Diabetic ketoacidosis
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Jason, a 54-year-old man with a history of type 1 diabetes for 48 years, presents to the emergency room with abdominal pain, nausea, fatigue, and a fruity odor on his breath. His blood sugars have been elevated. His initial diagnosis is diabetic ketoacidosis, which is confirmed by blood tests showing high blood glucose, low pH and bicarbonate levels, and ketones in his blood and urine. Diabetic ketoacidosis occurs when blood sugars rise over 250mg/dl and the body breaks down fat and produces ketones due to lack of insulin. It can be life-threatening if untreated but with proper treatment of insulin and fluid replacement, the condition can be managed.
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A 45-year-old woman experienced heartburn, regurgitation, and coughing at night. Tests found low LES pressure, acid reflux, and esophagitis. She was prescribed medication and lifestyle changes but had minimal relief, so underwent surgery with no further symptoms.
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1Diabetes SOAP NoteName xxxxUnited State
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
...
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2. Initial investigations showed anemia, elevated inflammatory markers, and positive anti-gliadin antibodies. Endoscopy found patchy erythema in the esophagus, stomach, and colon.
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Abdominal Assessment Case Study SOAP Note
Subjective:
•CC: “My stomach hurts, I have diarrhea, and nothing seems to help.”
•HPI: JR, 47-year-old WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards.
•PMH: HTN, Diabetes, hx of GI bleed 4 years ago
•Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs
•Allergies: NKDA
•FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD
•Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)
Objective:
•VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs
•Heart: RRR, no murmurs
•Lungs: CTA, chest wall symmetrical
•Skin: Intact without lesions, no urticaria
•Abd: soft, hyperactive bowel sounds, pos pain in the LLQ
•Diagnostics: None
Assessment:
•Left lower quadrant pain
•Gastroenteritis
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
Analyze the subjective portion of the note. List additional information that should be included in the documentation.
Subjective Analysis
According to Ball et al, (2015) when treating a patient with generalized abdominal pain, it is important to collect a detailed subjective history of the pain in order to better narrow down possible differential diagnoses. Chief complaint needs to be “stomach hurts.” The HPI needs to include the timing and characteristics of abdominal pain, more information is needed about the history of the patient concerning the present condition (HPI) and the general health from the past, this could be achieved by asking more focused questions. More investigation into the diet of the patient and history before the condition should be inquired. In the scenario, in the subjective part of the SOAP note, more information is needed about the history of the patient concerning the present condition (HPI) and the general health from the past, this could be achieved by asking more focused questions. More investigation into the diet of the patient and history before the condition should be inquired. Also, additional information about any changes in appetite and bowel movements is also needed. The history of present illness should incorporate data like onset, duration, characteristics, exacerbating, and alleviating symptoms as it relates to abdominal pain. Location is one of the most critical questi ...
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Type 1 diabetes is caused by an autoimmune disorder where the body's immune system attacks and destroys the beta cells in the pancreas that produce insulin. It commonly develops in children and young adults. Diagnosis involves blood tests showing high blood sugar levels or the presence of glucose in the urine. Treatment requires lifelong insulin injections via syringes or insulin pumps to control blood sugar levels, as well as following a regulated diet and exercise plan. Without proper treatment, type 1 diabetes can be life-threatening.
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This document provides information about irritable bowel syndrome (IBS), including its pathophysiology, diagnosis, signs and symptoms, and treatment. IBS is classified as a functional disorder caused by altered gastrointestinal function rather than structural issues. It is related to visceral hypersensitivity and abnormal bowel motility. Diagnosis involves reviewing symptoms and ruling out other conditions through tests. Signs include abdominal pain, changes in bowel habits, bloating and gas. Treatment focuses on dietary changes like reducing trigger foods, stress management techniques, fiber intake, and medications in some cases.
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Diabetic ketoacidosis
- 1. Case Study: Diabetic Ketoacidosis Kimberly Schaible
- 2. Consider the Following Patient Jason is 54 year-old who has had Type 1 diabetes since he was 6 years-old. Recently, he has been experiencing vague abdominal pain and nausea but no vomiting. He presents today at the emergency room a distinct fruity odor on his breath and complains that his blood sugars have been elevated more than normal. He also appears pale and complains of being very tired.
- 3. What is Jason’s initial diagnosis? What tests would help verify this diagnosis?
- 4. Jason’s Blood Test Results
- 5. Case Study Diabetic Ketoacidosis is characterized by: Increased blood sugars over 250mg/dl Distinct fruity odor of breath Appear dehydrated and weak Vague abdominal pain Nausea and vomiting Increased thirst and urination
- 6. Lab Test Results Lab Tests: Metabolic Profile Low pH, low bicarbonate levels, low sodium levels, high glucose levels, high potassium levels, high creatine/BUN, high anion gap Complete Blood Count (CBC) Normal to elevated white blood cell count, elevated hemoglobin level
- 7. Lab Test Results Serum Ketone Test Positive HgbA1c Normal to elevated (indicator of how diabetes is being controlled) Arterial pH Low
- 10. How do you treat DKA?
- 12. How DKA Affects Me The case study patient, Jason, is actually my uncle. Both my aunt and uncle have Type 1 diabetes had have suffered diabetic ketoacidosis as a complication of their diabetes. If untreated, diabetic ketoacidosis can be life-threatening. However, with the right care and maintenance (of diabetes), the patient can treat diabetic ketoacidosis.