SOAP Note on Diabetes: Pharmacotherapeutics Practical
Name: Sanjay Gupta
Age: 56 Years
Height: 6 Feet 2 Inches
Weight: 90 Kg
Subjective: The subjective include what the patient says about the problem/ intervention.
I am Type 2 diabetes first diagnosed two years ago.
I am also suffering from obesity and hypothyroidism.
I take heavy alcohol but quit drinking alcohol 3 years ago
O: Objective Findings
Objective: The objective section contains the information that the healthcare provider observes or measures from the patient current presentation.
The patient is asymptomatic.
PMH (Patient Medical History) of alcohol abuse (quit 2 years ago), obesity, and hypothyroidism.
Pertinent vital signs and Lab Values.
Blood Pressure: 165/101.
Regular pulse: 82 bpm.
Serum Creatinine: 1.2mg/dl.
Creatinine Clearance was calculated at 105.6mL/min or 65.7mL/min.
LDL: 134 mg/dl.
Assessment: The therapist’s analysis of various components of assessment after subjective and objective study. Here an assessment is diagnosis or condition the patient has.
High blood pressure
Nephropathy manifested as proteinuria
Obesity (BMI greater than 25) o AIC>/=5.7%
Blood pressure >/= 140/90; Hypertension.
Tight glycaemic control: Reduce A1C to less than 7% without causing hypoglycaemia.
Prevention of cardiovascular disease Diabetes Case SOAP.
The goal blood pressure for patients with diabetes is <130/<80. Reduce CVD risks by maintaining healthy cholesterol levels. LDL goal should be <100,
No current medications were mentioned. There is a need for therapy in order to lower AIC and manage the patient’s diabetes and related conditions.
Plan: How the treatment will be developed to reach the goal or objectives.
Further Tests and Work-Up
Liver function tests.
Repeat blood pressure to confirm hypertension.
CBC to rule out and monitor for infections.
A more detailed history is needed.
List of medications (current and failed therapies).
Medication Regimen adherence and barriers to adherence.
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