historian.
Subjective
CC: "I have been experiencing frequent urination, and fatigue"
HPI: Patient is a 50-year-old man who arrives at the clinic
complaining of frequent urination. Aside from the increased
frequency of urination, other symptoms include thirst, hunger,
and tiredness. He reports that the symptoms have been going on
for about two months. He has a past medical history of
hypertension, which was diagnosed last year 2021. He reports
he has not had any other long-term illnesses or allergies.
He also reports that he has not taken any medication that have
made his condition worse or helped. He reports drinking alcohol

2. occasionally about 2 bottles of beer in a week. He denies any
burning or pain while urinating, denies fever or chills.
Past Medical History:
· Medical Problem: Hypertension
· Surgeries: none
· Allergies: No known allergies
· Immunization: Fully immunized
· Current Medications: Lisinopril 10 mg po daily for Blood
pressure
Family History:
Mother, age 78, has diabetes
Father, age 80, diseased, with history of hypertension
Brother, age 60, has diabetes
Social History
Living situation: He lives with his wife and 3 grandchildren in a
safe environment.
Occupation: He is a high school teacher
Tobacco or marijuana use: Denies
Alcohol use: Drinks 5 bottles of beer in a week.
Diet: Vegan
Exercise: Rare physical activity
Review of System
Constitutional: The patient reports fatigue. Denies chills or
fever.
Skin: Denies skin rashes, bruises, color changes, or lesions.
HEENT: Head: No previous head injury reported.
Eyes: Denies use of corrective lenses. No eye irritation, color
blindness, dryness, or copious tears
were reported.
Ear: Denies experiencing hearing difficulties, ear pain, ear
ringing, discharges, or hearing loss.
Nose: No nosebleed, loss of smell, nasal congestion, or pain
reported.
Months/ throat: No bleeding gums or mouth wounds were
reported. No sore throat and hoarseness were reported.
Respiratory: Denies difficulties in breathing, wheezing, or

3. coughing.
Cardio: Denies chest pains but reports episodic heart
palpitations
Endocrine: Reports an increase in appetite and thirst.
Musculoskeletal: Denies having joint pain, muscle pain, or
swelling.
Genitourinary: Denies discomforts when urination. Reports an
increase in urination more often during the night.
Neuro: Denies tremors, headaches, or dizziness.
Psychiatric: Denies sleep disturbances or ideas of hurting
himself, such as suicidal thoughts. Denies depression and
anxiety
Objective
Vital Signs:
Blood Pressure 138/89, Resp: 18, Heart rate: 88, Temperature
98.6 F, SpO2 100
Height 5'3" Weight 158lbs BMI 28.2.
Physical Exam:
General appearance: The patient is a nice looking 50-year-old
Caucasian man who is
conscious, oriented, and well-groomed
Head: normocephalic, symmetric, atraumatic
Ears: T.M. intact and pearly gray with the cone of light bilat.
Pinna clean, no exudate noted.
Eyes: Normal PERRLA findings. Anicteric sclera.
Nose: No maxillary sinuses, lesions, or bleeding. The mucous
membrane is moist.
Throat: No lesions, exudate, or inflammation.
Skin: Soft, warm, supple, and dry. There are no rashes,
bruising, or changes in skin color.
Cardiovascular: Normal S1 and S2 sounds. Irregular heartbeat.
Gastrointestinal: No palpable masses. Soft, non-distended, and
non-tender abdomen.
Respiratory: Lung auscultation indicates no abnormalities. No
wheezes

4. Musculoskeletal: No joints or muscles that are inflamed or stiff.
Extremities: No discernible edema.
Neurological: Gait is normal, and balance is stable. Clear
communication with a clear tone of
voice.
Psychiatric: He is cooperative, alert, and has a pleasant
disposition and conduct.
Assessment
Differential Diagnoses
Type 2 diabetes- (ICD-10-E11.65) This illness is characterized
by a reduction in beta cells in the pancreas of the patient, which
leads to high blood glucose (CDC, 2022b). The condition
typically manifests following the start of type I diabetes. The
primary signs and symptoms are blurred vision, excessive thirst,
weight loss, headaches, excessive urination, poor wound
healing, and numbness (CDC, 2022b). The patient's symptoms,
which include increased thirst, weariness, increase in urination,
and a family history of diabetes, make the possibility that this
diagnosis is the most likely.
Urinary tract infection (UTI) - (ICD-10-N39.0) This is an
infection that constitutes the kidneys, bladder, ureters, or
urethra (Cleveland Clinic, n.d.). These are the parts of the body
that urine goes through before leaving the body. Early
symptoms and indicators of a UTI are typically straightforward
to spot and mostly involve pain, irritation, or burning when
urinating (Cleveland Clinic, n.d.). This can be accompanied by
an urgent need to urinate, known as urinary urgency, or the need
to urinate frequently, known as urine frequency. Even though
the urge to urinate is strong, one may only pass a small volume
of urine. The urine may appear crimson or cloudy (Cleveland
Clinic, n.d.). As the patient reported frequent urination, we
deemed this a likely diagnosis. However, since no discharge or
pain has been reported, we rule out this possibility.
Nephrogenic diabetes insipidus (NDI) - (ICD-10-N25.1)
Patients with Nephrogenic Diabetes Insipidus are affected by an
imbalance in their water intake and output (Hoffman, 2020).

5. The body generally maintains a balance between fluid intake
and urine output. Patients with NDI produce increased thirst due
to polyuria (polydipsia) (Hoffman, 2020). Afflicted persons
might become dehydrated rapidly if they do not consume
enough water, especially during hot weather or while they are
ill. NDI can be inherited or acquired. There are some medicines
and chronic disorders that might cause the acquired form, and it
can happen at any time in life (Hoffman, 2020). Since the
patient reports symptoms of frequent urination, we
consider NID a plausible diagnosis; nevertheless, we deemed it
less likely due to the absence of family history that could have
indicated that the disease was inherited.
Plan
Diagnostic Tests
Hemoglobin A1C tests - are recommend in aid to confirm a
diagnosis of diabetes. The test can also be used to monitor
diabetes patients' blood sugar levels (Mayo Clinic, n.d.). A1C
test results show the average blood glucose level over the
previous 2 to 3 months (Mayo Clinic, n.d.). Particularly, the
A1C test evaluates the amount of sugar-coated hemoglobin
proteins in the blood. Hemoglobin is a protein that moves
oxygen around in red blood cells (Mayo Clinic, n.d.). The
greater the A1C score, the worse the blood sugar management
and the greater the chance of developing diabetic complications.
A test result of 6.5% or greater on two different occasions
implies diabetes (Mayo Clinic, n.d.). In this case, the HbA1C
level is 8.7%, and the 269 mg/dL blood sugar level.
A urinalysis - Urinalysis is a urine examination. It is used to
evaluate a variety of conditions, including urinary tract
infections or diabetes (Cleveland Clinic, n.d.). A urinalysis
examines the color, concentration, and composition of urine.
For example, if someone has an infection in the urinary tract,
the urine might appear cloudy instead of clear. Elevated protein
levels in the urine can imply renal dysfunction (Cleveland
Clinic, n.d.). Lab findings reveal negative results for ketones,
1+ protein

6. Final diagnosis Diabetes type II (ICD-10-E11.65) Elevated A1C
and family history of diabetes.
Treatment
Metformin is commonly used as the initial treatment for type 2
diabetes. Primarily, it reduces glucose synthesis in the liver and
increases insulin sensitivity, allowing the body to utilize insulin
more efficiently (Lv & Guo, 2020).
The patient is prescribed to take metformin 500 mg twice a day
with meals.
Continue with his prescribed Lisinopril 10 mg orally once daily
for the treatment of high blood pressure.
Patient Education
Stop drinking alcohol. Depending on the amount of alcohol
consumed and whether or not the food was consumed at the
same time, the effects of alcohol on blood sugar can range from
normal to dangerously high. Diabetic patients are recommended
to reduce their intake of alcohol or stop drinking alcohol (Mayo
Clinic, 2022).
Take responsibility for diabetes management. The patient is
educated to be sure to include healthy food and exercise in
every aspect of life. Start exercise plan of walking at least 3
times a week and gradually increase as tolerated to 30 mins.
Exercise should be avoided if fasting blood sugar is more than
250 mg/gl. Keep the weight in a good range. Keep an eye on the
blood sugar levels and keep a record of daily fasting sugar for
the next visit. Follow the healthcare provider's advice on how to
keep them in check. Take the medication as prescribed, review
hyperglycemic/hypoglycemic signs and symptoms and advice on
what to do (Mayo Clinic, 2022).
Referral – Referred to a diabetic educator and dietitian who will
guide on the best nutrition plan for diabetic control.
Follow up - After 30 days, the patient is recommended to come
back for a check-up visit, which will assist evaluate his signs
and symptoms, the effect of the treatment, blood pressure, and
glucose levels.

7. References
CDC. (2022a). Diabetes risk factors. Centers for Disease
Control and Prevention.
https://www.cdc.gov/diabetes/basics/risk-factors.html
CDC. (2022b, March 2). What is diabetes? Centers for Disease
Control and Prevention.
https://www.cdc.gov/diabetes/basics/diabetes.html
Cleveland Clinic. (n.d.). Urinalysis: What It Is, Purpose, Types
& Results.
https://my.clevelandclinic.org/health/diagnostics/17893-
urinalysis
Hoffman, M. (2020). An Overview of Nephrogenic Diabetes
Insipidus. WebMD.
https://www.webmd.com/diabetes/nephrogenic-diabetes-
insipidus-symptoms-causes-and-treatments
Lv, Z., & Guo, Y. (2020). Metformin and its benefits for
various diseases. Frontiers in Endocrinology, 11, 191.
https://doi.org/10.3389/fendo.2020.00191
Mayo Clinic. (n.d.). A1C test. Mayoclinic.Org.
https://www.mayoclinic.org/tests-procedures/a1c-test/about/pac-
20384643
Mayo Clinic. (2022). Diabetes care: 10 ways to avoid
complications. Mayo Clinic.
https://www.mayoclinic.org/diseases-conditions/diabetes/in-
depth/diabetes-management/art-20045803
WebMD. (n.d.). Lisinopril oral: Uses, side effects, interactions,
pictures, warnings & dosing - WebMD. Webmd.Com.
https://www.webmd.com/drugs/2/drug-6873-1785/lisinopril-
oral/lisinopril-solution-oral/details