Assignment:Focused SOAP Note on Diabetes Mellitus Type 2

Assignment:Focused SOAP Note on Diabetes Mellitus Type 2

Assignment:Focused SOAP Note on Diabetes Mellitus Type 2

Focused SOAP Note on Diabetes Mellitus Type 2
Patient Information:
Patient Initials: B. C Age: 48 Gender: Male Race: African American
Subjective Data:
Chief Complaint (CC): The patient presents with complaints of decreased sensation in the toes of the left foot and numbness with tingling in the heel of the right foot.
History of Present Illness (HPI):
Mr. B.C., a 48-year-old African American male with a history of type 2 diabetes, presents with complaints of decreased sensation in the toes of the left foot and numbness with tingling in the heel of the right foot that started about six months ago and progressively worsened over time. He reports that the sensation is like pins and needles, and sometimes it feels like his feet are burning or freezing. The patient also complains of difficulty walking and balance problems, as he has noticed that his feet are weakening, and he has started to stumble more often. He denies any recent trauma or injury to his feet, and there is no family history of similar symptoms. The patient reports that he has been managing his diabetes with diet and exercise, and he takes metformin daily. He has not been monitoring his blood glucose levels regularly but denies any recent changes in his medication regimen.
Current Medications:
Metformin 500 mg orally once daily for two years to manage diabetes mellitus type 2.
Allergies:
No known drug or food allergy.
Past Medical History (PMHx):
The patient’s medical history included admission to manage hyperglycaemic hyperosmolar non-ketotic syndrome (HHNS) one year ago.
Social History (Soc Hx):
The patient, Mr. B.C., works as an accountant at XYZ Bank and lives with his spouse and two children. They reside in a secure neighborhood with reliable transportation, low health risks, and financial stability. Their modern apartment is equipped with advanced technology, including smoke detectors. Mr. B.C takes necessary precautions while driving, such as refraining from using his cell phone and not driving under the influence of alcohol. He reports occasional alcohol consumption during special events, like birthdays and anniversaries, but denies tobacco use. Mr. B.C has a strong support system, which includes his colleagues at work and occasional visits from his parents.
Family History Fam Hx:
Mr. B.C is the eldest child in his family, having a younger sister who is alive and in good health. His parents are both alive, with his mother undergoing treatment for type 2 diabetes mellitus while his father is managing his hypertension.
Sexual History:
He is sexually active. No erectile dysfunction or pain during coitus.
Health Maintenance: Eats healthy diet, physically active.
Immunization History: The patient is compliant with all immunizations. The last one is the Covid-19 vaccine booster he received in February of this year.
Review of Systems (ROS):
General Appearance:
Mr. B.C. is an African American male who is well-groomed and kept. He weighs 85 kilograms and reports no weight loss. He is well nourished with no scars on his face but looks worried.
HEENT:
Eyes: No loss of vision, blurred vision, diplopia, painful eyes, or jaundice.
Ears, Nose, Throat: The patient reported having no hearing problems, sneezing, congestion, runny nose, or sore throat. He has not experienced any incidences of nosebleeding or nasal polyps in the recent past, nor has he had any sinus infections. Additionally, he has not experienced any difficulty chewing or swallowing, and there have been no signs of gingivitis or bleeding gums.
Cardiovascular: No palpitations, chest discomfort, murmurs, or lower limb edema. Capillary refill time is less than 2 seconds.
Respiratory: No shortness of breath, cough, or sputum
Gastrointestinal: No abdominal pain, anorexia, nausea, vomiting, or diarrhea.
Genitourinary: Sometimes experience polyuria, no urinary or bowel incontinence.
Neurological: Reports complaints of decreased sensation in the toes of the left foot and numbness with tingling in the heel of the right foot. No headache, dizziness, or syncope.
Musculoskeletal: Decreased range of motion, muscle weakness.
Hematological: No bleeding, bruising, or anemia.
Lymphatics: Enlarged and palpable lymph nodes.
Psychiatric: No history of mental illnesses such as depression or anxiety.
Endocrinology: No cold or heat intolerance, occasional polyuria, or polydipsia.
Allergies: No known allergies, no history of rhinitis, hives, or asthma
Skin/hair/nails: The skin appears normal with no rashes or itching, and the hair is evenly distributed across the scalp with no signs of hair loss. The nails are intact without clubbing.
Objective Data:
Physical Exam:
Vital Signs: B/P: 121/68mmHg, P-78b/min, T- 97.9F, RR- 18b/min, Weight- 85 kg.
General: Mr. B.C. is an African American male who is well-groomed and kept. He weighs 85 kilograms and reports no weight loss. He is well nourished with no scars on his face but looks worried.
HEENT:
Eyes: No loss of vision, blurred vision, diplopia, painful eyes, or jaundice.
Ears, Nose, Throat: The patient reported having no hearing problems, sneezing, congestion, runny nose, or sore throat. He has not experienced any incidences of nosebleeds or nasal polyps in the recent past, nor has he had any sinus infections. Additionally, he has not experienced any difficulty chewing or swallowing, and there have been no signs of gingivitis or bleeding gums.
Neck: No thyromegaly, no bruits on carotids.
Chest/Lungs: No rhonchi or wheezes.
Heart/Peripheral Vascular: Capillary refill less than 2 minutes. No murmurs, rub, or gallop.
Abdomen: Symmetrical
Genital/Rectal: Normal size, shape, and consistency without lumps or masses.
Musculoskeletal: Decreased range of motion, muscle weakness
Neurological: Numbness, tingling, and reflex changes.
Skin: No rashes or itching
Diagnostic results: Nerve conduction studies (NCS), Electromyography (EMG) and Ankle-brachial index (ABI) testing
Assessment:
Differential Diagnoses:
1. Diabetic neuropathy
2. Peripheral arterial disease
3. Lumbar spinal stenosis
4. Multiple sclerosis
5. Vitamin B12 deficiency
Based on the patient’s presenting symptoms of decreased sensation in the toes of the left foot and numbness with tingling in the heel of the right foot, the differential diagnosis could include diabetic neuropathy, peripheral arterial disease, lumbar spinal stenosis, multiple sclerosis, and vitamin B12 deficiency. Diabetic neuropathy is a common complication of diabetes mellitus and can damage the nerves, resulting in symptoms such as numbness and tingling in the feet (Yang et al., 2020). Peripheral arterial disease can also cause similar symptoms due to reduced foot blood flow. Lumbar spinal stenosis can cause weakness and difficulty walking due to pressure on the nerves in the lower back (Zemaitis et al., 2019). Multiple sclerosis is a neurological condition that can cause various symptoms, including numbness, tingling, and limb weakness. Vitamin B12 deficiency can cause peripheral neuropathy, leading to numbness and tingling in the feet, among other symptoms. Further evaluation, including a physical exam and diagnostic tests, may be necessary to determine the underlying cause of the patient’s symptoms.
In addition to the differential diagnosis, the patient’s medical history of type 2 diabetes, history of hyperglycemic hyperosmolar non-ketotic syndrome (HHNS), and current metformin medication should be considered. Poorly controlled diabetes can lead to nerve damage, making the patient more susceptible to developing diabetic neuropathy. The patient’s history of HHNS may suggest poor diabetes control and the need for closer monitoring of blood glucose levels. Furthermore, metformin is a medication commonly used to manage type 2 diabetes, but it can also cause vitamin B12 deficiency, which may need further evaluation in this patient (Kim et al., 2019).
Based on the patient’s history and presenting symptoms, physical exams and diagnostic tests appropriate for Mr. B.C. would be focused on confirming the diagnosis of diabetic neuropathy. The physical exam should include testing for sensory deficits and muscle weakness in the lower extremities, with particular attention to the feet (Einarson et al., 2020). It is essential to assess the patient’s gait and balance, as he reports difficulty walking and frequent stumbling. Diagnostic tests that would be useful in this situation include nerve conduction studies (NCS), electromyography (EMG), and ankle-brachial index (ABI) testing to evaluate arterial blood flow to the feet. A1C levels and fasting blood glucose should be measured to assess blood glucose control over the previous three months.

References
Einarson, T. R., Acs, A., Ludwig, C., & Panton, U. H. (2020). Prevalence of cardiovascular disease in type 2 diabetes: A systematic literature review of scientific evidence from across the world in 2007–2017. Cardiovascular Diabetology, 17(1). https://doi.org/10.1186/s12933-018-0728-6
Kim, J., Ahn, C. W., Fang, S., Lee, H. S., & Park, J. S. (2019). Association between metformin dose and vitamin B12 deficiency in patients with type 2 diabetes. Medicine, 98(46), e17918. https://doi.org/10.1097/md.0000000000017918
Yang, H., Sloan, G., Ye, Y., Wang, S., Duan, B., Tesfaye, S., & Gao, L. (2020). A new perspective in diabetic neuropathy: From the periphery to the brain, a call for early detection, and precision medicine. Frontiers in Endocrinology, p. 10. https://doi.org/10.3389/fendo.2019.00929
Zemaitis, M. R., Boll, J. M., & Dreyer, M. A. (2019, June 28). Peripheral arterial disease. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430745/

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CASE STUDY

A 48year old male with a history of diabetes mellitus type 2 complaints of not being able to feel his toes in the left foot. He also complains of numbness in the heel of the right foot and a tingling sensation.

Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.

Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.

With regard to the case study you were assigned:

Review this week’s Learning Resources, and consider the insights they provide about the case study.

Consider what history would be necessary to collect from the patient in the case study you were assigned.

Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?

Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

THE CASE STUDY ASSIGNMENT

Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.