(Student Name)
Miami Regional University
Date of Encounter:
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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 values Temperature: 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
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