sop note

Name: PK

Pt. Encounter Number: 23

Date: October 2, 2020

Age: 55

Sex: male

SUBJECTIVE

CC:

Type II diabetes.

HPI:

PK visited the clinic with complaints that he suspected to have type II diabetes. He complained of symptoms such as getting tired easily without doing a hard task, feeling hungry, increased thirst and urinating regularly. He has been assuming for the past three weeks that these symptoms were developing because of his dieting, but it was not the case.

Medications: Not under medication for now, but has ever received a surgical operation in removing his appendix 3 years ago.

PMH

Allergies: allergic to dust

Medication Intolerances: none

Chronic Illnesses/Major traumas:

1. Diabetes

2. Heart murmur

3. Hypertension

Hospitalizations/Surgeries

None

Family History

He is a healthy family, through his maternal grandmother was diagnosed with diabetes, and his paternal grandfather died of diabetes. The paternal grandmother had diabetes at old age, while his maternal grandfather had asthma. In her early 50s, PK’s mother was living healthy though later diagnosed with hypertension while his father was diagnosed with pre-diabetes. One of his sisters is suffering from high blood pressure, while the rest of her sisters are healthy.

Social History

PK has been interacting with his friends as well as in the community to improve his life socially. He is living in a 2-bedroom house with his family, who says he is happy with it. His two daughters are married, and they meet after some time to enhance the spirit of togetherness. He values every workmate in his place of work, and he is very cheerful.

ROS

General

The patients look generally healthy; even one could not tell that he is suffering from symptoms such as frequent urination, thirst, and hunger. He is alert, and he timely responses to questions.

Cardiovascular

Sometimes he is stressed for being unable to cater to her family. Reports to have diagnosed with Hyperlipidemia, HBP, running short of breath, palpitations, and heart murmurs.

Skin

Wrinkled, rough with rashes.

Respiratory

Denies sneezing nor coughing.

Eyes

Clear with no pain. No inflammations, not itching.

Gastrointestinal

All 4 quadrants have sound bowel. Hepatosplenomegaly was absent after exam.

Ears

Pain free ear.

Genitourinary/Gynecological

Examination results shows he has non-distended and palpable bladder. No CVA tenderness identified.

Nose/Mouth/Throat

Nose clears its drainage well with no pain. his throat has no sores and does not feel pain swallowing the food.

Musculoskeletal

denies back pain, joint pain, stiffness, fracture, or join swelling.

Breast

N/A

Neurological

Patient communicates in a deep and auto voice.

Heme/Lymph/Endo

No identified blood clotting disorders.

Psychiatric

He is no depressed. Have never thought of committing suicide.

OBJECTIVE

Weight 82lbs BMI 24.3

Temp 97.2

BP 83/60

Height 8.8 ft

Pulse 88

Resp 22.5

General Appearance

The patient looks alert, neat and sensitive to questions. He looks health and appear to know what is happening to his life.

Skin

denies having bruised or lesioned skin. His has wrinkles and pale skin.

HEENT

Head: normocephalic, symmetric, and atraumatic. There is no presence of hernia around the neck and the trachea.

Eye: non-inflamed eyes. The covering of the eye is bilaterally aligned with the eyelids.

Ears: the absence of exudation. The ear is bilaterally aligned with side appearance. Both the skin and the ear look healthy.

Nose: no presence of lesions. The mucous membrane is moist and pink.

Throat: front sinus and maxillary are tender to palpation. The gap response is sensitive. Both tongue and uvula lie in the middle line—no exudating tonsils. Mucus is scant and thick.

Cardiovascular

Presence of murmurs, gallops, rubbing, and sipping. Absence of splits from both S1 & S2.

Respiratory

He is neither sneezing nor coughing plus his lungs are clear to auscultation.

Gastrointestinal

All 4 grands have sound bowels plus after exam there is no hepatosplenomegaly.

Breast

N/A

Genitourinary

His bladder is non-distended and palpable. Tenderness lacks in CVA.

Musculoskeletal

No kyphosis or scoliosis. No swollen joints.

Neurological

Patient communicates in a deep and auto voice.

Psychiatric

Not depressed or have ever have thoughts of committing suicide.

Lab Tests

CBC WBC; 11000, Hgb; 10.2, Hct; 42, RBC; 12 (Wiener, Wiener & Larson, 2008)

Urinalysis – negative for UTI

Liver function test

CMP

BMP

Vitamin B-12

Special Tests

There was no evidence of acute infarct after head CT was conducted because the cerebral atrophy was consistent with his age (Wiener, Wiener & Larson, 2008).

Diagnosis

· Diabetic Ulcers

· Insulin Resistance (Cefalu, 2017).

· Diabetic Ketoacidosis

PLAN

Diagnostic Testing: None.

Therapy/Treatment:

1. Insulin therapy

Patient/Family Education:

· Avoid taking foods with excess salt and sugar. 

· Follow the doctor’s medication instructions (American Diabetes Association, 2010). 

· Eat a healthy balanced diet. 

· To drink plenty of water and often to avoid dehydration. 

Call your doctor if:

· When the symptoms continue for a long period 

· The moment hunger and thirst have reached an uncontrolled level (American Diabetes Association, 2018). 

· Persistence of symptoms. 

· In case there are urinalysis complications. 

Follow-up: a primary healthcare provider will provide a follow-up program during the first week after he is discharged from the hospital to ensure that the treatment plan is working as intended.