Comprehensive SOAP note

Comprehensive SOAP Note: New-Onset Type 2 Diabetes Mellitus (T2DM) with Obesity and Early Albuminuria Student's Name Institution Course Name Instructor Date Comprehensive SOAP Note: New-Onset Type 2 Diabetes Mellitus (T2DM) with Obesity and Early Albuminuria S: Subjective JM, a 54-year-old male, has an enquiry about history and physical. The patient denies cutting back on fluid consumption but urinates three to four times per night. JM also reports that he is fatigued, has blurred vision, and has lost 10 lbs of weight. He rejects fever, chills, dysuria, pain in the flank, pain in the abdomen, vomiting, chest pain, dyspnea, confusion, or recent use of glucocorticoid (Le et al., 2024). Food is upgraded carbohydrates and sugary sweet drinks; he is inactive in his delivery work. This is an average of five to six hours of sleep. A history of an earlier observed borderline high blood pressure, which was untreated, is documented. No kidney issues, heart ailments, CVA, or pancreas issues; has had the appendix removed at age 13. JM does not take any medications and has no known drug allergies. He has type II diabetes mellitus in his paternal family history (in his 60s) and a cardiac infarction. His maternal family has a history of hypertension (Młynarska et al., 2025). Socially, JM does not smoke and consumes only 1-2 alcoholic beverages per week. He lives with his partner. Polyuria, polydipsia, fatigue, blurred vision, and tingling sensations are notable upon reviewing the system's history. There are no outlying foot wounds, claudication, or burning during urination. O: Objective Vitals BP 148/92 mmHg (repeat 146/90), HR 88 bpm, RR 16, Temp 36.8°C, SpO₂ 98% on room air, BMI 32 kg/m². Physical Examination The patient has not expressed any physical discomfort at this time, has no sores in the mouth or throat area, has a full range of motion throughout their neck, and does not show signs of swelling in any area of their neck. JM's heart appears normal with no irregular rhythms or other sounds. The lungs sound clear when taken in both directions; the individual's abdomen shows no signs of inflammation or other abnormalities. The individual's skin has patches of darkened areas of skin that appear on both sides of his body, down toward his legs, with no puffiness to either side of his body. JM feels a slight sensation in both feet with a level 2 out of a possible 5 in both legs, but has some difficulty maintaining balance when walking due to early signs of significant nerve damage and slow-moving compared to other individuals. Diagnostics Random glucose 246mg/dl, fasting glucose 182mg/dl, HbA1c 8.9%. Urinalysis: glucosuria, no infection, negative ketones. Creatinine 1.0mg/dL (eGFR 85mL/min/1.73m2), potassium 4.3mEqL. Lipids: LDL 148, HDL 38, triglycerides 210. UACR 45 mg/g. The patient has lipid levels and microalbuminuria, which are signs of poor glycemic control. A: Assessment ...