Soap Note, Research Paper Example

Subjective Data:

Chief Complaint: Child has been complaining of frequent thirst and a dry mouth for approximately two weeks and has been wetting the bed over the past month. He has not wet the bed in over 3 years.

History of Present Illness: 8 year-old Caucasian male is presented to the clinic for excessive thirst and a dry mouth, which is especially difficult to manage at night. He frequently drinks water at the bedside and while at school, frequently leaves class to use the drinking fountain. His mother reports that he has been wetting the bed almost every night over the past month. Prior to these incidents, he had not wet the bed in over 3 years.

Medications:

No daily medications at this time. On occasion, he will take OTC Children’s Tylenol for headaches.

Allergies: No known drug allergies; allergic to peanuts

Past Medical History: Chicken pox, influenza, sore throat/congestion

 Past Surgical History: No prior history of surgeries.

Personal/Social History: Child has experienced troubles as school because of his weight; many children call him chubby or fat. He does not participate in any after school sports and struggles in gym class.

Immunizations: All up to date.

Family History: His mother is hypertensive and diabetic, and his father has a mild heart condition. He has two older brothers (ages 11 and 14) and a younger sister (age 6).

Review of Systems:

General: obese, continuous weight gain over the past 3 years, no fever or weakness. Frequently tired at home and in school.

Skin: no current rashes but has dry skin, especially on the hands and feet.

Eyes: No eye pain but wears glasses for nearsightedness.

Ears: No problems with hearing and no ear pressure.

Nose: Occasional runny nose but not on a consistent basis.

Throat: No sore throat but excessive dry mouth.

Neck: Supple without any indication of a lymph node or thyroid condition.

Respiratory: No wheezing or coughing.

Cardiovascular: No chest pain or edema. Experiences shortness of breath when physical activities are excessive.

Gastrointestinal: No nausea, diarrhea, constipation, or vomiting.

Endocrine: No history to report.

Objective Data:

T: 37.2 Celsius (oral), BP 115/72, P: 102, RR: 17, wt 39 kg

Generalized appearance is satisfactory with excessive obesity. No rashes on the skin and no other visible markings.

Head: Normocephalic

Ears: No drainage, small pocket of fluid observed in left ear; eardrums intact.

Nose: Mild clear nasal discharge

Pharynx: No hoarseness, low moisture

Neck: Neck is supple and no tenderness identified

Cardiac: Heart rhythm is regular and no murmurs detected

Respiratory: No wheezing or diminished breath sounds observed
Abdominal: No masses observed, abdomen soft and non-tender

GU: Not assessed.

Neuro: Orients well to current location and time period

Labs: Glucose 285, Hemoglobin A1C 10.2, Triglycerides 321

Assessment:

Diagnosis 1: Type 1 diabetes (T1D): This disease is primarily diagnosed in children and is characterized by the inability to produce adequate insulin as a result of the destruction of pancreatic b cells (Burn, 2010). The possible cause could be underlying genetic factors, but these are unclear (Burn, 2010).
Diagnosis 2: Diabetic ketoacidosis: This condition is characterized by three primary factors: ketonuria, acidosis, and hyperglycemia in children (Usher-Smith et.al, 2011). This diagnosis leads to the potential risk of low glycemic control in patients and possible insulin resistance in children (Usher-Smith et.al, 2011).

Diagnosis 3: Type 2 diabetes: This condition in children is often identified in patients who exhibit obesity and is responsible for 45 percent of all diabetes cases in children (Mohamadi and Cooke, 2011). However, the types of treatment and level of control in children are difficult to predict within this population (Mahamadi and Cooke, 2011).

Plan:

1. The treatment of type 1 diabetes requires daily insulin therapy in order to sustain effective blood glucose levels on a regular basis (Khardori, 2013). Rapid-acting insulin is preferred and provides greater glycemic control for patients (Khardori, 2013). This patient requires insulin once daily with routine monitoring in order to stabilize blood sugar levels and improve quality of life (Khardori, 2013).
2. Glucose self-monitoring: The patient must learn how to self-monitor his glucose levels in the home environment in order to address any spikes in blood sugar as quickly as possible (Khardori, 2013). This practice should be conducted on a daily basis prior to consuming meals so that if changes to the insulin dosage are required, they are administered accordingly (Khardori, 2013).
3. Diet: The patient must maintain control over his diet through the development of strategies to address number of calories consumed, carbohydrate intake, and number of meals and snacks per day (Khardori, 2013). The patient must recognize that his level of food intake is directly correlated to his blood glucose levels; therefore, the dietary approach must follow a plan that is established in conjunction with nutritional recommendations (Khardori, 2013).

4. Health Promotion: The patient should maintain any and all dietary requirements on a regular basis. Also, he should engage in exercise several times per week for at least 30 minutes and beyond what is required in physical education class. The patient should also engage in other extracurricular activities with other students in order to improve his psychosocial wellbeing. His health is dependent on his ability to regulate blood glucose levels; therefore, diet, exercise, and psychosocial wellbeing play a role in these practices.
5. Disease Prevention: Address any illnesses or complications that arise as soon as possible. Obtain routine blood work as required by the physician to address hemoglobin A1C and blood glucose levels, and follow up with a doctor’s visit within one month to assess nutrition, weight loss, and level of physical activity.

Reflection Notes

For this patient, I am in agreement with the plan of care that has been established. This patient is in a difficult position due to his young age and excess weight. Therefore, he must be provided with the tools that are necessary to promote greater health and wellbeing through medication administration, accompanied by other factors such as improved nutrition to promote weight loss, greater physical activity, and routine blood testing as recommended by the physician. Insulin self-administration should be evaluated closely so that the patient is prepared for this practice. In addition, the patient must monitor his blood glucose levels on a daily basis in the home environment. It is important for the patient to recognize that he faces many risks with his health at such a young age; therefore, he must adhere to physician orders as closely as possible in order to prevent widespread and long-term complications that could impact his health even further. I believe that although the diagnosis of type 1 diabetes is challenging and very difficult to accept, the patient’s surrounding support system will provide an improved outlook regarding the disease. Managing this condition also requires an effective understanding of the challenges that are likely to occur; however, due to the patient’s young age, the disease must be explained in a manner that he will comprehend. The physician must continue to evaluate the patient on a regular basis because I believe that this is the only means by which the patient is able to successfully manage the condition with as few complications as possible. This will ensure that his long-term prognosis is positive for the foreseeable future.

References

Burn, P. (2010). Type 1 diabetes. Nature Reviews Drug Discovery, 9, 187-188.

Khardori, R. (2013). Type 1 diabetes mellitus treatment & management. Medscape, retrieved from http://emedicine.medscape.com/article/117739-treatment

Mohamadi, A., and Cooke, D.W. (2010). Type 2 diabetes mellitus in children and adolescents. Adolescent Medicine: State of the Art Reviews, 21(1), 103-119.

Usher-Smith, J.A., Thompson, M.J., Sharp, S.J., and Walter, F.M. (2011). Factors associated with the presence of diabetic ketoacidosis at diagnosis of diabetes in children and young adults: a systematic review. BMJ, 343, 1-16, doi: 10.1136/bmj.d4092