Question

Directions: Please read the directions below carefully. I have left the document in WORD format so that it’s easier for you to do your assignment. You will have to take the pertinent information in the document and organize it into a SOAP note.

1. Use the case to develop the Subjective, Objective, Assessment, and Plan sections of the SOAP. You will need to take the information received from the patient interview and the information obtained from the patient chart to write the SOAP note. Be sure to include only pertinent information that is complete, concise, and correct. Remember to follow the format with header, CC, HPI, PMH, etc. DO NOT CREATE YOUR OWN ASSESSMENT AND PLAN, JUST USE THE STATEMENTS PROVIDED IN THE CASE.

2. Be sure to include the appropriate header and closure, and sign the SOAP note properly.

You receive the following information from your patient, SM: SM is a 55 y/o AAF (DOB 07/07/64; MRN 54321) who comes to the pharmacy for the diabetes education class taught by you, the pharmacist. She tells you, “my sugars are high.” She would like for the pharmacist to check her blood sugar before the class begins. She was diagnosed with type 2 DM about 1 year ago. She had been attempting to control her disease with diet and exercise, but had no success. Her physician started her on metformin 1000mg BID about 6 months ago. She has gained 10lb over the past year. SM monitors her blood sugar once a day. She brought her glucometer with readings from the past 2 weeks, which includes a log with blood glucose levels ranging from 215 to 280 mg/dL around 2 hours after dinner, and fasting blood sugars ranging from 170 to 202 mg/dL. Pt states she cannot remember what her blood glucose levels are supposed to be. She wants to lose 10 pounds. When asked about her family history, the patient explains her father had high blood pressure, DM2, dyslipidemia, and died of a heart attack at the age of 75. Her mother is still alive at 80 years old with hypothyroidism and high blood pressure. Brother has DM2 thought to be secondary to alcoholism. She has twin sons, ages 19, both are healthy. The patient is happily married to her husband of 25 years. She is currently employed as a social worker. She has 1-2 glasses of sangria on Saturdays during book club with her friends. She has been smoking 1/2 pack of cigarettes daily for the past 35 years. You ask her if she would like to quit smoking and she replies, “yes”, and is interested in the patch. She has a “sweet tooth” and loves to snack on cookies and chips throughout the day. She tells you her favorite foods are soul food and Italian food including fried chicken, spaghetti, and macaroni and cheese. She drinks 2-3 cans of soda pop daily at work. She walks a lot at work but does not exercise. You take the patient’s random blood glucose measurement with a point-of-care device (POCT), which you find to be 245 mg/dL. She also wants her blood pressure measured because she has had high blood pressure for 5 years. She’s allergic to sulfa- she had anaphylaxis. In addition to DM2, she also has hypertension. She is taking metformin 1000mg by mouth twice a daily with breakfast and dinner for 6 months for type 2 diabetes, amlodipine 10mg by mouth once a day in the morning for high blood pressure for 5 years, and one or two tablets of acetaminophen 500mg by mouth every six hours as needed about 1-2 times a week when she gets back pain. She is adherent to her meds, however, she will get a headaches sometimes when she is hungry. The following information you found in the patient’s chart: Labs 10/22/19: Na 140 mEq/L Ca 9.8 mg/dL T. chol 151 mg/dL Gluc (POCT) 245 mg/dL K 3.7 mEq/L LDL 76 mg/dL A1C 8.6% Cl 100 mEq/L HDL 46 mg/dL CO2 22 mEq/L AST 16 IU/L Trig 147 mg/dL RBC 5.03 X 106/uL ALT 17 IU/L Hgb 13.8 g/dL BUN 10 mg/dL Alk phos 81 IU/L TSH 1.49 Hct 41.5 % SCr 0.93 mg/dL T. bili 0.7 mg/dL Plts 284 X 103/uL The MD performs a physical examination on the patient and finds the following: Vitals-10/22/19 BP: 126/78 P: 98, RR 18 Temp: 37.0°C Weight: 85 kg Height: 5’6” BMI 30.2 kg/m2 ROS Gen: The patient is in NAD HEENT: PERRLA, EOMI, R & L fundus exam without retinopathy Lungs: Clear to A & P CV: RRR, no m/r/g Abd: centrally obesity, nontender, nondistended, + bowel sounds Genit/Rect: Deferred MS/Ext: Carotids, femorals, popliteals, and right dorsalis pedis pulses 2+ throughout; left dorsalis pedis 1+; feet show mild calluses on MTPs Neuro: A&O x 3, CN II-XII grossly intact, no focal neurologic deficits You, the pharmacist, make your assessment and plan as follow: Type 2 diabetes is uncontrolled due to elevated A1c of 8.6%, elevated POCT glucose at 245 mg/dL, also, elevated glucometer readings with fasting glucose ranging from 170 to 202 mg/dL and postprandial glucose ranging from 215 to 280 mg/dL. The goal is to decrease the A1c to less than 7%, and reduce fasting glucose to 80-130 and postprandial glucose to less than 180. Plan is to initiate empagliflozin 10mg daily for better diabetes control and add atorvastatin 20mg daily for primary prevention of cardiovascular events. Educated patient that side effects of empagliflozin                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        include urinary tract infection and genitourinary fungal infection. She should continue to check blood fasting and post-prandial dinner sugars. She was advised to incorporate lifestyle modifications such as increasing moderate-intensity physical activity to at least 150 min/week, reduction in calories and carbohydrates, and losing weight. The patient should return to clinic for a follow-up A1c in 3 months. Hypertension is controlled at 126/78 mmHg and the goal is less than 130/80. Pt is to continue amlodipine 10mg daily. She was educated to decrease sodium and fried food intake. The patient should return to clinic for a follow-up for a blood pressure at the next visit. The patient is currently smoking 1/2 ppd of cigarettes and would like to quit smoking with the nicotine patch. The goal is to reduce the number of cigarettes a day. Since patient is smoking 1/2ppd she will start with 14mg/day for six weeks, followed by 7 mg/day for two weeks. The patient was counseled to apply one patch each morning to any non-hairy skin site and rotate the site daily to avoid skin irritation. The patient was also counseled if she experiences insomnia and vivid dreams at night then she can remove the patch before bedtime. The patient should return to clinic for a follow-up to assess smoking status at the next visit.

Answer 1

Name: SM

MRN: 54321

DOB: 07/07/1964

DOS;

S: Chief Complaint: Diabetes education class for diabetes mellitus type 2.

HPI:  SM is a 55-year-old African-American female who presents to the pharmacy for the diabetes education class. She says her sugars are high. She wants a blood sugar check before the class begins. She was diagnosed with type 2 DM about one year ago. She had been attempting to control her disease with diet and exercise, but had no success. She was started on metformin 1000 mg b.i.d. about 6 months ago. She has gained 10 pounds over the past year. She monitors her blood sugar once a day. She brought her glucometer with readings from the past 2 weeks, which includes a log with 2 hours postprandial blood glucose levels ranging from 215 to 280 mg/dL and fasting blood sugars ranging from 170 to 202 mg/dL. The patient states she cannot remember what her blood glucose levels are supposed to be. She wants to lose 10 pounds. The patient’s random blood glucose measurement with a point-of-care device (POCT), which you find to be 245 mg/dL. She also wants her blood pressure measured because she has had high blood pressure for 5 years.

In addition to DM2, she also has hypertension.

Family history: When asked about her family history, the patient explains her father had high blood pressure, DM2, dyslipidemia, and died of a heart attack at the age of 75. Her mother is still alive and is 80 years old with hypothyroidism and high blood pressure. Brother has DM2 thought to be secondary to alcoholism. She has twin sons, ages 19, both are healthy.

Social history: The patient is happily married to her husband of 25 years. She is currently employed as a social worker. She has 1-2 glasses of sangria on Saturdays during book club with her friends. She has been smoking 1/2 pack of cigarettes daily for the past 35 years. When asked if she would like to quit smoking, she replied “yes,” and is interested in the patch. She has a “sweet tooth” and loves to snack on cookies and chips throughout the day. She tells you her favorite foods are soul food and Italian food including fried chicken, spaghetti, and macaroni and cheese. She drinks 2-3 cans of soda pop daily at work. She walks a lot at work, but does not exercise.

Allergies: She’s allergic to SULFA - she had anaphylaxis.

Medications: The patient is taking metformin 1000 mg by mouth b.i.d. with breakfast and dinner for 6 months for type 2 diabetes, amlodipine 10 mg by mouth once a day in the morning for high blood pressure for 5 years, and one or two tablets of acetaminophen 500 mg by mouth every six hours as needed about 1-2 times a week when she gets back pain.

ROS:

O: Vitals-10/22/19: BP: 126/78. P: 98. RR 18. Temp: 37.0°C. Weight: 85 kg. Height: 5’6”. BMI 30.2 kg/m². Physical examination: Gen: The patient is in NAD. HEENT: PERRLA, EOMI, R & L fundus exam without retinopathy. Lungs: Clear to A & P. CV: RRR, no m/r/g. Abd: central obesity, nontender, nondistended, positive bowel sounds. Genit/Rect: Deferred. MS/Ext: Carotids, femorals, popliteals, and right dorsalis pedis pulses 2+ throughout; left dorsalis pedis 1+; feet show mild calluses on MTPs. Neuro: A&O x 3, CN II-XII grossly intact, no focal neurologic deficits.

LABORATORIES: Na 140 mEq/L, K 3.7 mEq/L, Cl 100 mEq/L, CO2 22 mEq/L, BUN 10 mg/dL, Ca 9.8 mg/dL, SCr 0.93 mg/dL, AST 16 IU/L, ALT 17 IU/L, alkaline phosphatase 81 IU/L, T. bili 0.7 mg/dL, T. Chol 151 mg/dL, LDL 76 mg/dL, HDL 46 mg/dL, triglycerides 147 mg/dL, TSH 1.49, glucose (PCOT) 245 mg/dL, A1C 8.6%, RBC 5.03 X 106/uL, Hgb 13.8 g/dL, Hct 41.5%, and platelets 284 x 103 uL.

A: 1. Type 2 diabetes is uncontrolled due to elevated A1c of 8.6%, elevated POCT glucose at 245 mg/dL, also, elevated glucometer readings with fasting glucose ranging from 170 to 202 mg/dL and postprandial glucose ranging from 215 to 280 mg/dL. The goal is to decrease the A1c to less than 7%, and reduce fasting glucose to 80-130 and postprandial glucose to less than 180.

2. Urinary tract infection and genitourinary fungal infection.

3. Hypertension is controlled at 126/78 mmHg and the goal is less than 130/80.

4. The patient is currently smoking 1/2 ppd of cigarettes and would like to quit smoking with the nicotine patch. The goal is to reduce the number of cigarettes a day. Since patient is smoking 1/2 ppd, she will start with 14 mg/day for six weeks, followed by 7 mg/day for two weeks.

P: Plan is to initiate empagliflozin 10 mg daily for better diabetes control and add atorvastatin 20 mg daily for primary prevention of cardiovascular events. Educated patient side effects of empagliflozin. She should continue to check blood fasting and post-prandial dinner sugars. She was advised to incorporate lifestyle modifications such as increasing moderate-intensity physical activity to at least 150 min/week, reduction in calories and carbohydrates, and losing weight. The patient should return to the clinic for a follow-up A1c in 3 months. The patient is to continue amlodipine 10 mg daily. She was educated to decrease sodium and fried food intake. The patient should return to the clinic for a follow-up for blood pressure at the next visit. The patient was counseled to apply one patch each morning to any non-hairy skin site and rotate the site daily to avoid skin irritation. The patient was also counseled if she experiences insomnia and vivid dreams at night, then she can remove the patch before bedtime. The patient should return to the clinic for a followup to assess smoking status at the next visit.