Sample Patient Case SOAP Note Subjective: - Patient: AZ, 25 years old brought to the ED - Chief complaint: altered mental status - Found lethargic and slight confusion by her roommate - Experiencing 3 day history of cough and fever and 1 day of vomiting - Reports headache with pain score of 6/10 - Fingerstick glucose checked at home resulted as “high” - Medication allergies: Penicillin - rash, Bactrim - rash - PMH: type 1 diabetes, anxiety, hypercholesterolemia, asthma(exercise-induced) - Current meds - insulin glargine 18 units SQ at bedtime - insulin aspart 5 units SQ three times a day - escitalopram 10 mg PO daily - Lessina 1 tab PO daily Obiective: Vital signs Height 165 cm Weight 62 kg Temp Temp HR 125 bpm BP RR O2 saturation Glucose Pain score 100/65 mmHg 22 breaths/min 99% on room air > 600 mg/dL 6/10, headache Physical Exam constitutional Febrile, diaphoretic skin No rash, no petechiae eyes Pink conjunctiva, anicteric neck Supple, no meningismus, no JVD CARD RRR, no murmurs, equal radial pulses bilaterally 2+ resp CTAB, tachypneic ABD Sofr, non-tender, non distended, no peritoneal sign, no CVA tenderness EXT Normal rom x4, no edema neuro/psych Somnolent, cooperative, appropriate Other pertinent lab values sodium 125 mmoL/L chloride 91 mmoL/L potassium 3.6 mmoL/L glucose 665 mg/dL pH 7.22 PCO2 28 WBC 5.6 k/mcL acetone detected Urinalysis pregnancy negative WBC 0 RBC 0 glucose positive ketone positive Leukocyte esterase negative Assessment 1. Electrolyte imbalance from vomiting: Low sodium (125 mmoL/L), low chloride (91 mmoL/L) 2. Diabetic ketoacidosis which is evident by presence of ketones, glucose >600 mg/dL, pH 7.22, diarrhea, vomiting, presence of acetone, and mental state of lethargy and confusion 3. Possible lung infection: fever 101.4 F, cough, tachycardia, tachypnea (RR 22 bpm) Plan: Infection - Start on azithromycin 500 mg in D5W 250 mL IVPB over 60 minutes STAT - Start Ceftriaxone 1000 mg in D5W 50 mL IVPB over 30 minutes STAT Fluid replenishment - Fluid replenishment: administer Sodium Chloride 0.9% 1000 mI IV bolus over 30 minutes once STAT. - Add 20mmol/L potassium chloride to rehydration fluids Headache and fever - Administer 1000 mg acetaminophen IVPB over 15 min once STAT for headache and fever Nausea - Ondansetron 4 mg IV push once STAT Diabetic acidosis - Once electrolyte level are balanced, start a low dose of insulin therapy, intravenous bolus of 0.15 unit of regular insulin per kg followed by the continuous intravenous infusion of regular insulin prepared in normal saline or hypotonic saline solution at a rate of 0.1 unit per kg per hour for 30 minutes. - When a blood glucose concentration of 250 mg per dI has been achieved the continuous or hourly insulin dosage can be reduced to 0.05 unit per kg per hour. The insulin and fluid regimens are continued until ketoacidosis is controlled - When the patient is able to tolerate oral intake and DKA is resolved transition to subcutaneous insulin of the same regimen that AZ uses at home Further testing - Blood cultures and chest X-ray to identify potential source of infection Counseling points Upon Discharge - To monitor blood glucose at home - Prevent dehydration by drinking extra fluids - Emphasize the importance of medication adherence Monitoring drug adverse effects - Insulin: hypoglycemia, allergic reaction, erythema at injection site - Azithromycin: diarrhea, nausea, stomach pain - Ceftriaxone: Allergic reaction, shortness of breath, black tarry stool - Ondansetron: confusion, vomiting, diarrhea, QT prolongation - Acetaminophen: constipation, abdominal pain, nausea Reference Eledrisi MS, Elzouki A-N. Management of diabetic ketoacidosis in adults: A narrative review. Saudi journal of medicine & medical sciences. 2020. Accessed August 16, 2024. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7485658/. Podder V. Soap notes. StatPearls [Internet]. August 28, 2023. Accessed August 16, 2024. https://www.ncbi.nlm.nih.gov/books/NBK482263/. Osama Hamdy M. Diabetic ketoacidosis (DKA) treatment & management. Approach Considerations, Correction of Fluid Loss, Insulin Therapy. March 21, 2024. Accessed August 16, 2024. https://emedicine.medscape.com/article/118361-treatment?form=fpf.
