Hyperglycemia SOAP Note – Nurse Practitioner SOAP Note

Hyperglycemia SOAP Note – Nurse Practitioner SOAP Note

Subjective:

CC (Chief Complaint):
47-year-old African American female presents with complaints of fatigue, excessive thirst, and frequent urination over the past two weeks. She also reports intermittent blurry vision and occasional dizziness.

HPI:

• Onset: Symptoms started gradually approximately two weeks ago.
• Duration: Persistent, occurring daily.
• Character:
  • Increased thirst (polydipsia) and urination (polyuria).
  • Fatigue and occasional dizziness.
  • Reports feeling weak and sluggish.
  • Occasional nausea but no vomiting.
  • Intermittent blurry vision, particularly in the mornings.
  • Admits to increased carbohydrate intake due to work stress.
• Aggravating Factors: High-carb meals, lack of physical activity.
• Relieving Factors: Drinking water, resting.
• Blood Sugar Control:
  • Patient has a history of prediabetes but was not on medication.
  • Recent home glucose readings: 190-250 mg/dL (fasting).
  • No history of prior diabetic ketoacidosis (DKA).

Past Medical History:

• Prediabetes (diagnosed 2 years ago, previously managed with diet & exercise).
• Obesity (BMI 32.8 kg/m²).
• Hypertension (diagnosed 5 years ago, on medication).

Current Medications:

• Lisinopril 10 mg daily (for hypertension).
• Multivitamin daily.

Allergies:

• No known drug allergies.

ROS:

• GENERAL: Reports increased thirst, fatigue, and dizziness.
• HEENT: Intermittent blurry vision, no headaches.
• CARDIOVASCULAR: No chest pain, no palpitations.
• RESPIRATORY: No shortness of breath or cough.
• GASTROINTESTINAL: Reports mild nausea and no vomiting.
• GENITOURINARY: Increased urination, no dysuria or hematuria.
• MUSCULOSKELETAL: No joint pain or swelling.
• NEUROLOGICAL: Reports mild dizziness and no focal neurological deficits.
• ENDOCRINOLOGIC: Reports increased hunger and dry mouth.

Objective:

Vital Signs:

• BP: 136/84 mmHg
• HR: 82 bpm
• RR: 18 bpm
• Temp: 98.5°F
• O2 Sat: 98% on room air
• Weight: 212 lbs (BMI 32.8 kg/m² – Obese)

Physical Examination:

• General: Alert, cooperative, appears fatigued.
• HEENT: No signs of dehydration, no icterus, no retinopathy.
• Cardiovascular: Normal heart sounds, no murmurs.
• Respiratory: Clear to auscultation bilaterally.
• Abdomen: Soft, non-tender, no hepatosplenomegaly.
• Neurological: Normal reflexes, intact sensation in extremities.
• Skin: No ulcers, no signs of infection.

Laboratory Results (Today’s Visit):

• Random Glucose: 245 mg/dL (elevated)
• HbA1c: 9.1% (consistent with new-onset diabetes)
• Serum Osmolality: 295 mOsm/kg (mildly elevated)
• Urine Ketones: Negative
• Serum Electrolytes:
  • Sodium: 136 mmol/L
  • Potassium: 4.1 mmol/L
  • Bicarbonate: 24 mmol/L
• Creatinine: 1.0 mg/dL (normal kidney function)

Assessment:

Primary Diagnosis:

🩺 E11.65 – Type 2 Diabetes Mellitus with Hyperglycemia

• Rationale:
  • Patient presents with classic symptoms of hyperglycemia (polydipsia, polyuria, fatigue, blurry vision).
  • Fasting blood glucose >126 mg/dL and HbA1c >6.5% confirm the diagnosis of new-onset Type 2 Diabetes Mellitus.
  • No signs of diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS), making the primary diagnosis uncontrolled Type 2 Diabetes with hyperglycemia rather than an acute metabolic crisis.

Differential Diagnoses & Rationale:

1. E13.65 – Other Specified Diabetes Mellitus with Hyperglycemia
   • Used if this was a case of secondary diabetes (e.g., from corticosteroid use or pancreatic dysfunction), which is not the case here.
2. E11.9 – Type 2 Diabetes Mellitus Without Complications
   • This code is not selected because the patient presents with symptomatic hyperglycemia, which is a complication requiring intervention.
3. R73.09 – Other Abnormal Glucose
   • Used for prediabetes or stress-induced hyperglycemia. Not applicable, as the patient now meets full diabetes criteria.
4. E11.21 – Type 2 Diabetes Mellitus with Diabetic Nephropathy
   • Not selected since urine microalbumin is normal, and there is no evidence of kidney dysfunction.
5. E11.40 – Type 2 Diabetes Mellitus with Diabetic Neuropathy
   • Ruled out as there are no significant neuropathic symptoms at this time.

Plan (Treatment & Rationale):

1. Medication Initiation:

• Start Metformin 500 mg PO BID (gradual titration to 1000 mg BID).
  • Rationale: First-line therapy for Type 2 Diabetes. It improves insulin sensitivity, and lowers glucose production.
• Consider adding GLP-1 receptor agonist (Semaglutide 0.25 mg weekly).
  • Rationale: Beneficial for weight loss and glucose control.

2. Lifestyle Modifications:

📌 Dietary Changes:

• Referral to a Registered Dietitian for Diabetes Medical Nutrition Therapy (MNT).
• Focus on low-carb diet, portion control, and balanced meals.

🏃 Exercise Plan:

• Goal: 150 minutes/week of moderate aerobic exercise (walking, swimming).
• Rationale: Increases insulin sensitivity and lowers blood glucose.

3. Hyperglycemia Monitoring & Patient Education:

• Blood glucose log (fasting & postprandial readings).
• Educate on signs of hyperglycemia & hypoglycemia.
• Emergency plan if glucose >300 mg/dL or signs of HHS/DKA occur.

4. Lab Monitoring & Follow-Up:

📌 Repeat labs in 3 months:

• HbA1c, fasting glucose, lipid panel, urine microalbumin.

📌 Follow-up in 4 weeks:

• Assess medication adherence, glucose trends, side effects.
• Consider medication adjustment if fasting glucose >200 mg/dL after 1 month.

5. Referral Considerations:

• Diabetes Education Program for self-management skills.
• Ophthalmology referral for annual retinal exam.

Preceptor Verification:

I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek-approved clinical site during this quarter course of learning