This document contains a SOAP note for a 48-year-old Hispanic male who presented with numbness in the soles of both feet for one week. The patient has a history of type 2 diabetes and hypertension. On examination, he had bilateral foot edema and loss of sensation in his feet. He was diagnosed with diabetic neuropathy and prescribed increased insulin and pain medication. He was referred for further testing and management of his diabetes and neuropathy.

1. Running head: SOAP: DM NEUROPATHY 1
SOAP: DM NEUROPATHY
Cherry B. Maglaya-Lee
Charles Drew University

2. SOAP: DM NEUROPATHY 2
CC: Numbness of soles of both feet of 1 week duration.
S: Case of a 48 y/o Hispanic male known diabetic and hypertensive, who came in for
consult due to numbness of his soles of one week duration. His condition started a month ago as
an itchy spot on the plantar aspect of the right foot for which he self-medicated with
Hydrocortisone cream. This is the first time he felt this sensation and therefore didn’t pay much
attention to it. Three weeks prior to this consult, he noticed a change from itchiness to tingling
sensation. At times he said, he would wake up in the middle of the night suffering from leg
cramps. He also noticed that his blood sugars tested thru his home Accucheck machine were a
little bit higher than usual ranging from 190 to 210 mg/dl but would go down towards the end of
the day. A week ago, he started feeling numbness on his soles. This was associated with edema.
He presented to the clinic with his wife feeling anxious and tired.
Pertinent (+2) bipedal edema, numbness, pain bilateral feet plantar aspect, nausea and vomiting,
weakness, leg cramps
Pertinent (-), exertional dyspnea, fever
Medications: Amaryl, ASA, Terazosin, Catapres, Hydrochlorthiazide, Verapamil,
Lisinopril, Glucophage, Lovastatin, Lantus 25units, Indocin, Clarinex, Albuterol, Protonix,
Robitussin DM
Drug Allergy: Vicodin, Tylenol Codeine
Past Medical History: Type II DM Since 2005, Hypertension, Hypercholesterolemia
Obesity
O: General: Well-nourished, well developed, obese, not in respiratory distress
Vitals: BP=160/82 Right arm sitting; P-94; R=20; T=98.6F; O2 Sat= 96% at Room Air;
Wt= 287 lbs; Ht.=5’ 8”; BMI=44

3. SOAP: DM NEUROPATHY 3
HEENT: Normocephalic, anicteric sclerae, pinkish palpebral conjunctivae, pupils 3 mm
equally reactive to light, no ear discharges, TM intact, no nasal septal deviation, nasal
turbinates congested and hyperemic, (-) tonsillopharyngeal congestion without exudates,
no thyroid enlargement
Heart: S1S2 audible, no murmur, regular heart rate and normal sinus rhythm
Lungs: No alar flaring, Equal vocal and tactile fremiti, Clear breath sounds
Extremities: (+2) bipedal edema, pitting, Motor strength 3/5 lower extremities
Skin: Dry, scaly on the lower extremities, no pressure ulcers, no pallor or cyanosis
Neurologic: Intact Cranial nerves, Hypoactive Deep tendon reflexes, (no sensation to
light touch on the plantar aspect of both feet.
A: DM Neuropathy
P:Dxtics: Accucheck; Labs: CBC, CMP, Uric Acid Level, HbA1c, Endocrine referral,
Podiatry referral.
Txtics: Increase Lantus to 30 units q HS, Tramadol 100 mg IM then 50 mg tab PO q 4 hrs
for pain as needed.
FNP Teaching: Strict Blood sugar control, Lifestyle and diet modification, Follow strict
low fat diet, 1800 ADA caloric diet, Good foot care, referral to podiatry, Advised to call
clinic if symptoms persist, Follow-up after 10 days.