(Student Name) Miami Regional University Date of Encounter: Preceptor/Clinical Site: Clinical Instructor: Soap Note # Main Diagnosis Diabetes Mellitus type 2 PATIENT INFORMATION Name: Mr. ET Age: 56-year-old Gender at Birth: Female Gender Identity: Female Source: Patient Allergies: Penicillins Current Medications: · Multi-Vitamin Centrum Silver · Lisinopril 10 mg daily · PMH: HTN Diabetes mellitus type 2 Immunizations: Preventive Care: Coloscopy 3 years ago (Negative) Surgical History: laparoscopic cholecystectomy Family History: Father alive Mother-alive, 90 years old, Diabetes Mellitus, HTN Daughter-alive, 21 years old, healthy Social History: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, she lives alone. Sexual Orientation: Straight Nutrition History: Diets off and on Subjective Data: Chief Complaint: “I cannot stop to drink water and to pee, I need to see my labs” Symptom analysis/HPI: The patient is 56 years old female who complaining of she cannot stop to drink water and to pee. Patient noticed the problem started 1 month ago and sometimes it is accompanied by anxious for eat. She states that she has been under stress because her daughter for the last month. Patient denies pain, or another symptom. She makes some labs and coming to see the results. Review of Systems (ROS) CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures. HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing. RESPIRATORY: Patient denies shortness of breath, cough or hemoptysis. CARDIOVASCULAR: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal dyspnea. GASTROINTESTINAL: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or diarrhea. GENITOURINARY: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence. MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound. SKIN: No change of coloration such as cyanosis or jaundice, no rashes or pruritus. Objective Data: VITAL SIGNS and Lab valuesTemperature: 97.5 °F, Pulse: 84, BP: 142/82 mmhg, RR 20, PO2-98% on room air, Ht- fill, Wt fill lb, BMI 37.2. No report pain 0/10. HbA1C 9.5 %. Serum creatinine 1.2 mg/dl, add more GENERAL APPREARANCE: The patient is alert and oriented x 3. No acute distress noted. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5. HE.

1. (Student Name)
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor:
Soap Note # Main Diagnosis Diabetes Mellitus type 2
PATIENT INFORMATION
Name: Mr. ET
Age: 56-year-old
Gender at Birth: Female
Gender Identity: Female
Source: Patient
Allergies: Penicillins
Current Medications:
· Multi-Vitamin Centrum Silver
· Lisinopril 10 mg daily
· PMH: HTN
Diabetes mellitus type 2
Immunizations:
Preventive Care: Coloscopy 3 years ago (Negative)
Surgical History: laparoscopic cholecystectomy
Family History: Father alive
Mother-alive, 90 years old, Diabetes Mellitus,
HTN
Daughter-alive, 21 years old, healthy
Social History: No smoking history or illicit drug use,
occasional alcoholic beverage consumption on social
celebrations. Retired, widow, she lives alone.
Sexual Orientation: Straight
Nutrition History: Diets off and on
Subjective Data:

2. Chief Complaint: “I cannot stop to drink water and to pee, I
need to see my labs”
Symptom analysis/HPI:
The patient is 56 years old female who complaining of she
cannot stop to drink water and to pee. Patient noticed the
problem started 1 month ago and sometimes it is accompanied
by anxious for eat. She states that she has been under stress
because her daughter for the last month. Patient denies pain, or
another symptom. She makes some labs and coming to see the
results.
Review of Systems (ROS)
CONSTITUTIONAL: Denies fever or chills. Denies weakness or
weight loss. NEUROLOGIC: Headache and dizziness as
describe above. Denies changes in LOC. Denies history of
tremors or seizures.
HEENT: HEAD: Denies any head injury, or change in LOC.
Eyes: Denies any changes in vision, diplopia or blurred vision.
Ear: Denies pain in the ears. Denies loss of hearing or drainage.
Nose: Denies nasal drainage, congestion. THROAT: Denies
throat or neck pain, hoarseness, difficulty swallowing.
RESPIRATORY: Patient denies shortness of breath, cough or
hemoptysis.
CARDIOVASCULAR: No chest pain, tachycardia. No orthopnea
or paroxysmal nocturnal
dyspnea.
GASTROINTESTINAL: Denies abdominal pain or discomfort.
Denies flatulence, nausea, vomiting or diarrhea.
GENITOURINARY: Denies hematuria, dysuria or change in
urinary frequency. Denies difficulty starting/stopping stream of
urine or incontinence.
MUSCULOSKELETAL: Denies falls or pain. Denies hearing a
clicking or snapping sound.
SKIN: No change of coloration such as cyanosis or jaundice, no
rashes or pruritus.

3. Objective Data:
VITAL SIGNS and Lab valuesTemperature: 97.5 °F, Pulse: 84,
BP: 142/82 mmhg, RR 20, PO2-98% on room air, Ht- fill, Wt
fill lb, BMI 37.2. No report pain 0/10.
HbA1C 9.5 %.
Serum creatinine 1.2 mg/dl, add more
GENERAL APPREARANCE: The patient is alert and oriented x
3. No acute distress noted. NEUROLOGIC: Alert, CNII-XII
grossly intact, oriented to person, place, and time. Sensation
intact to bilateral upper and lower extremities. Bilateral UE/LE
strength 5/5.
HEENT: Head: Normocephalic, atraumatic, symmetric, non-
tender. Maxillary sinuses no tenderness. Eyes: No conjunctival
injection, no icterus, visual acuity and extraocular eye
movements intact. No nystagmus noted. Ears: Bilateral canals
patent without erythema, edema, or exudate. Bilateral tympanic
membranes intact, pearly gray with sharp cone of light.
Maxillary sinuses no tenderness. Nasal mucosa moist without
bleeding. Oral mucosa moist without lesions,. Lids non-
remarkable and appropriate for race.
Neck: supple without cervical lymphadenopathy, no jugular vein
distention, no thyroid swelling or masses.
CARDIOVASCULAR: S1S2, regular rate and rhythm, no
murmur or gallop noted. Capillary refill < 2 sec.
RESPIRATORY: No dyspnea or use of accessory muscles
observed. No egophony, whispered pectoriloquy or tactile
fremitus on palpation. Breath sounds presents and clear
bilaterally on auscultation.
GASTROINTESTINAL: No mass or hernia observed. Upon
auscultation, bowel sounds present in all four quadrants, no
bruits over renal and aorta arteries. Abdomen soft non-tender,
no guarding, no rebound no distention or organomegaly noted
on palpation

4. MUSKULOSKELETAL: No pain to palpation. Active and
passive ROM within normal limits, no stiffness.
INTEGUMENTARY: intact, no lesions or rashes, no cyanosis or
jaundice.
ASSESSMENT:
Main Diagnosis: Diabetes mellitus type 2 explain why
Obesity, HTN
Differential diagnosis: Put 3 and explain
PLAN: Metformin 500 mg one tablet daily in addition to daily
style modifications. This dose can be increased to twice daily as
needed or as tolerated every 1 o 2 weeks, until a maximum of 2
grams daily.
Hydrochlorothiazide (thiazide diuretic) 1 tablet daily added to
the treatment for HTN to better control.
Labs and Diagnostic Test to be ordered:
· CMP
· Complete blood count (CBC)
· Lipid profile
· Liver function test (because the metformin requires routine
monitoring)
· Serum creatinine
· Potassium because the ACE inhibitors requires monitoring of
electrolytes
· Urinalysis with Micro
· Electrocardiogram (EKG 12 lead)
· Urine to monitor ketone and glucose
Pharmacological treatment:
· Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally
once daily.
· Lisinopril 10mg PO Daily
· Metformin tab 500 mg one tablet daily.
Non-Pharmacologic treatment:

5. · Weight changes must be done to manage better the Diabetes
· Healthy diet (DASH dietary pattern): Diet rich in fruits,
vegetables, whole grains, and low-fat dairy products with
reduced content of saturated and trans l fat
· Reduced intake of dietary sodium: <1,500 mg/d is optimal
goal but at least 1,000 mg/d reduction in most adults
· Enhanced intake of dietary potassium
· Exercises must be done at least 3 times per week like:
walking, swimming or running
· Measures to release stress and effective coping mechanisms.
Education
· Provide with nutrition/dietary information.
· To avoid GI side effects, take the Metformin with foods.
· Instruction about medication intake compliance.
· Avoid drinking alcohol: Alcohol has a negative interaction
with Metformin and contribute to hyperglycemia.
· Education of possible complications of Diabetes such as
stroke, heart attack, and other problems.
· Educate to the importance to foot examination and to choose
diabetes footwear.
Follow-ups/Referrals
· Follow up appointment 1 weeks for managing blood sugars: It
is important to target levels of A1C less than 7 %, so labs will
be every 3 months.
· Follow up nutritionist to…..
References(acerca de la enfermedad y el tratamiento, en
alfabetico orden, en APA