SOAP Note on Diabetes: Pharmacotherapeutics Practical
1. SOAP notes for Hypertension 2. SOAP notes for Angina Pectoris 3. SOAP notes for Myocardial Infarction 4. SOAP notes for Hyperlipidaemia 5. SOAP notes for Rheumatoid arthritis 6. SOAP notes for Asthma 7. SOAP notes for COPD 8. SOAP notes for Diabetes 9. SOAP notes for Epilepsy 10. SOAP notes for Stroke 11. SOAP notes for Depression 12. SOAP notes for Tuberculosis 13. SOAP notes for Anaemia 14. SOAP notes for Viral infection 15. SOAP notes for Dermatological conditions
Patient Information
Name: Sanjay Gupta
Age: 56 Years
Height: 6 Feet 2 Inches
Weight: 90 Kg
S: Subjective
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.
A: Assessment
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.
Related Complications
High blood pressure
Dyslipidaemia
Nephropathy manifested as proteinuria
Risk Factors
Obesity (BMI greater than 25) o AIC>/=5.7%
Blood pressure >/= 140/90; Hypertension.
Therapeutic Goals
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.
P: Plan
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).
Family history.
Previous immunizations.
Medication Regimen adherence and barriers to adherence.
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