Ana Mort

SOAP note #2 diabetes

SUBJECTIVE:
CC: “My sugar is not regular at home”
XX is a 71 year old woman presenting to clinic with worsening diabetes type 2 and obesity. She
was unaware her cholesterol levels were high. She monitors sugar at home with Delica device.
Additionally, she mentioned her bp is normal and no concerns or low blood sugars.

Patient is adherent with medications and lifestyle recommendations. Patient expresses no other
concerns at follow up or side effects like kidney symptoms. She reports no problems with chores
or worsening conditions. However, her bp was elevated as measured by nurse.

OBJECTIVE:
Vitals: 156/92, 96.7 F, 86 bpm, rr 20, 96% o2
193 LBS, BMI 32.6
Physical Exam: General: normal affect, pleasant.
Heart and lung: clear lungs, no wheezes, normal heart sounds
Extremities: no ulcers on feet, normal

Current medications:
lisinopriL 10 mg tablet
simvastatin 40 mg tablet
Adult Low Dose Aspirin 81 mg tablet,delayed release
metFORMIN ER 500 mg tablet,extended release 24 hr
One touch Delica Lancets 30 gauge and Blue test strips

Labs:
116 fingerstick glucose 11/22/23 high
Ha1c-6.1 4-19-22
eye exam normal 3/5/2024
foot exam- normal 3/5/2024
urine micro albumin- 5.0 high 10-25-2023
pneumococcal vaccine- yes 2/6/2020
presence of statin-yes

ASSESMENT AND PLAN:

XX is a 71 year old woman presenting to clinic with worsening diabetes and obesity.

Diabetes: controlled
Patients HA1C was 6.1 on 4-19-22. Follow up requires new blood work to follow up on blood
control. This A1C was less than the maximum ADA guidelines of 7.0%.
Plan- continue medication regimen of metformin and increase exercise. Medications are
concordant with first line recommendations. Control blood pressure with lifestyle modifications
like healthy diet and low sodium. If worsening, questioning patients on difficulties with
medications or adherence can be done before talking about increasing dosage of medications.

Obesity- uncontrolled.
Plan-continue lifestyle modifications like exercise and diet. Patient was educated on
modifications including 30 min exercise daily and diet. If worsening, medications can be
discussed to help with blood sugar and weight loss.