Posted: May 12th, 2023

Discussion Topic: Soap Note 4 “Diabetes Mellitus”

Soap Note # ____ Main Diagnosis ______________

Gender at Birth:
Gender Identity:
Current Medications:

Preventive Care:
Surgical History:
Family History:
Social History:
Sexual Orientation:
Nutrition History:

Subjective Data:
Chief Complaint:
Symptom analysis/HPI:
The patient is …

Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )

Objective Data:


(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data)
Example : “Pt came in to our clinic c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and that etc.)
Main Diagnosis
(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 7th Edition.
Differential diagnosis (minimum 4)

Labs and Diagnostic Test to be ordered (if applicable)
• –
• –
Pharmacological treatment:

Non-Pharmacologic treatment:
Education (provide the most relevant ones tailored to your patient)

References (in APA Style)

Discussion Topic: Soap Note 4 “Diabetes Mellitus”

SOAP Note #4: Diabetes Mellitus

Name: John Doe
Age: 45
Gender at Birth: Male
Gender Identity: Male
Source: Self-referred
Allergies: None
Current Medications: None
PMH: Hypertension, Hyperlipidemia
Immunizations: Up-to-date
Preventive Care: Last physical exam 6 months ago
Surgical History: Appendectomy
Family History: Father with Type 2 diabetes
Social History: Non-smoker, social alcohol use
Sexual Orientation: Heterosexual
Nutrition History: High-calorie, high-fat diet, fast food consumption, limited exercise

Chief Complaint: “I have been feeling very thirsty and urinating frequently. I also feel tired all the time.”
Symptom analysis/HPI: John reports a 3-month history of increased thirst, increased urination, and fatigue. He also noticed a 10-pound weight loss during this period. He denies any fever, chills, or night sweats.

CONSTITUTIONAL: Reports fatigue
NEUROLOGIC: Denies headache, dizziness, or syncope
HEENT: Denies visual changes, hearing loss, or tinnitus
RESPIRATORY: Denies cough, shortness of breath, or chest pain
CARDIOVASCULAR: Denies chest pain, palpitations, or leg swelling
GASTROINTESTINAL: Reports occasional heartburn
GENITOURINARY: Reports increased frequency of urination
MUSCULOSKELETAL: Denies joint pain or stiffness
SKIN: Reports no rashes or skin changes

VITAL SIGNS: Blood pressure 138/90 mmHg, heart rate 86 bpm, respiratory rate 18 breaths/min, temperature 98.6°F, oxygen saturation 98% on room air
GENERAL APPEARANCE: Alert and oriented, no acute distress
NEUROLOGIC: Cranial nerves intact, normal sensation and reflexes, no focal deficits
HEENT: Pupils equal, round, and reactive to light, normal extraocular movements, no nystagmus, normal tympanic membranes
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops, distal pulses palpable
RESPIRATORY: Clear to auscultation bilaterally, no wheezes, rhonchi, or crackles
GASTROINTESTINAL: Soft, non-tender, non-distended abdomen, no hepatosplenomegaly, no masses or tenderness
MUSKULOSKELETAL: No edema or deformity noted
INTEGUMENTARY: No rashes or skin lesions noted

John presents with a 3-month history of increased thirst, increased urination, and fatigue, along with a 10-pound weight loss. Based on these symptoms and his medical history, the most likely diagnosis is Type 2 Diabetes Mellitus (ICD10 E11.9) (American Diabetes Association [ADA], 2021). Differential diagnoses include Type 1 Diabetes, Hyperthyroidism, Cushing’s Syndrome, and Polycystic Ovary Syndrome (PCOS).

Labs and Diagnostic Test to be ordered:

Fasting Plasma Glucose (FPG) test to confirm the diagnosis of Diabetes Mellitus (ADA, 2021).
Hemoglobin A1c (HbA1c) test to assess long-term glycemic control (ADA, 2021).
Lipid profile to assess cardiovascular risk factors (ADA, 202 • Blood pressure measurement to assess hypertension (ADA, 2021).

Pharmacological treatment:
Metformin 500mg orally twice daily to improve insulin sensitivity and decrease hepatic glucose production (ADA, 2021).
Insulin therapy may be considered based on the FPG and HbA1c levels (ADA, 2021).

Non-Pharmacologic treatment:
Diet and exercise counseling to promote weight loss and improve glycemic control (ADA, 2021).
Patient education on monitoring blood glucose levels and identifying signs and symptoms of hypoglycemia (ADA, 2021).


Importance of maintaining a healthy diet and regular exercise routine.
Proper technique for monitoring blood glucose levels.
Identification of symptoms of hyperglycemia and hypoglycemia.
Importance of medication adherence and regular follow-up appointments with healthcare provider.
Patient to return in 2 weeks for follow-up FPG and HbA1c testing.
Referral to a registered dietitian for dietary counseling.

American Diabetes Association (ADA). (2021). Standards of medical care in diabetes – 2021. Diabetes Care, 44(Suppl. 1), S1-S232.

Tags: , , , , , , , , , , , , , ,

Order for this Paper or Similar Assignment Writing Help

Fill a form in 3 easy steps - less than 5 mins.

Why choose us

You Want Best Quality and That’s our Focus

Top Essay Writers

We carefully choose the most exceptional writers to become part of our team, each with specialized knowledge in particular subject areas and a background in academic writing.

Affordable Prices

Our priority is to provide you with the most talented writers at an affordable cost. We are proud to offer the lowest possible pricing without compromising the quality of our services. Our costs are fair and competitive in comparison to other writing services in the industry.

100% Plagiarism-Free

The service guarantees that all our products are 100% original and plagiarism-free. To ensure this, we thoroughly scan every final draft using advanced plagiarism detection software before releasing it to be delivered to our valued customers. You can trust us to provide you with authentic and high-quality content.

How it works

When you decide to place an order with Nursing Assignment Answers, here is what happens:

Complete the Order Form

You will complete our order form, filling in all of the fields and giving us as much detail as possible.

Assignment of Writer

We analyze your order and match it with a writer who has the unique qualifications to complete it, and he begins from scratch.

Order in Production and Delivered

You and your writer communicate directly during the process, and, once you receive the final draft, you either approve it or ask for revisions.

Giving us Feedback (and other options)

We want to know how your experience went. You can read other clients’ testimonials too. And among many options, you can choose a favorite writer.