| Course | NUR 616 Primary Care of Adults and Gerontological Patients |
|---|---|
| Module | Module 2 |
| Paper type | SOAP note for type 2 diabetes with chronic kidney disease |
| Length | About 1,010 words, 6 pages |
| Format | APA 7 student paper |
| School | Southern New Hampshire University |
| Program | MSN |
| Updated | September 2026 |
Free sample paper for NUR 616 Module 2
SOAP Note: Type 2 Diabetes With Albuminuric Chronic Kidney Disease in a 58-Year-Old Man
[Student Name]
Southern New Hampshire University
NUR 616: Primary Care of Adults and Gerontological Patients
Module Two SOAP Note
[Instructor Name]
[Date]
The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.
SOAP Note: Type 2 Diabetes With Albuminuric Chronic Kidney Disease in a 58-Year-Old Man
For many years, the main question at a diabetes visit was how to lower the A1c. For patients whose kidneys are already leaking albumin, the more important question is how to slow kidney failure and prevent heart events, and some drugs answer that question independently of their effect on glucose. This SOAP note documents a visit in which a man's diabetes treatment is changed chiefly for his kidneys. It shows how staging chronic kidney disease correctly, choosing drugs with outcome evidence and planning safety monitoring turn a routine visit into kidney protection.
Subjective
Chief concern: follow-up for diabetes and review of laboratory results.
History of present illness: Mr. B., 58, services city buses for a living and learned he had type 2 diabetes nine years ago. He takes metformin 1,000 mg twice daily and reports missing an evening dose about once a week. He checks his glucose a few mornings a week, with readings between 150 and 190 mg/dL. He denies symptoms of low blood sugar, increased thirst, blurred vision and foot numbness or ulcers. He was told last year that there was "a little protein" in his urine. For blood pressure he takes lisinopril 20 mg each morning, and for cholesterol, atorvastatin 20 mg at night. He denies chest pain, shortness of breath, leg swelling and change in urination.
Other history: no history of heart attack, stroke, heart failure, pancreatitis or genital infections. Allergies: none. Social: married; never smoked; drinks two beers on weekends; eats one fast-food meal most workdays; walks little outside work. Family: father on dialysis in his late sixties with diabetes; mother with hypertension.
Review of systems: General: no weight change. Eyes: last dilated eye examination 18 months ago, told "early changes." Genitourinary: no dysuria, frequency or nocturia. Musculoskeletal: no joint pain. Neurologic: no numbness or tingling.
Objective
Vital signs: blood pressure 142/88 mm Hg and 140/86 mm Hg on repeat after five minutes, pulse 78, weight 104 kg, BMI 33.1.
Examination: no acute distress. Eyes: fundoscopy through undilated pupils limited; no hemorrhages seen. Cardiovascular: regular rhythm, no murmur; no carotid bruits. Lungs: clear. Extremities: no edema. Feet: skin intact, no calluses or ulcers; both foot pulses easy to feel on each side; he felt the monofilament everywhere it was applied; vibration sense intact at the great toes.
Laboratory results: hemoglobin A1c 8.4% (7.9% six months ago). Serum creatinine 1.52 mg/dL with eGFR 52 mL/min/1.73 m² (eGFR 55 one year ago). Urine albumin-to-creatinine ratio 420 mg/g today and 360 mg/g three months ago. Potassium 4.6 mmol/L. LDL cholesterol 96 mg/dL. Liver enzymes normal.
Assessment
1. Chronic kidney disease, stage G3a A3, due to diabetic kidney disease. His eGFR of 52 places him in category G3a, and two albumin-to-creatinine ratios above 300 mg/g three months apart place him in category A3, severely increased albuminuria. This combination carries a high risk of progression to kidney failure and of cardiovascular events, and his father's dialysis underlines it.
2. Type 2 diabetes, above goal, with A1c 8.4% and rising.
3. Hypertension, not at goal; the KDIGO target for most people with diabetes and chronic kidney disease is a systolic pressure below 120 mm Hg when tolerated, and his readings are well above that.
4. Hyperlipidemia on moderate-intensity statin; obesity.
The central decision is to add a sodium-glucose cotransporter 2 inhibitor. CREDENCE randomized 4,401 people whose diabetic kidneys were already spilling large amounts of albumin, and canagliflozin reduced the composite of kidney failure, doubling of creatinine or death from kidney or cardiovascular causes by 30%, with a hazard ratio of 0.70 (Perkovic et al., 2019). DAPA-CKD, with 4,304 participants, about two thirds of them diabetic, found that dapagliflozin cut a similar composite with a hazard ratio of 0.61 (Heerspink et al., 2020). KDIGO's 2022 diabetes guideline therefore advises an SGLT2 inhibitor for anyone with type 2 diabetes whose kidney disease has left an eGFR of at least 20, alongside metformin when eGFR is 30 or higher and a maximally tolerated ACE inhibitor or angiotensin receptor blocker when albuminuria is present (Rossing et al., 2022). Mr. B. meets each criterion.
Plan
Kidney and diabetes: start dapagliflozin 10 mg once daily. Continue metformin 1,000 mg twice daily, which remains appropriate at an eGFR of 45 or higher, and use a weekly pill box to help with missed evening doses. Blood pressure and albuminuria: increase lisinopril from 20 mg to 40 mg daily, the maximum dose. Laboratory monitoring: basic metabolic panel in two weeks to check potassium and creatinine after both changes; an early fall in eGFR of up to about 10% to 30% after starting an SGLT2 inhibitor is expected and is not a reason to stop. Repeat A1c and urine albumin-to-creatinine ratio in three months. If albuminuria remains high despite these steps, a nonsteroidal mineralocorticoid receptor antagonist can be considered at the next review. Lipids: increase atorvastatin to 40 mg daily for his high cardiovascular risk. Eyes: referral for a dilated eye examination, overdue.
Education
Mr. B. was told that the new pill protects his kidneys and heart even beyond its effect on blood sugar. Sick day rules: on any day that vomiting, diarrhea or fever keeps him from eating and drinking as usual, he skips dapagliflozin, metformin and lisinopril, and restart when he has been eating and drinking for 24 to 48 hours; this lowers the risk of dehydration, kidney injury and a rare form of ketoacidosis with near-normal glucose. He was taught to keep the genital area clean and dry and to report itching or discharge, since genital yeast infections are the most common side effect. He will also try to replace the workday fast-food meal with a packed lunch three days a week, a goal he chose.
Conclusion
This visit changed Mr. B.'s treatment because of his kidneys, not only his glucose. Staging his disease as G3a A3, adding an SGLT2 inhibitor with outcome evidence, maximizing his ACE inhibitor and planning for the expected creatinine change give him the best available chance of avoiding the dialysis his father needed.
References
Heerspink, H. J. L., Stefansson, B. V., Correa-Rotter, R., Chertow, G. M., Greene, T., Hou, F.-F., Mann, J. F. E., McMurray, J. J. V., Lindberg, M., Rossing, P., Sjostrom, C. D., Toto, R. D., Langkilde, A.-M., & Wheeler, D. C. (2020). Dapagliflozin in patients with chronic kidney disease. New England Journal of Medicine, 383(15), 1436-1446. https://doi.org/10.1056/NEJMoa2024816
Perkovic, V., Jardine, M. J., Neal, B., Bompoint, S., Heerspink, H. J. L., Charytan, D. M., Edwards, R., Agarwal, R., Bakris, G., Bull, S., Cannon, C. P., Capuano, G., Chu, P.-L., de Zeeuw, D., Greene, T., Levin, A., Pollock, C., Wheeler, D. C., Yavin, Y., . . . Mahaffey, K. W. (2019). Canagliflozin and renal outcomes in type 2 diabetes and nephropathy. New England Journal of Medicine, 380(24), 2295-2306. https://doi.org/10.1056/NEJMoa1811744
Rossing, P., Caramori, M. L., Chan, J. C. N., Heerspink, H. J. L., Hurst, C., Khunti, K., Liew, A., Michos, E. D., Navaneethan, S. D., Olowu, W. A., Sadusky, T., Tandon, N., Tuttle, K. R., Wanner, C., Wilkens, K. G., Zoungas, S., & de Boer, I. H. (2022). KDIGO 2022 clinical practice guideline for diabetes management in chronic kidney disease. Kidney International, 102(5S), S1-S127. https://doi.org/10.1016/j.kint.2022.06.008
What the NUR 616 Module 2 instructions ask for
SOAP note assignments in NUR 616 usually give an adult or older adult case, or ask you to write up a clinical encounter, and expect subjective and objective data, an assessment with each problem and its status and a plan with medications, monitoring, education and follow-up. The Module 2 note often centers on a common chronic condition such as diabetes, hypertension or hyperlipidemia. Expect three to five pages in APA 7 with current guidelines and trials. Stage or classify each condition with its criteria, give complete doses, explain why each drug was chosen over alternatives and state how you will monitor safety, because the course grades the link between data, decision and follow-up. Put each problem on its own numbered line.
How this NUR 616 Module 2 soap note example is built
This note follows a composite 58-year-old bus mechanic with type 2 diabetes, an A1c of 8.4%, uncontrolled blood pressure and two urine albumin-to-creatinine ratios above 300 mg/g with an eGFR of 52. The subjective section records adherence, home readings and a father on dialysis. The objective section repeats the blood pressure, documents the foot examination and trends the labs. The assessment stages chronic kidney disease as G3a A3 and uses CREDENCE, DAPA-CKD and the 2022 KDIGO guideline to justify dapagliflozin. The plan maximizes lisinopril, keeps metformin, raises the statin, anticipates the early eGFR dip and teaches sick day rules and infection signs, with three primary sources in support.
Where the NUR 616 Module 2 rubric puts the points
SOAP note rubrics in this course usually award points for relevant subjective data, a focused examination, accurate interpretation of laboratory results, a problem-based assessment with correct staging or classification, an evidence-based plan with complete prescriptions, monitoring, patient education and APA 7 support. Top-band notes explain why a drug was selected with outcome evidence, not only glucose effect, and include safety planning such as expected laboratory changes and sick day rules. Graders reward notes in which each problem's status is clear and each plan item follows from it. Referral for overdue screening, such as eye examinations, often earns points under health maintenance, as does a clear follow-up date.
NUR 616 Module 2 help: the mistakes that cost points
Diabetes SOAP notes lose points when kidney disease is described without eGFR and albuminuria categories, when an SGLT2 inhibitor is added without mentioning the expected creatinine rise, when metformin is stopped unnecessarily or when doses and follow-up laboratory tests are missing. Another common gap is treating glucose while ignoring blood pressure and lipids. Stage each condition, cite outcome trials for major drug choices, give complete doses, plan monitoring with timing and teach sick day rules. If your case involves insulin, heart failure or an older adult with hypoglycemia risk, send the case and template for a note built on that patient and the guideline that governs the decision.
Get NUR 616 Module 2 written to your instructions
Send the case, your SOAP template and the rubric. A note that stages each condition, chooses drugs with outcome evidence, gives complete doses and plans monitoring and education will be finished in 24 to 48 hours, and the first one is free. The paper above is an original model document written by our desk, not a submitted student paper and not an official Southern New Hampshire University document.
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NUR 616 Module 2 questions, answered
Where can I find a free NUR 616 Module 2 SOAP Note sample?
This page shows a complete SOAP note: type 2 diabetes with albuminuric chronic kidney disease in a 58-year-old, with CKD staging, an SGLT2 inhibitor, ACE titration and sick day rules.
How is chronic kidney disease staged?
By eGFR category, G1 to G5, and albuminuria category, A1 to A3, based on the urine albumin-to-creatinine ratio. An eGFR of 52 with a ratio above 300 mg/g is stage G3a A3.
Why use an SGLT2 inhibitor in diabetic kidney disease?
Trials such as CREDENCE and DAPA-CKD showed that SGLT2 inhibitors slow kidney decline and reduce kidney failure and cardiovascular death, beyond their effect on glucose.
Is a creatinine rise after starting an SGLT2 inhibitor dangerous?
A modest early fall in eGFR is expected and reflects reduced pressure within the kidney's filters. It is not usually a reason to stop the drug, but labs should be checked.
What are sick day rules for diabetes medicines?
When a patient cannot eat or drink normally because of illness, SGLT2 inhibitors and metformin are paused, and often ACE inhibitors and diuretics, then restarted after recovery to prevent dehydration and kidney injury.