SOAP NOTE – Medication Management of Type 2 Diabetes Mellitus

“I’m here for my diabetes medication refill.”

The patient, Mr. John Doe, is a 60-year-old male who has Type 2 Diabetes Mellitus (T2DM) without insulin dependency and seeks a medication restock. Mr John Doe maintains his daily medication routine with metformin 1000 mg at two dosages. Mr John Doe shows no signs of hypoglycemia or vision changes, while his home glucose results remain stable at 110–140 mg/dL fasting. He also does not experience polyuria, neuropathic symptoms or vision changes. No recent infections or hospitalizations. He obtained a 7.2% HbA1c result during his test three months back. His current health status includes normal well-being with occasional experiences of fatigue.

Metformin 1000 mg PO BID – for blood glucose control in T2DM

Allergies:

No known drug allergies

Medication Intolerances:

None reported

Chronic Illnesses/Major traumas

Type 2 Diabetes Mellitus, Hypertension

Hospitalizations/Surgeries

Appendectomy at age 23.

Previously diagnosed with Diabetes and hypertension; denies PUD, asthma, lung disease, cancer, TB, thyroid, kidney disease, or psychiatric illness.

Father was also diagnosed with Type 2 diabetes, and, unfortunately, he succumbed to myocardial infarction. Mother had hypertension and osteoarthritis. One brother with prediabetes. No known family history of TB, cancer, kidney disease, or psychiatric disorders.

High school graduate. Retired auto mechanic. Lives with spouse. Denies tobacco or drug use. Occasionally drinks (1–2 alcoholic beverages/week). No safety concerns were reported.

Reports fatigue; denies weight change, fever, chills, or night sweats.

Denies chest pain, palpitations, orthopnea, or edema.

No delayed healing, rashes, or discoloration.

Denies cough, wheezing, dyspnea, or history of pneumonia or TB.

Uses reading glasses. No blurriness or recent visual changes.

No nausea, vomiting, diarrhea, constipation, black stools, ulcers, or abdominal pain.

No hearing loss, tinnitus, discharge, or pain.

No urgency, frequency, dysuria, or hematuria. Sexually active; no STIs. Normal urinary stream.

Denies dysphagia, hoarseness, bleeding, or dental pain.

No joint pain, swelling, or stiffness. Denies fractures or osteoporosis.

No lumps, bumps, or nipple discharge.

Denies weakness, syncope, seizures, or paresthesia.

No bruising, swollen glands, or transfusions. Denies excessive thirst or hunger.

Denies anxiety, depression, suicidal thoughts, or sleep difficulties.

Well-groomed, alert, in no acute distress.

Warm, dry, intact; no lesions.

Normocephalic; PERRLA; clear TM bilaterally; moist mucosa; non-erythematous throat.

Regular rate and rhythm; no murmurs or edema.

Breath sounds clear bilaterally; no wheezing or rales.

Soft, non-tender, obese abdomen; active bowel sounds.

No masses, tenderness or discharge. There is no discoloration of the skin.

Normal external genitalia; prostate smooth and non-tender.

Full ROM; ambulates without difficulty.

Alert, oriented; no motor or sensory deficits.

Calm, cooperative, with appropriate affect.

HbA1c, CMP, lipid panel, and urine microalbumin ordered today; previous A1c: 7.2%

A monofilament test was performed, and sensations were normal in both lower limbs. There were no symptoms of ulcerations or skin breakdown in any of them. The fundoscopic exam is to be deferred; instead, it is recommended that an annual examination of the retinae be carried out. At this time, no other tests were carried out.

o    1. Impaired glucose tolerance (R73.03): This condition represents a prediabetic stage with elevated glucose levels not yet diagnostic for diabetes. It’s typically asymptomatic and identified through routine labs (Liu et al., 2022). While this diagnosis is less likely in a patient already on therapy, continued monitoring is warranted to prevent worsening glycemic control and reclassification.

o    2. Diabetic peripheral neuropathy (E11.40): Often asymptomatic early on, this complication of T2DM involves sensory nerve damage, especially in the lower extremities. Although the patient currently has no symptoms, periodic screening remains essential (Bodman et al., 2024). Foot exams and sensation testing are critical to detect changes early and prevent ulceration or injury.

o    3. Essential hypertension (I10): A common comorbidity of diabetes that significantly increases cardiovascular risk (Iqbal & Jamal, 2023). Though controlled now, it requires long-term lifestyle and pharmacologic management. Monitoring for nephropathy and heart disease is essential in this population due to overlapping risk factors.

Diagnosis

o    Type 2 Diabetes Mellitus without complications (E11.9): The diagnosis is therefore consistent with the patient’s history, medication profile, and laboratory results. There are no signs of other complications, such as nephropathy, retinopathy or neuropathy. The current A1c is reasonable, given the patient’s age and other comorbidities. Metformin should still be continued, and the patient is compliant and possesses adequate knowledge of his condition (Goyal et al., 2023).

§  Further testing

In order to assess his diabetes and metabolic condition, the patient will be subjected to appropriate laboratory investigations. The ordered tests include a hemoglobin A1c as a measure of glycaemic control; a comprehensive metabolic panel (CMP) that tests the kidney and liver composite; a fasting lipid panel (FLP) that determines cardiovascular risk factors; and a urine microalbumin that checks for the onset of nephropathy among the diabetic population. These will enable any needed alterations in treatment and intervention if any abnormality is noted at the early stage.

§  Medication

The patient should still be on metformin 1000 mg orally twice a day. This is the first-line treatment for Type 2 diabetes mellitus based on efficacy, safety, and additive cardiovascular effects (Corcoran & Jacobs, 2021). The patient has stated that there has been no complaint of side effects of metformin, nausea, vomiting, or lactic acidosis signs. To maintain the safety and appropriateness of this medication, renal functions will be assessed.

§  Education

While with the patient, factors such as blood glucose checks, medication compliance, and lifestyle changes were emphasized (AlHaqwi et al., 2023). He was advised to maintain a healthy diet, avoid excessive portions, reduce carbohydrates and have balanced meals. The importance of physical activity and weight control programs was stressed. Screening tests for diabetic complications, including retinal exams as well as foot examinations, were discussed, and the need for annual examinations was emphasized.

§  Non-medication treatments

The patient was advised on the minimum recommendation of 150 minutes of moderate-intensity exercise in a week to include walking, swimming, or cycling. In the event that weight gain or eating issues do not improve, then the client will be referred to a dietitian. Smoking and alcohol use were quickly asked and answered and did not raise any concerns.

The patient is well-maintained and compliant in his treatment plan as well as actively involved in his well-being. No acute concerns were noted. A check-up is arranged in three months or if complications occur or develop in between.