SOAP Note Soap Note essay



PatientInitials: ANG Age:27 years Gender:Female


ChiefComplaint (CC):complains of having escalated hypertension

History ofPresent Illness (HPI):27-year-oldfemalehasbeen having severe hypertension after being in a diabeticketoacidosis medication for 14 years. Her medical history unravelsthat she contracted diabetic ketoacidosis aged fourteen years. Thepresence of hyaline and blood in her urine coupled with the severehypertension prompted her to visit the clinic.

Medications:Currently under 25 mg daily Hydrochlorothiazide medication.

Allergies:No specific allergies.

PastMedical History:The patient has been diabetic for 14 years. No history ofhospitalization.

PastSurgical History:None.

Sexual/ReproductiveHistory:No highlighted key sexual or reproductive aspects.



SignificantFamily History:None


Review ofSystems:

General:Thepatient confides of weight gain

Skin:The patient affirms that no rashes or skin sores that have beenexhibited during the ailing period.



Key Signs:Blood pressure of 172/108 mmHg

General:A27-year-old female who appears energetic, healthy and in excellentposture. General body weakness

Review ofSystems:


Head-Symmetrical head.

Eyes-theeyes have a completely transparent cornea coupled by a white sclera.

Ears-appear to be in the right posture and no lesions or visible palpablemasses.

Nose:her nose appears symmetrical with no evidence of nasal discharges orvisible lesions.

Tongue:The patients tongue appears centrally positioned.

Neck: No physical evidence of trauma.

Breasts:No pain or discharge.

Respiratory:No evidence of respiratory disorders or cough.

Cardiovascular/PeripheralVascular:No evidence of chest pain.

Gastrointestinal:Normal stool.

Genitourinary: No change in frequency.

Musculoskeletal:No symptoms of musculoskeletal complications.

Psychiatric:No evidence of psychiatric ailments.

Neurological:No evidence of neurological ailments.

Skin:No evidence of lumps or skin rashes.

Hematologic:No evidence ofhematologic ailments or complications.

Endocrine:Normal endocrine system.






The primarydiagnosis is accelerated hypertension. However, the assessment issubject to further analysis so as to ascertain the diagnosis.


The optimumobjective is to cut down the rate of hypertension and leverage thesymptoms of diabetic ketoacidosis.

TreatmentPlan:The patient can undergo a fluidreplacement either orally or intravenously. The patient can undergoan electrolyte replacement as well (electrolytes may encompasschlorides and potassium). Lastly, the patient can undertake anInsulin therapy.

HealthPromotion:take part in regular exercise and take balanced diet with extremelyminimal fat and cholesterol

DiseasePrevention:Maintain a steady daily diet.


From aclinical perspective, I’m now furnished with the information thatpatients ailing from diabetes ketoacidosis have intricate symptomswhich jeopardize their general health and wellbeing. Faced with acongruent scenario, I’ll screen the patients’ medical history ata deeper scrutiny level. I would also enquire concerning the patientsfamily history. I concur with the preceptor based evidence.


Gosmanov, A.,Gosmanova, E., &amp Dillard-Cannon, E. (2014). Management of adult diabetic ketoacidosis. Diabetes, Metabolic Syndrome And Obesity:Targets And Therapy, 255.

Westerberg, D.(2016). Diabetic Ketoacidosis: Evaluation and Treatment – American Family Physician. Retrieved 12 May 2016, from

Diabeticketoacidosis – Treatment – NHS Choices. (2016). Retrieved 12May 2016, from

Type 1diabetes in adults: diagnosis and management | diabetic-ketoacidosis| Information for the public | NICE. (2015). Retrieved12 May 2016, from