NURSING: CP2 SOAP1 WELL EXPLAINED RATED
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Soap Note: Type 2 Diabetes Mellitus
Zara Tariq
The University of Texas at Arlington College of Nursing
,NURSING: CP2 SOAP1 WELL EXPLAINED RATED
A+ DOWNLOAD TO SCORE A WITH
REFERENCES
In partial fulfillment of the requirements of
NURS 5338 Clinical Practice 2
Phyllis Wood, DNP, APRN, FNP-BC
June 24, 2020
, cp2soap1.
SOAP Note Form Clinical Practice
2 S/ Identifying Information: (initials, age/DOB,
gender, reliability)
Family Hx:
J.B, 54 year old male, reliable historian
Father: deceased surgery complications- had history of
Type 2 DM and heart disease Mother: Alive, age 80
Brother: Alive, Hyertension
Personal/Social Hx:
Chief Complaint/RFE:
Single, 2 children, does not smoke or drink, works as an underwriter.
“I went to a testosterone clinic one week ago and my blood sugar was very
high. This has scared me into changing my diet and wanting to be more
compliant with my medication.”
Hx Present Illness: (7 Variables)
Patient notes he went to a Testosterone clinic a week ago and had his
A1C tested and fasting blood glucose. Patient notes that his A1C was 11.3
and fasting blood glucose was 483 at that time.
Morning FBS was 511 when checked at home. He notes this "scared him
into changing his diet" and he no longer drinks 5 sodas a day or eats ice
cream. He also notes that now he drinks only 1/5th of a soda instead and
has been making slow changes. Patient also notes after making these
changes his blood sugar at home has been in the 200s. Patient notes that
he has noticed that his toes look purple and he is no longer growing hair on
his lower legs. He notes he is taking Metformin ER 750mg twice a day.
CURRENT HEALTH
Medications: Metformin ER 750mg twice a day.
Action: Decreases liver glucose production, and intestinal glucose
production, increases insulin sensitivity.
A+ DOWNLOAD TO SCORE A WITH
REFERENCES
Soap Note: Type 2 Diabetes Mellitus
Zara Tariq
The University of Texas at Arlington College of Nursing
,NURSING: CP2 SOAP1 WELL EXPLAINED RATED
A+ DOWNLOAD TO SCORE A WITH
REFERENCES
In partial fulfillment of the requirements of
NURS 5338 Clinical Practice 2
Phyllis Wood, DNP, APRN, FNP-BC
June 24, 2020
, cp2soap1.
SOAP Note Form Clinical Practice
2 S/ Identifying Information: (initials, age/DOB,
gender, reliability)
Family Hx:
J.B, 54 year old male, reliable historian
Father: deceased surgery complications- had history of
Type 2 DM and heart disease Mother: Alive, age 80
Brother: Alive, Hyertension
Personal/Social Hx:
Chief Complaint/RFE:
Single, 2 children, does not smoke or drink, works as an underwriter.
“I went to a testosterone clinic one week ago and my blood sugar was very
high. This has scared me into changing my diet and wanting to be more
compliant with my medication.”
Hx Present Illness: (7 Variables)
Patient notes he went to a Testosterone clinic a week ago and had his
A1C tested and fasting blood glucose. Patient notes that his A1C was 11.3
and fasting blood glucose was 483 at that time.
Morning FBS was 511 when checked at home. He notes this "scared him
into changing his diet" and he no longer drinks 5 sodas a day or eats ice
cream. He also notes that now he drinks only 1/5th of a soda instead and
has been making slow changes. Patient also notes after making these
changes his blood sugar at home has been in the 200s. Patient notes that
he has noticed that his toes look purple and he is no longer growing hair on
his lower legs. He notes he is taking Metformin ER 750mg twice a day.
CURRENT HEALTH
Medications: Metformin ER 750mg twice a day.
Action: Decreases liver glucose production, and intestinal glucose
production, increases insulin sensitivity.
