Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Follow-up for central diabetes insipidus (CDI) or evaluation of new symptoms.
SOAP
Subjective (S):
Urinary Symptoms:
Inquire about the frequency and volume of urination.
Explore for symptoms suggestive of polyuria (excessive urination):
Nocturia (waking up at night to urinate)
Disrupted sleep due to frequent urination
Daytime urinary urgency
Hydration Status:
Ask about thirst and fluid intake.
Explore for any signs of dehydration, such as:
Dry mouth
Fatigue
Headache
Dizziness
Past Medical History:
Briefly summarize relevant past medical history, including:
Underlying cause of CDI (e.g., idiopathic, pituitary surgery, head trauma)
Comorbidities like diabetes mellitus
Treatment History:
Note the current medications used to manage CDI, including:
Desmopressin (DDAVP) dosage and route of administration (oral, intranasal)
Any other medications used for symptom control (e.g., diuretics for underlying conditions)
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, and respiratory rate. Assess for signs of dehydration.
Physical Exam:
Briefly document:
Skin turgor (hydration status)
Mucous membranes (dryness)
Weight (if relevant)
Consider neurological exam if suspicion of new central nervous system involvement.
Assessment (A):
Hydration Status:
Based on symptoms and physical exam findings, assess the patient’s hydration status.
CDI Control:
Evaluate the effectiveness of current CDI treatment based on:
Improvement in polyuria symptoms
Reduction in nocturia
Urine output and osmolality (if measured)
Absence of dehydration signs
Electrolytes (if measured):
Briefly mention serum sodium and potassium levels, which can be affected in CDI.
Plan (P):
Treatment Adjustments (if needed):
If symptoms persist or dehydration is present, adjust the CDI treatment plan:
Consider increasing DDAVP dosage or changing the route of administration.
Address other contributing factors like diuretic medications.
Laboratory Monitoring:
Order electrolytes (sodium, potassium) periodically to monitor for potential imbalances.
Consider measuring urine osmolality if needed to assess urine concentrating ability.
Education:
Reinforce patient education regarding:
Importance of staying hydrated based on thirst and urine output.
Recognizing signs of dehydration.
Proper administration of desmopressin medication.
Importance of follow-up appointments.
Follow-up:
Schedule follow-up visits based on disease control and the need for medication adjustments.
Additional Notes:
Document any other relevant information, such as:
Communication with consulting physicians (e.g., endocrinologist)
Addressing underlying causes of CDI (if possible)
Importance of managing other medical conditions that might contribute to polyuria (e.g., diabetes mellitus)
Exploring alternative treatment options if DDAVP is ineffective or poorly tolerated
Discussing the potential long-term complications of uncontrolled CDI (e.g., electrolyte imbalances)