CLINICAL CHART SOAP NOTE Type 2 Diabetes Mellitus (E11.9) Case Study- NR 601 Chamberlain 2021/2022

Patient Information: Mrs. G., 55, Female, Hispanic S: Chief Complaint: Fatigue and increased weight gain HPI: Mrs. G., a 55-year-old Hispanic female, presents to the office for her annual exam. She reports that lately she has been very fatigued and just does not seem to have any energy. This has been occurring for 3 months. She is also gaining weight since menopause last year. She joined a gym and forces herself to go twice a week, where she walks on the treadmill at least 30 minutes but she has not lost any weight, in fact she has gained 3 pounds. She doesn’t understand what she is doing wrong. She states that exercise seems to make her even more hungry and thirsty, which is not helping her weight loss. She wants get a complete physical and to discuss why she is so tired and get some weight loss advice. She also states she thinks her bladder has fallen because she has to go to the bathroom more often, recently she is waking up twice a night to urinate and seems to be urinating more frequently during the day. This has been occurring for about 3 months too. This is irritating to her, but she is able to fall immediately back to sleep. Current Medications: Tylenol 500 mg 2 tabs daily for knee pain. Daily multivitamin. Allergies: NKDA, allergic to cats and pollen. No latex allergy PMHx: Left knee arthritis. Had chicken pox and mumps as a child. Vaccinations up to date. GYN Hx: G2 P1. 1 SAB, 1 living child, full term, wt. 9 lbs. 2 oz. LMP 15 months ago.