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    15-05-29 TBTC Soap Note

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    jhk0428
    This SOAP note summarizes a follow-up visit for a 58-year-old African American female with diabetes, COPD, depression, and obesity. Her blood sugar levels remain high at 200-260. She reports tingling in her extremities and blurred vision. Though she walks 3 times per week, her diet consists of unhealthy foods. Her depression is well-managed on Prozac. She smokes one pack every 3 days and wants to quit. The plan is to increase her diabetes medications, encourage more exercise, continue depression medications, reduce smoking, and schedule preventative screenings. The patient understood the plan as explained through teach-back methods.

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    15-05-29 TBTC Soap Note

    Uploaded by

    jhk0428
    355 views2 pages
    This SOAP note summarizes a follow-up visit for a 58-year-old African American female with diabetes, COPD, depression, and obesity. Her blood sugar levels remain high at 200-260. She reports tingling in her extremities and blurred vision. Though she walks 3 times per week, her diet consists of unhealthy foods. Her depression is well-managed on Prozac. She smokes one pack every 3 days and wants to quit. The plan is to increase her diabetes medications, encourage more exercise, continue depression medications, reduce smoking, and schedule preventative screenings. The patient understood the plan as explained through teach-back methods.

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    15-05-29 Tbtc Soap Note

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    This SOAP note summarizes a follow-up visit for a 58-year-old African American female with diabetes, COPD, depression, and obesity. Her blood sugar levels remain high at 200-260. She reports tingling in her extremities and blurred vision. Though she walks 3 times per week, her diet consists of unhealthy foods. Her depression is well-managed on Prozac. She smokes one pack every 3 days and wants to quit. The plan is to increase her diabetes medications, encourage more exercise, continue depression medications, reduce smoking, and schedule preventative screenings. The patient understood the plan as explained through teach-back methods.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    355 views2 pages

    15-05-29 TBTC Soap Note

    Uploaded by

    jhk0428
    This SOAP note summarizes a follow-up visit for a 58-year-old African American female with diabetes, COPD, depression, and obesity. Her blood sugar levels remain high at 200-260. She reports tingling in her extremities and blurred vision. Though she walks 3 times per week, her diet consists of unhealthy foods. Her depression is well-managed on Prozac. She smokes one pack every 3 days and wants to quit. The plan is to increase her diabetes medications, encourage more exercise, continue depression medications, reduce smoking, and schedule preventative screenings. The patient understood the plan as explained through teach-back methods.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    Team-based Teaching Clinic (TBTC) SOAP note

    Student name: James Kaan


    Date: 05-29-2015
    Student Gender: M
    Subjective The patient, a 58-year-old African-American female with a past medical
    history of Diabetes Mellitus Type 2, COPD, and depression, presented to clinic for a
    follow-up visit.
    1. T2DM and Obesity:
    - The patient reports that she has been checking her blood sugar 3 times / day
    and its been around 200-260
    - Has experienced some tingling in her arms and legs feels like bugs
    crawling on me
    - Exercise: She says shes been walking 3 times / week for about 30 minutes
    - Diet: Eats whatever she wants. Likes pizza, chicken, fish
    a. Vision: Has experienced blurred vision for a few weeks wants an eye
    appointment
    b. Foot: Wants an appointment with the foot doctor
    2. Depression:
    - The patient reports that her mood has been doing a lot better
    - She is taking Prozac and acknowledges that she does not do well without it
    - She reports that she has been sleeping well
    - Has a lot of undue stress in her life because of her family members
    3. Tobacco use:
    - Down to 1 pack every 3 days
    - Expresses a desire to quit but does not want to use Chantix because of a
    previous bad experience with it
    The patients full past medical history includes: T2DM, COPD Chronic Bronchitis, HTN,
    Depression, Vit D deficiency, obesity, and arthritis.
    Health Maintenance:
    - Mammogram is due (2 months)
    - Diabetes Labs due (1 month)
    Medication Review:
    - Accucheck
    o Checks sugar 3 times per day
    - Taking Janumet, but seems to be less compliant with insulin injections
    - No long-acting insulin currently on her med list probably needs one if its
    not a clerical error
    Objective: * (I did not perform this PE, because my patient did not show up.
    Therefore, some of these are based on what I assume Seth felt, saw, and heard as
    I observed him)

    As of 7-29-2013

    Temp 98.9 F

    BP 142/88

    Weight 296 lbs

    1. General appearance: Seemed sad and her affect was noticeably depressed.
    However, her mood and affect improved dramatically when Dr. Marion came in.
    2. HEENT: PERRLA, no carotid bruits, neck supple, no thyroid masses
    3. CV: Regular rhythm w/ no murmurs
    4. Resp: Normal breath sounds
    5. Abdominal: Normal bowel sounds, no renal bruits, no masses, soft and
    nontender, no hepatosplenomegaly
    6. Ext: No pitting edema, 2+ pedal pulses
    7. Skin: No rashes, discoloration, lesions
    8. Neuro: Sensation in feet was normal
    9. Psych: no obvious signs of depression or anxiety
    10. Eye Exam: R. 20/20; L. 20/25;
    Assessment and Plan:
    This is a 58-year-old female with poorly-controlled T2DM, obesity, COPD, and
    depression. Although she acknowledges the need for lifestyle changes, she needs a
    greater sense of urgency to manage her conditions, particularly her weight and DM.
    1. T2DM and Obesity:
    - Her blood sugar recordings of 200-260 is still too high. Also, her med list did
    not include a long-acting insulin (i.e Lantus)
    o Increase Novolog 2 units with meals (up to 50 units)
    If blood sugar above 200, increase another 2 units
    o Meet with Dr. Kirk to address diabetes control and fine-tune
    medication
    o Return in 1 month for labs and blood work
    - Encourage patient to increase walking from 3 to 5 times per week
    4. Depression:
    - Support and reassurance
    - Medication seems to be working
    o Continue Prozac 2 capsules by mouth every morning
    5. Tobacco use:
    - Continue decreasing tobacco use
    o Consider cutting back to 1 pack per 4 days
    6. Health Maintenance:
    - Schedule a mammogram for July (in 2 months)
    The above plan was discussed with and provided to the patient in written form. The
    teach-back method was used and the patient expressed adequate understanding.

    As of 7-29-2013

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