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SOAP Note Diabetes Mellitus

SOAP Note Diabetes Mellitus

Assignment 2:  Follow-up Diabetes Mellitus, Type 2

Focused History and Physical Exam

Subjective Data

Chief Complaint: Type 2 diabetes mellitus follow-up

History of Present Illness: The patient is a 45-year-old Hispanic obese female with a history that is significant for type 2 diabetes mellitus, diabetic neuropathy, hypertension, hypothyroidism, and heart palpitation. She does not want to take medication even if her HgbA1c is 9. Instead, she believes that herbal medicines and natural healing can cure diabetes. The patient has a sedentary lifestyle, as she does not exercise or follow her recommended diabetic diet. Last month, she was admitted to the hospital after developing chest pain. During her hospitalization, she was given medication to regulate her blood sugar along with diabetic teaching. This is a follow-up evaluation to assess her diabetes self-management education and follow-up A1C blood tests. She will begin group support sessions in September. The patient has not reported any complaints today.

Review of Systems

General Symptoms: Denies weight changes, fatigue, weakness, appetite loss, polydipsia, or polyphagia. Her overall status is ill-looking and slightly anxious
HEENT: Denies headaches, blurred vision, sinuses, or pain
Cardiovascular: Positive palpitations and chest pain. Denies edema, hypothermia, cyanosis, orthopnea, pallor, sensations, pain, ulcers, or pigmentation.

Respiratory: Denies wheezing, dyspnoea, coughing, sputum production

Gastrointestinal: Denies reflux, nausea, indigestion, heartburn, abdominal pain, bleeding, epigastric pain, vomiting, diarrhoea, and constipation
Genitourinary: Positive dysuria, increased urination, polydipsia, flank pain, nocturia, or

polyuria.

Musculoskeletal: Denies weakness, neck/back pain, or arthralgias
Neurological:  Positive numbness, paresthesias, and memory loss
Psychiatric: Denies depression, drug abuse, anxiety, or suicide ideas
Endocrine: Obese, denies weight loss, heat or cold intolerances
Past Medical History: Type 2 DM (August 2019)

Past Surgical History: Breast biopsy (2007), Cesarean delivery (2009), Arthroscopy (2014)

Family History: Both parents are alive

Father: Hypertension, type 2 diabetes mellitus, and dyslipidemia,

Mother: Myeloma Multiple, Chronic Obstructive Pulmonary Disease

Social History: Does not smoke and is a social drinker. But, she does not exercise regularly.

Medication: Acarbose, metformin, and glimepiride

Allergies: NKDA

Objective Data

Physical Exam

General Appearance: Awake, no acute distress, alert, slightly anxious

Vitals:

Sex: F HT: 5’6’’ WT: 189 (Previous 190, 194) Race: Hispanic

BMI: 30.5, HR: 78, RR: 16, Temp: 97.9

BP 149/57 (no hypertension medicines taken today) (Previous) 115/78, 115/74mmHg

PPBG: 128mg/dl (ate cereals at 8.00AM) Previous FBG: 9/17 (185, 1 hour PPBG)

K: 4.30; LFT: within normal limits; Scr: 0.73

Lipids: within normal limits, except lower HDL 20 mg/dl

TC 146            TG 134            LDL 98           HDL 22

EsGFR: 122ml/min (MDRD) 149 ml/min (CG),

Microalbuminuria: none

HbA1C: 9.0% (9% hospitalized and 10.5% when diagnosed)

HEENT: Normocephalic, conjunctivae, EOMI; PERRLA, TM pearly gray present landmarks. Nares patent. No redness, jaundice, swelling, pallor, or cyanosis. Nontender sinuses.

Neck: Supple. Full ROM, Negative JVD, LAD, carotid bruit, nodes, and thyroid enlargement.

Skin: Positive scattered seborrheic keratoses, negative for skin cancer signs or melanomas.

Cardiac: RRR. No gallop, murmurs, or rubs

Respiratory: CTA bilaterally.

Abdomen: Non-tender soft, positive for bowel sound. Negative hepatosplenomegaly or masses

Lymphatics: Negative for lymphadenopathy in inguinal, cervical, or axillary areas.

Neurologic: Significant lower extremity numbness

Foot Examination: Microfilament test reveals more than 4 regions with no sensations bilaterally. Bottom of feet are dry and calloused, intact skin.

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Diagnoses

Differential diagnosis:

1. Diabetes Mellitus Type 1: Low (<0.6 nanogram/mL) or absent C-peptide level. Presence of one or more autoantibodies: GAD ICA insulin autoantibodies, autoantibodies to tyrosine phosphates IA-2 and IA-2beta during diagnosis

2. Metabolic syndrome: The presentation of the patient is not indicative of metabolic syndrome that is diagnosed when three of these conditions exist: Abdominal obesity, low level of HDL cholesterol, elevated triglyceride level, Fasting glucose value above 100 mg/dL, and elevated blood pressure.

3. Hyperthyroidism:Fatigue and weight loss may be indicative of hyperthyroidism. The presence of autoantibodies ruled out hyperthyroid Thyroid function tests did not confirm the diagnosis and imaging ruled out other causes, nodules, overactivity, and inflammation.

Diagnosis: Diabetes Mellitus Type 2: The glycosylated hemoglobin level is above 6.50% (February 2020; May 2020), diabetes mellitus plus random plasma glucose above 200.0 mg/dL (February 2020; May 2020), fast plasma glucose above 126.0 mg/dL twice, and two-hour post-loading plasma glucose above 200.0 mg/dL (February 2020; May 2020). Basal C-peptide level is more than 1 ng/Dl.

Patient/ Family Teaching

The ADA Medical Care Standards provide the clinicians, researchers, patients, payers, and families in diabetes care, treatment goals, and toolkits for the evaluation of the quality of care (Grant & Kirkman, 2015). Type 2 DM is a complicated and chronic illness necessitating ongoing care, coupled with multi-factorial strategies for risk mitigation beyond the glycemic control. Thus, continuing support and diabetes self-management education on prevention and treatment of complications and periodic assessment of goals. Education will prevent health acute complications and diminish long-term complications (ADA, 2020). There is substantial evidence that supports a wide range of interventions for the improvement of diabetes outcomes (Burant et al., 2012). An effective treatment program necessitates regular self-monitoring the blood glucose, nutritional therapy, weight reduction plans, oral, insulin, and consistent exercise.

Nutritional therapy is a fundamental but challenging component of type 2 DM management that seeks to attain and maintain blood glucose levels, blood pressure, and lipid goals (Dunphy et al., 2019). The recommended meal plan is based on food choices, weight, exercise, lifestyle, medical history, cultural, financial, and ethnic factors. Exercise is a core component in type 2 DM management. The patient is overweight; thus, weight loss is one of the significant elements in meal planning to control glucose and promote healthy eating patterns. The exercise program should include a minimum of 150 minutes weekly of moderately intense aerobic activity and muscle-strengthening exercises. SMBG is useful for the guidance of treatment decisions and self-management when being treated with insulin, especially since the patient has not consistently realized the treatment goals of blood glucose. The patient will be trained to maintain a record of test results for periodic reviews by the provider.

Treatment Plan

The American Diabetes Association recommends Glycated hemoglobin (A1C) for diagnosing diabetes. The sensitivity and specificity of the A1C greater than 6.50% for diagnosing cases of diabetes by single fasting glucose above 126 mg/dl) were 47% and 98%, respectively. In definition 2, fasting glucose above 126 mg/dl at two occasions, sensitivity and specificity is 67% and 97% (Selvin et al., 2011). The pharmacological therapy for type 2 D.M. will be considered an adjunct therapy to nutritional therapy and exercise, but not as a substitute. The oral medication can be initiated for three months of exercise, and nutritional therapy has not yet attained and maintained fasting plasma glucose level below 120 mg/dL and A1C of below 7%.

The current drug therapy for type 2 DM comprises drugs that can change insulin action, impact glucose absorption, stimulate insulin secretion, mimic the incretin effects, an insulin secretagogue, stimulate insulin secretion, suppress postprandial glucagon and insulin release.¬† The ADA recommends metformin as first-line medication. The metformin is a monotherapy and biguanide that suppresses the production of excessive hepatic glucose and increases glucose use in peripheral tissues. The metformin diminishes fasting, postprandial hyperglycemia, and hepatic gluconeogenesis. Metformin is ideal for obese patients as it has a neutral impact on weight. The dose should be titrated towards a dose of 2,000 mg once a day with breakfast. The common adverse reactions include diarrhea, abdominal discomfort, nausea, and anorexia that resolve with the dosage’s gradual surge. At the peak dose, the U.S.’s monthly metformin costs are $4 on majority generic formularies. In addition, second generation sulfonylureas glimepiride (1 mg) is recommended once-daily before breakfast to stimulate pancreatic insulin secretion and increase peripheral glucose metabolism. Glimepiride is more potent, produces fewer adverse effects, and has fewer interactions with other medications. Acarbose (Precose) will be used to slow down the breakdown of complex carbohydrates into monosaccharides and delay absorption of glucose. The recommended dose is 50 mg/day; 3 times every day with meals. Exenatide is an incretin mimetic for enhancing glucosedependent insulin secretion and slowing gastric emptying. The dose of 5 mcg twice daily subcutaneously.

Research Article Critique

Different studies have reviewed the recommendations for screening, diagnosing, and other therapeutic actions that favorably affect the healthcare outcomes of diabetes patients. In 2018, a study was conducted to examine Type 2 Diabetes management among culturally diverse population groups. In the U.S, type 2 diabetes affects racial and ethnic group minorities at alarming rates. But, the quality of medical care offered to these groups is suboptimal, which results in the worsening of patient outcomes in comparison to majority populations (Caballero, 2018). Thus, an in-depth understanding of the biological elements influencing the development and course of diabetes in high-risk groups is essential as it can be implemented in prevention and treatment programs. The study discussed the multiple factors that need to be addressed in delivering care to the diabetes patient. The relevant factors to the Hispanic female patient’s case include cultural awareness, educational level, language, fears, knowledge of the disease, medication adherence, alternative medicine, socio-economic status, and unconscious bias. Considering these factors in the prevention and treatment plans will enhance diabetes-related effects and minimize disparities in health care.

Billing

Medicare Part B (durable medical equipment, outpatient care, preventive and ambulance services medical insurance cover the initial and follow-up for the outpatient diabetes self-management training. Two hours are permitted for DSMT follow-up in explicit time frames subsequent to the first intervention. For the beneficiaries starting the first DSMT in one year and completing the next year, the follow-up begins in the month following the completion of the preliminary intervention. The 2 hours of follow-up per year can be furnished as per the basis of the calendar year. The ten initial DSMT hours and two follow-up DSMT hours are furnished in an increment of not less than 30 minutes face to face since the procedure codes are time-based codes. The procedure codes obligatory by Medicare for DSMT claims are DSMT individuals for 30 minutes (G0108) and group for 30 minutes (G0109).¬† The provider maintains a healthcare plan for diabetes care in the patient’s medical records and submits a referral. The document contains proof that follow-up DSMT is required, diagnosis ICD-10 diagnosis code (E11.9), name of beneficiary, date, and signature and NPI number of the referring provider

References

American Diabetes Association (2020). Introduction: Standards of Medical Care in Diabetes. 43(Supplement 1): S1-S2. https://doi.org/10.2337/dc20-Sint

Bickley, L. S., Szilagyi, P. G., In Hoffman, R. M., & Bates, B. (2017).¬†Bates’ pocket guide to physical examination and history taking. Philadelphia: Lippincott Williams & Wilkins.

Burant, C. F., Young, L. A., Burant, C. F., & American Diabetes Association. (2012). Medical Management of Type 2 Diabetes. Virginia: American Diabetes Association.

Caballero A. E. (2018). The “A to Z” of Managing Type 2 Diabetes in Culturally Diverse Populations.¬†Frontiers in endocrinology,¬†9, 479. https://doi.org/10.3389/fendo.2018.00479

Dunphy, L. M. H., In Winland-Brown, J. E., In Porter, B. O., & In Thomas, D. J. (2019). Primary care: The art and science of advanced practice nursing Рan interprofessional approach. Philadelphia, PA: F.A. Davis Company.

Gong, L., Goswami, S., Giacomini, K. M., Altman, R. B., & Klein, T. E. (2012). Metformin pathways: pharmacokinetics and pharmacodynamics.¬†Pharmacogenetics and genomics,¬†22(11), 820‚Äď827. https://doi.org/10.1097/FPC.0b013e3283559b22

Grant, R. W., & Kirkman, M. S. (January 01, 2015). Trends in the evidence level for the American Diabetes Association’s “Standards of Medical Care in Diabetes” from 2005 to 2014.¬†Diabetes Care,¬†38,¬†1, 6-8.

Owora A. H. (2018). Commentary: Diagnostic Validity and Clinical Utility of HbA1c Tests for Type 2 Diabetes Mellitus.¬†Current diabetes reviews,¬†14(2), 196‚Äď199. https://doi.org/10.2174/1573399812666161129154559

Selvin, E., Steffes, M. W., Gregg, E., Brancati, F. L., & Coresh, J. (2011). Performance of A1C for the classification and prediction of diabetes.¬†Diabetes care,¬†34(1), 84‚Äď89. https://doi.org/10.2337/dc10-1235

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