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SOAP note on diabetes management
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RUNNING HEAD: SOAP note #1
Diabetes Mellitus Management
SOAP #1
Michael Thorn
September 16th, 2013
RUNNING HEAD: Soap Note #1
Objective:
History of Present Illness:
Patient is a 66-year-old Caucasian male here today for his 3-month follow
up for his diabetes mellitus management. He was diagnosed back in 2008
and has had issues in maintaining his blood sugars and changing his
lifestyle habits (diet and exercise). He checks his blood sugars on a
consistent basis and logs them appropriately. His A1C in May of this year
was 7.9. He currently is taking Metformin, Byetta, Lantus, and Novolog
for his DM II management. Patient is frustrated at this time because he has
to face the physician and go over his gain in weight and the need to
change medication management. He states that he has been trying to watch
his diet but has not been getting exercise in his daily life.
Patients log of recent blood sugars (10 days)
Blood Sugar Log Averages
Morning: 232 190 201 145 133 186 199 155 175 166
Noon: 175 169 210 132 178 240 112 90 142 178
Bedtime: 110 131 180 210 160 224 155 121 190 285
Past Medical & Surgical History:
Diabetes Mellitus – 2008
Hyperlipidemia – 1998
Hypertension – 1993
Left Knee Arthroplasty – 2010
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RUNNING HEAD: Soap Note #1
Obesity - 1990
Medications:
Metoprolol XL 100mg once daily
Lisinopril 20mg once daily
Aspirin 81mg once daily
Metformin 1000mg BID
Byetta 10mcg SQ BID
Lantus 25 units BID
Novolog 7u morning, 5u noon, 5 u afternoon
Atorvastatin 40mg once daily
Social History:
Retired metal fabricator from Honeywell. Married and has 3 children.
Socially active in the Lions Club and with the Boys & Girls Club. Drinks
2-3 beers two times a week.
Family History:
Father died at the age of 71 (COPD/Pneumonia)
Mother died at the age of 62 (ovarian cancer)
Brother living, 76, prostate cancer
Sister living, 69, COPD & Diabetes
Health Maintenance/Promotion:
Up to date in immunizations except influenza shot for this year. Performs
foot exams on a regular basis. Non-smoker. Does not exercise on a regular
basis. No financial issues with obtaining medications.
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RUNNING HEAD: Soap Note #1
Review of Systems:
General: has had a weight chance of +/- 10 pounds in the past 3 months,
appetite has increased, sleeping well with no report of
disturbances; exercise intolerance. Denies fever, chills, or sweats.
Skin: dryer skin than normal; no evidence of skin breakdown, denies
seeing any open wounds or ulcers
HEENT: no headaches or vision changes, does have unchanged bilateral
hearing loss corrected by hearing aids. Last eye exam November
2012. Denies difficulty with swallowing or drinking fluids.
CV: no report of chest pain, dyspnea, or palpitations. Denies pain or
cramping when walking. Most recent EKG was 2011
(unremarkable).
Lungs: no coughs or shortness of breath. Denies any recent respiratory
infections.
GI: denies nausea, vomiting, abdominal pain, or bloating. No heartburn
experienced; diet patterns have changed/appetite increased, having a daily
BM. No food intolerance and denies seeing blood in the stool.
GU: No increase in urgency; no incontinence. Denies having any flank
pain or seeing blood in his urine.
MSK: some left knee pain but not debilitating; no muscle cramping;
ambulates up ad lib.
Neuro: no report of near syncope, vertigo, falling, or weakness; denies any
tingling or numbness in his upper and lower extremities
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RUNNING HEAD: Soap Note #1
Endo: obese, no temperature intolerance, has noticed increase polyphagia
and polydipsia. No increase in nervousness.
Psych: no report of feeling depressed or anxious but is worried about
diabetes management.
Objective:
Physical Examination:
General: Patient is overweight, dressed appropriately for weather
conditions, nervous about meeting with physician because of his weight
gain; skin color consistent with ethnicity.
VS: BP 136/81, HR 59, RR 18, Sp02 97% on RA, Temp 36.6 BMI 27.2
Skin: No lesions noted. Skin intact, dry and warm, nails well trimmed and
no clubbing present. Bottom feet inspected with no evidence of skin
breakdown.
HEENT: lymph nodes nonpalpable; head atraumatic and normocephalic,
some balding, PERRLA, conjunctiva white in color, EOMI, red reflex
present, discs flat with sharp margins, no retinal hemorrhages present,
receding gums with tooth decay present.
CV: s1/s2 audible with no pathological auscultation; PMI with landmarks
Lungs: CTA, equal chest expansion, no evidence of cough; no
adventitious breath sounds.
Abd: Bowel sounds present in all 4 quadrants, no pain upon palpation
(both deep and soft) in all 4 quadrants, and no masses palpated (*Didn’t
check hepatosplenomegaly – will check next time*)
GU: not assessed
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RUNNING HEAD: Soap Note #1
Rectal: not assessed
PV: +2 pulses in upper and lower extremities; extremities normal
temperature with equal hair distribution; no edema present
MSK: full ROM in all extremities with some 2/10 pain upon extension of
the left knee
Neuro: steady gait, no neuropathy present in lower extremities,
monofilament and two-point discrimination negative for pathological
concerns from diabetes. Alert and oriented
Diagnostic Tests:
CBC/HematologyHemoglobin: 12.7Hematocrit: 46.8WBC (w/o diff): 9.1HgA1c: 8.2 (5/13 7.9)
Lipid Profile:Cholesterol: 236Triglycerides: 212HDL/LDL: 49/110
CMP:Na: 138K: 4.3Cl: 98BUN: 20Cr: 1.1Glucose (fasting): 168GFR: 92
Assessment & Plan
Diabetes: Patient has ongoing diabetes that needs treatment plan
modifications. Patient has been adhering to medication dosing but
has not been following dietary and lifestyle changes.
1. Patient will continue to monitor his blood sugars in the home setting.
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RUNNING HEAD: Soap Note #1
2. A refill will be made for the patient’s glucose strips.
3. Patient will follow up in 3months for his a1c and revaluation of
whether medications are effective
4. Byetta will be discontinued at this time. His blood sugars are not coming
within optimal range and his weight has been increasing. It appears that the
effectiveness of Byetta has tapered off and not giving the patient much of a
benefit anymore.
5. Because the patients A1C has not dropped and his blood sugars are
mainly running in the high 100’s, we will increase his Novolog insulin
regimen 10%. We will keep the Lantus at 25units BID but will increase the
Novolog 6units to 9-7-7.
6. We will initiate a sliding scale insulin regimen with the patient’s meals.
Patient has been given a sliding scale reference guide. Patient agrees to new
treatment plan and we will follow up in 2 weeks to see how the changes have
affected his blood sugar levels.
7. Patient is being referred to a dietitian for meal planning and
grocery shopping advice. Insurance covers the initial visit and we think it
would be beneficial to him. We think he needs some more intense conversation
on dietary changes since primary care visits are limited on time.
8. Patient will have a follow up appointment with his ophthalmologist
to assess optical functioning. He hasn’t noticed any visual changes but
think its important that he follow up with the ophthalmologist since he hasn’t
in 1.5 years.
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RUNNING HEAD: Soap Note #1
9. Patient will continue to perform diabetic foot care with the help of his
wife. Patient instructed to contact the clinic if notices any non- healing
wounds or if he developed numbness or tingling in his extremities.
10. Educated on grocery shopping on budget. Gave patient information
on saving money when shopping, since food costs is an issue.
Directed him to look at Aldi to shop for fruits and vegetables.
Hypertension: Hypertension is being well controlled. This can be
enhanced if the patient makes dietary and activity lifestyle
changes. If this is so, we may be able to eliminate his beta-blocker
but would continue the ACE inhibitor to protect the kidneys from
diabetes related microvascular changes.
1. He will also continue to log his daily blood pressures and notify us if the
blood pressure becomes high or low or if he becomes symptomatic.
2. Patient will follow up in 3 months for a basic metabolic panel
3. At this time we will maintain the same dosing of metoprolol and
lisinopril.
Hyperlipidemia: Patients hyperlipidemia management is continuing to
improve since past visits. He is getting close to the range we want
him to be at, especially with his diabetes. Again, as I stated earlier, simple
dietary changes and an increase in activity can help bring him within
range.
1. Patient will follow up 3 months for a lipid profile
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RUNNING HEAD: Soap Note #1
2. At this time we will maintain the same dosing of his atorvastatin
Clinical Decision Making:
Pathophysiology:
Diabetes Mellitus is such disorder that is complex in nature as well as complex in
the effects it has on other organ systems. From a pathological standpoint, the main issue
with diabetes in general is that it results from a deficiency in insulin in the bloodstream.
“Type 2 diabetes presents on a background genetic predisposition and is characterized by
insulin resistance and relative insulin deficiency. Insulin resistance is aggravated by
physical inactivity and by overweight or being obese (O’Connor, 2013).” Because our
cells need insulin to carry in glucose from the blood stream, our bloodstream accumulates
with glucose. But when it comes to diabetes mellitus, it can be caused by a decrease in
the production of insulin in the beta cells of the pancreas or our cells in our body build a
resistance to the insulin. This is what defines diabetes mellitus from Type-1 Diabetes,
which is due to the fact that our beta cells no longer make insulin and rely on insulin
through injection.
With diabetes mellitus characterized by decreased insulin production and/or
cellular insulin resistance, this causes a pathway of problems for our body. It leads to
vascular destruction due to the high osmolality gradient caused by the high serum blood
glucose. This vascular destruction tends to work initially on the microvascular tissue
including the eyes, peripheral nerve tissue, kidneys, and coronary tissue. Diabetes and
hyperglycemia create a proinflammatory microenvironment that progress to
microvascular complications such as nephropathy, retinopathy, and neuropathy (Nguyen,
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RUNNING HEAD: Soap Note #1
Grant, Shaw, 2012). Therefore, the microvascular tissue destruction then will cause a
further decline and cause ischemia and organ death over a period of time.
Leadership/Professional Role:
The leadership in this visit was initially me, but when it came to treatment
changes and treatment plan modifications, my preceptor took over. I was able to get a
good history on the patient and identify issues in the follow up. I was able to lead the
education for the patient and provide health promotion from a nursing perspective. When
it came to the treatment plan, my preceptor took over and helped the patient and I
understand what was going to change and why.
Barriers to Care:
There was one perceived barrier in this visit and it was dietary intake associated
with finances. He will be going to go see a nutritionist to talk about modifying his meal
plans. Patient has had a hard time trying to eat better and it is due to “everything good for
you costs too much.” Explaining to him that, even though the costs of the food are higher
than junk food, the costs of increasing the medications and the increase in the progression
of his illnesses cost more in the long run. I also advised him to locate Aldi’s grocery
stores. He could be saving a lot of money on groceries and he would be able to buy
groceries that were good and nutritious for him. He liked the idea and I helped him locate
a couple stores in his residential area. Hopefully this education will help alleviate barriers
in the future.
Pharmacology Information:
Incretin is a hormone, which is produced in the gastrointestinal tract and responds
to food when it enters. This hormone causes the pancreas to quickly release insulin to
help initiate the push of glucose into the cells because more glucose will be entering the
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RUNNING HEAD: Soap Note #1
bloodstream. GLP-1, also known as glucagon like peptide-1, is derived from incretin and
plays a crucial role in helping people with Diabetes Mellitus because of its role in
slowing down gastric contents, increasing insulin secretion, and by increasing satiety in
the brain (Cooppan, n.d.).
A medication, known as Byetta (exenatide), helps diabetic patients by mimicking
GLP-1. “Exenatide mimics incretin and promotes insulin secretion, suppresses glucagon,
and slows gastric emptying (Exenatide Injectable Solution (Rx) - Byetta).” Since it was
FDA approved in 2005, it has made a positive impact on helping diabetic patients and
their weight. Unlike some of the other diabetic medications such as Metformin, it has
been shown to help decrease weight in patients who have Diabetes Mellitus. “A weight
loss of 1–4 kg is generally observed in patients treated with a GLP-1 receptor agonist,
whereas DPP-4 inhibitors are weight neutral (Reid, 2012).”
Byetta is not for everyone. It shouldn’t be used in pediatric patients and should
not be solely used as monotherapy in diabetic patients. Like any other medications,
Byetta does have serious and common reactions. Nausea, vomiting, diarrhea,
hypoglycemia, and constipation are a few of the common reactions with this medication.
One of the serious reactions with this medication is pancreatitis. It is important to educate
the patient to stop taking the medication if they experience signs of pancreatitis such as
severe abdominal pain, especially in the upper stomach. Other education should include
what signs and symptoms to watch of hypoglycemia to watch for.
From a financial point of view, Byetta is a very expensive drug if the patient does
not have health insurance or a drug plan. After reviewing goodrx.com, which my
preceptor linked me to, it shows that the cost of the medication ranges $370-$400 per
month. Insurance plans typically will cover the medication with a co-pay. After looking
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RUNNING HEAD: Soap Note #1
into medications similar to Byetta, it appears that Byetta is cheaper among the GLP-1
agonists such as Bydureon (exenatide) and Victoza (liraglutide).
Critical Thinking/Critical Decision Making:
My first day in clinic was a day full of critical decision-making that made me
think hard. In my past clinical experience, I utilized my differential diagnosis handbook
quite often but this clinical day full of management of ongoing issues and didn’t really
get time to sit down and utilize the book. In this clinical case, I didn’t have to utilize the
differential diagnosis handbook because it was a follow up visit for diabetes
management.
The biggest critical decision making effort during this visit was the
discontinuation of Byetta. This was something that my preceptor was contemplating
during the patient visit and was thinking as to whether the medication had any ongoing
benefits anymore. His rationale behind why he was discontinuing it was quite interesting.
We looked at his weight trends since being on Byetta in 2008. We saw a big drop in
weight for the 1st two years and then saw a big spike back up in 2011. Since then, the
weight has been staggering upwards. My preceptor has stated that he has seen this trend
several different times in the past. He has seen that blood sugars are having trouble being
controlled and weight gain occurred. Therefore, because my preceptor thought that it was
no longer working for him, he would discontinue the medication and implement more
insulin into the treatment plan. I have not been able to find this in the literature but I will
continue to look.
Evidence Based Practice:
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RUNNING HEAD: Soap Note #1
Evidence is what drives our practice as nurses and nurse practitioners. It is
important to look to the research to gain knowledge and insight into why we do what we
do. When it comes to diabetic patients it is crucial to look at the evidence because
modalities of care change and we may need to revise our plan of care.
One-way my practice is evidenced based is because my preceptor and I utilize the
hemoglobin A1c to manage a patient’s diabetes. For over 2 decades the A1c test have
been widely accepted and utilized in measuring how well the patient manages their blood
sugars (Delamater, 2006). The significance of using this test is because it gives an
overview of how glycemic control has been and gives us a picture of what is going on.
Because medication and plan of care adherence can be an issue we can look at this test if
we have discrepancies in diabetic sugar logs and patients history. Utilizing this test in the
management of diabetes for patients is crucial because we cannot always rely on
logbooks and from what the patient states. It also drives the plan of care to show us how
aggressive we have to be with medications for treatment.
After reading further into a sliding scale insulin regiment in the literature, I have
found conflicting information for its use in primary care. When referring to diabetes
management I utilize the Yale University Diabetes Facts and Guidelines manual. It is a
great resource to go to for treatment regimens and patient education. When looking into
insulin regimens, it doesn’t give an outline for outpatient sliding scale insulin regiment. It
only talks about its use in the inpatient setting. I also found an article in the Journal of
Family Practice focused on discrediting the efficacy of sliding scale insulin treatment
plans based on the little evidence in the regimen. The article discusses the harm it causes
to patients due to the peaks and valleys in glucose levels. “The wide fluctuations and
excessive spikes in blood glucose levels associated with sliding scale management may
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RUNNING HEAD: Soap Note #1
cause reactive oxidative stress – a trigger for vascular damage, especially in patients with
type 2 diabetes (Guthrie et al, 2011).” With this being said, we may be causing more
damage on top of not well-controlled blood sugars, even though we are correcting the
blood sugar.
After reading about this sliding scale regimen and how it really isn’t supported in
the family practice setting, I want to discuss this with my preceptor. I work full time in
the hospital and I see the sliding scale insulin regimen on a daily basis. When I saw my
preceptor go through with initiating this for the patient, I thought it was fine and
evidenced based. But after reading into it, it seems it is not well supported. It seems to be
more work for the patient and not as effective as we may think.
Critique:
This was a very busy day for me in the clinic and I learned an immense amount of
information, especially about diabetes management and regimen changes. This was my
first experience when working with a patient on diabetes management. There was one
case last semester that we put a patient on Lantus and initiated Metformin but this was a
completely different case. This gentleman was on several different medications for his
diabetes and it was a little overwhelming at first.
I am looking forward to working with patients with diabetes. It has spread like
wildfire among our country and it is something that needs to be extinguished or at least
controlled. I feel as a nurse, I have very strong educational skills and I think that’s why
nurse practitioners can make a difference in primary care. We focus a lot of our attention
on health promotion and educating on lifestyle modifications. My preceptor, whom is an
MD, seems to focus a lot of attention on medications and testing, which is great! That is
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RUNNING HEAD: Soap Note #1
why the nurse practitioner in the clinical setting can offer more of the education because
it is part of our nursing care model.
Overall I think this visit went well. I was able to incorporate some of the diabetic
education information that I’ve learned in the program. I was able to learn how to
increase insulin dosages and what to watch for in blood glucose patient logs. I have a lot
to learn but that is why I am here!
References
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RUNNING HEAD: Soap Note #1
Byetta - Patient Education. (2012, March 8). Epocrates Online. Retrieved September 10, 2013,
from https://online.epocrates.com/noFrame/showPage.do?method=drugs
Cooppan, R. (n.d.). Type 2 Diabetes: The Pathophysiologic Basis of Treatment
Design. Medscape. Retrieved September 16, 2013, from
http://www.medscape.org/viewarticle/580684
Delamater, A. M. (2006). Clinical Use of Hemoglobin A1c to Improve Diabetes
Management. Clinical Diabetes, 24(1), 6-8. doi: 10.2337/diaclin.24.1.6
Exenatide injectable solution (Rx) - Byetta. (n.d.). Medscape. Retrieved September 11, 2013,
from http://reference.medscape.com/drug/byetta-exenatide-injectable-solution-342892
Guthrie, D., Hinnen, D., Childs, B., & Guthrie, R. (2011). It’s time to abandon the sliding
scale. Journal of Family Practice, 60(5), 266-270.
Nguyen, D., Shaw, L., & Grant, M. (2012). Inflammation in the pathogenesis of microvascular
complications in diabetes. Frontiers in Endocrinology, 3(170).
O'Connor, P. (2013, April 26). Type 2 Diabetes Mellitus in adults. Epocrates Online. Retrieved
September 10, 2013, from https://online.epocrates.com/noFrame/showPage.do?
method=diseases
Reid, T. (2012). Choosing GLP-1 Receptor Agonists or DPP-4 Inhibitors: Weighing the Clinical
Trial Evidence. Clinical Diabetes, 30(1), 3-12.
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