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Academic clinical SOAP note

Academic clinical SOAP note

 

History and Physical Note Template

Chief Complaint or Reason for Consult: “Disorientation and confusion.”

History of Present Illness (HPI): B.S. is a 38- year- old White male who was brought to the ED by paramedics after suddenly becoming disoriented and confused about an hour ago. The patient has Type I diabetes. The wife dialed 911 because she thought her husband had developed a stroke due to abrupt disorientation and confusion. About five hours before becoming disoriented, the patient had three vomiting episodes and reported abdominal pain. He then felt a generalized body weakness and became restless. The patient had taken an antacid to relieve the abdominal pain, but it had no effect.

 

Past Medical History:  Type I Diabetes, diagnosed at 7 years. Immunizations are up-to-date.

Past Surgical History: None.

Family History: The paternal grandmother had diabetes. The maternal grandfather died from a heart attack at 87 years. The father has COPD. The siblings are alive and well.

Social History: The patient is a high-school teacher with a Diploma in Education. He is married and has two children, 13 and 8 years. His hobbies are writing articles and watching athletics. He runs about 3 miles 3-4 days a week. He takes alcohol occasionally but denies smoking or using illicit substances.

Allergies: None.

Home Medications: Antacids.

Hospital Medications: Mixtard Insulin 40IU

Review of Systems:

CONSTITUTIONAL: Reports malaise and general body weakness. Denies fever, chills, or increased fatigue.

  • EYES: Denies double/blurred vision, eye pain, or teary eyes.
  • EARS, NOSE, and THROAT: Denies ear pain, discharge, sneezing, nasal discharge, sore throat, or voice hoarseness.
  • CARDIOVASCULAR: Denies edema, palpitations, chest pain, or dyspnea on exertion.

 

 

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  • RESPIRATORY: Denies chest pain, cough, wheezing, or sputum.
  • GASTROINTESTINAL: Positive for nausea, vomiting, and abdominal pain. Denies altered bowel patterns or rectal bleeding.
  • GENITOURINARY: Increased urine production. Denies dysuria, urinary incontinence, or penile discharge.
  • MUSCULOSKELETAL: Denies joint pain, stiffness, or muscle pain.
  • INTEGUMENTARY: Denies discoloration, rashes, or bruises.
  • NEUROLOGICAL: Positive for disorientation and confusion. Denies dizziness, fainting, tingling sensations, or muscle paralysis.
  • PSYCHIATRIC: Denies anxiety, depression, or mood disorders.
  • ENDOCRINE: Reports increased thirst and polyuria. Denies increased sweating or cold intolerance.
  • HEMATOLOGIC/LYMPHATIC: Denies bruises, delayed wound healing, or swollen lymph nodes.
  • ALLERGIC/IMMUNOLOGIC: Denies allergic reactions.

Physical Exam:

  • GENERAL APPEARANCE: The patient is a 38-year-old well-nourished White male. He is mildly disoriented and confused and appears ill and distressed.
  • VITAL SIGNS: BP-86/58; HR-122; Temp-98.4 RR- 28b/min; SPO2-98%;

WT- 158 pounds; HT-5’5

  • Head: Normocephalic and atraumatic. Eyes: Sclera is white; Conjunctiva is pink; PERRLA. Ears: Tympanic membranes are patent, transparent, and shiny. Nose: Acetone breath odor. Nares are patent. Throat: Dry mucous membranes. Patent Tonsillar glands. No exudates were seen.
  • NECK: Supple neck; Trachea is mid-line; Thyroid gland is normal.
  • CHEST: Very deep and rapid labored respirations
  • LUNGS: Lungs are clear on auscultation bilaterally. No wheezes, rhonchi, or rales.
  • HEART: No edema or neck vein distension; S1 and S2 normal on auscultation. No gallop sounds or systolic murmurs were heard.
  • BREASTS: No masses or lumps.
  • ABDOMEN: The abdomen is flat with normal pigmentation. BS are normoactive on all quadrants. Abdominal tenderness on palpation. No guarding or organomegaly.
  • GENITOURINARY: [Male]. Normal male genitalia. No penile plaques or genital skin lesions. The testicles are descended bilaterally with no masses or tenderness. Patent perineum.
  • RECTAL: [Male]. No rectal fissures; intact sphincter tone.
  • EXTREMITIES: Capillary refill time- 2 secs. No cyanosis or edema.
  • NEUROLOGIC: Normal gait and posture are normal. Muscle strength- 5/5; Decreased reflexes.
  • PSYCHIATRIC: Coherent speech and thought process. No delusions, hallucinations, obsessions, or suicidal thoughts.
  • SKIN: Dry skin, decreased skin turgor.
  • LYMPHATICS: Lymph nodes are non-palpable.

Laboratory and Radiology Results:

RBS- 270 mg/dL H

Ketones- ++

Serum pH- 7.10

HCO3- 15 mEq/L

Serum potassium- 3.2

Blood Urea Nitrogen (BUN) – Elevated

Creatinine- Elevated

Assessment:

·         Differential Diagnoses:

Type I diabetes mellitus with ketoacidosis (DKA) (ICD 10- E10. 10):  DKA is a complication of diabetes characterized by hyperglycemia, ketoacidosis, and ketonuria. It is diagnosed based on diagnostic findings of blood glucose >250mg/dL with the presence of ketones and a decreased serum bicarbonate level with an increased anion gap (Shahid et al., 2020). The patient presents with features of DKA like nausea, vomiting, abdominal pain, signs of dehydration, tachycardia, tachypnea, hypotensive state, Kussmaul respirations, polyuria, acute thirst, confusion, and disorientation (Shahid et al., 2020). Besides, a high RBS, presence of ketones, low pH, low bicarbonate levels, and elevated BUN and creatinine indicate DKA.

Hyperglycemic Hyperosmolar State (HHS) (ICD-10 code E08.00): HHS is a hyperosmolar state caused by hyperglycemia. It presents with similar features as DKA, like signs of dehydration, polyuria, polydipsia, weight loss, lethargy, and coma (Hassan et al., 2022). However, DKA is sudden, while HHS is gradual. HHS is a differential based on the patient’s findings of hyperglycemia, polyuria, polydipsia, and signs of dehydration. However, the patient’s symptoms were sudden, making HHS an unlikely diagnosis.

Acute Metabolic Acidosis (ICD-10: E87. 21): The patient presents with signs of acidosis like rapid, deep, and labored breathing, abdominal tenderness, disturbance of consciousness, low pH, and low bicarbonate levels.

  • Acute and Chronic Medical Conditions:

DKA

Acidosis

Dehydration

Type 1 Diabetes

Treatment Plan:

Medications:

1.      Fluid replacement with IV 0.9% saline to correct dehydration (Eledrisi & Elzouki, 2020).

The fluid replacement will be as follows:

i.            1L in the first 30 minutes

ii.            1L in the next hour

iii.            3L over the next 6 hours.

iv.            250 ml/hr till the fluid deficit is replaced.

v.            Dextrose will be added to saline when blood glucose levels reach 234-252 mg/dL (Eledrisi & Elzouki, 2020).

50 ml of 50% dextrose added to 450 ml saline administered every four hours.

2.      Regular (soluble) Insulin:

An initial IV bolus dose of 70 IU followed by an IV infusion of 70 IU every hour.

Continuous insulin infusion is indicated because of the 4-minute half-life of IV insulin, the delayed onset of action, and the prolonged half-life of subcutaneous regular Insulin (Evans, 2019).

3.      Potassium: Infusion of 10mEq KCl in 500 ml of IV fluid. This will be to correct electrolyte disturbance (Evans, 2019).

Health Education:

The patient will be educated to monitor blood glucose levels every 4 to 6 hours if he has symptoms like anorexia, nausea, and vomiting and if glucose levels are above 250 mg/dL (Eledrisi & Elzouki, 2020).

He will be educated to reduce the risk of dehydration by maintaining food and fluid intake by drinking at least 3 L of fluid daily. The amount of fluid taken should increase if he has an infection.

He will be advised to take fluids containing glucose and electrolytes if he has nausea.

Consultations: Consult an endocrinologist to assist with the management plan after stabilizing the patient.

Follow-up: A follow-up clinic visit after two weeks to assess the patient’s glycemic levels and evaluate for diabetes complications.

Geriatric Considerations:

DKA occurs most often in older patients with diabetes. Insulin noncompliance and comorbidities are the most common precipitating factors for DKA in geriatrics. Comorbidities often characterize the morbidity and mortality associated with DKA and are the hallmark of DKA in geriatric patients (Sehgal & Ulmer, 2019). In elderly patients, DKA is often complicated by sepsis, polypharmacy, atrial fibrillation, non-ketotic hyperosmolar states, atypical clinical presentations, acute kidney injury, dementia, and medication noncompliance. Thus, if the patient is geriatric, it would be necessary for the clinician to rule out comorbidities like infections, atrial fibrillation, kidney injury, and dementia (Sehgal & Ulmer, 2019). Furthermore, it would have been necessary to perform a medication review and reconciliation of the drugs the patient takes.

 

 

 

References

Eledrisi, M. S., & Elzouki, A. N. (2020). Management of Diabetic Ketoacidosis in Adults: A Narrative Review. Saudi Journal of Medicine & medical sciences, 8(3), 165–173. https://doi.org/10.4103/sjmms.sjmms_478_19

Evans, K. (2019). Diabetic ketoacidosis: update on management. Clinical medicine (London, England), 19(5), 396–398. https://doi.org/10.7861/clinmed.2019-0284

Hassan, E. M., Mushtaq, H., Mahmoud, E. E., Chhibber, S., Saleem, S., Issa, A., Nitesh, J., Jama, A. B., Khedr, A., Boike, S., Mir, M., Attallah, N., Surani, S., & Khan, S. A. (2022). Overlap of diabetic ketoacidosis and hyperosmolar hyperglycemic state. World Journal of clinical cases, 10(32), 11702–11711. https://doi.org/10.12998/wjcc.v10.i32.11702

Sehgal, V., & Ulmer, B. (2019). Clinical Conundrums in the Management of Diabetic Ketoacidosis in the Elderly. Journal of translational internal medicine, 7(1), 10–14. https://doi.org/10.2478/jtim-2019-0003

Shahid, W., Khan, F., Makda, A., Kumar, V., Memon, S., & Rizwan, A. (2020). Diabetic Ketoacidosis: Clinical Characteristics and Precipitating Factors. Cureus, 12(10), e10792. https://doi.org/10.7759/cureus.10792

 

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Important information for writing discussion questions and participation

Welcome to class

Hello class and welcome to the class and I will be your instructor for this course. This is a -week course and requires a lot of time commitment, organization, and a high level of dedication. Please use the class syllabus to guide you through all the assignments required for the course. I have also attached the classroom policies to this announcement to know your expectations for this course. Please review this document carefully and ask me any questions if you do. You could email me at any time or send me a message via the “message” icon in halo if you need to contact me. I check my email regularly, so you should get a response within 24 hours. If you have not heard from me within 24 hours and need to contact me urgently, please send a follow up text to

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Please, be advised I do NOT accept any assignments by email. If you are having technical issues with uploading an assignment, contact the technical department and inform me of the issue. If you have any issues that would prevent you from getting your assignments to me by the deadline, please inform me to request a possible extension. Note that working fulltime or overtime is no excuse for late assignments. There is a 5%-point deduction for every day your assignment is late. This only applies to approved extensions. Late assignments will not be accepted.

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Your initial discussion post should be a minimum of 200 words and response posts should be a minimum of 150 words. Be advised that I grade based on quality and not necessarily the number of words you post. A minimum of TWO references should be used for your initial post. For your response post, you do not need references as personal experiences would count as response posts. If you however cite anything from the literature for your response post, it is required that you cite your reference. You should include a minimum of THREE references for papers in this course. Please note that references should be no more than 5 years old except recommended as a resource for the class. Furthermore, for each discussion board question, you need ONE initial substantive response and TWO substantive responses to either your classmates or your instructor for a total of THREE responses. There are TWO discussion questions each week, hence, you need a total minimum of SIX discussion posts for each week. I usually post a discussion question each week. You could also respond to these as it would count towards your required SIX discussion posts for the week.

I understand this is a lot of information to cover in 5 weeks, however, the Bible says in Philippians 4:13 that we can do all things through Christ that strengthens us. Even in times like this, we are encouraged by God’s word that we have that ability in us to succeed with His strength. I pray that each and every one of you receives strength for this course and life generally as we navigate through this pandemic that is shaking our world today. Relax and enjoy the course!

Hi Class,

Please read through the following information on writing a Discussion question response and participation posts.

Contact me if you have any questions.

Important information on Writing a Discussion Question

  • Your response needs to be a minimum of 150 words (not including your list of references)
  • There needs to be at least TWO references with ONE being a peer reviewed professional journal article.
  • Include in-text citations in your response
  • Do not include quotes—instead summarize and paraphrase the information
  • Follow APA-7th edition
  • Points will be deducted if the above is not followed

Participation –replies to your classmates or instructor

  • A minimum of 6 responses per week, on at least 3 days of the week.
  • Each response needs at least ONE reference with citations—best if it is a peer reviewed journal article
  • Each response needs to be at least 75 words in length (does not include your list of references)
  • Responses need to be substantive by bringing information to the discussion or further enhance the discussion. Responses of “I agree” or “great post” does not count for the word count.
  • Follow APA 7th edition
  • Points will be deducted if the above is not followed
  • Remember to use and follow APA-7th edition for all weekly assignments, discussion questions, and participation points.
  • Here are some helpful links
  • Student paper example
  • Citing Sources
  • The Writing Center is a great resource