SOAP Template - separate A & P

Subjective:
1. Type 2 Diabetes Mellitus:
- Richard reports he has been trying to keep his blood glucose under control by eating better and increasing physical activity, specifically walking more. He confirms adherence to metformin therapy with no side effects. He reports no known drug allergies. He mentions that his younger brother was recently diagnosed with diabetes.

2. Hypertension:
- Richard states he is making efforts to control his blood pressure. He confirms regular use of ramipril with no side effects. He reports no known drug allergies.

Objective:
- BP: 138/84 mmHg (slightly elevated, improved from last visit)
- Weight: 84 kg
- BMI: 28.3
- Fasting glucose: 7.8 mmol/L
- HbA1c: 7.2%
- LDL: 2.4 mmol/L
- Triglycerides: 1.8 mmol/L
- Heart sounds: normal
- Lungs: clear
- No ankle swelling
- Abdomen: soft, no tenderness
- Foot sensation: intact
- No foot ulcers or skin issues

Assessment:
1. Type 2 Diabetes Mellitus (E11.9): Glycemic control is stable with recent HbA1c at 7.2%. Fasting glucose is 7.8 mmol/L. No reported side effects from metformin. Family history is notable for a younger brother recently diagnosed with diabetes.
- DDx:
- Type 2 diabetes mellitus: Supported by laboratory findings and ongoing management.
- Secondary causes of hyperglycemia: Less likely given stable medication use and absence of new symptoms.

2. Essential Hypertension (I10): Blood pressure is 138/84 mmHg, slightly above target. No reported side effects from ramipril. No ankle swelling.
- DDx:
- Essential hypertension: Supported by history and current blood pressure readings.
- Secondary hypertension: Less likely in the absence of suggestive symptoms or findings.

3. Dyslipidemia (E78.5): LDL is 2.4 mmol/L and triglycerides are 1.8 mmol/L, both slightly above optimal targets.
- DDx:
- Primary dyslipidemia: Supported by laboratory findings.
- Secondary dyslipidemia: Less likely given stable medication use and no new contributing factors.

Plan:
1. Type 2 Diabetes Mellitus:
- Continue metformin as prescribed.
- Encourage dietary modifications focusing on high-fibre, low-glycemic foods and avoidance of sugary drinks.
- Maintain a log of home blood glucose monitoring and bring it to the next visit.
- Refer to dietitian for personalized nutritional guidance.
- Repeat laboratory tests in 3 months.

2. Essential Hypertension:
- Continue ramipril as prescribed.
- Limit sodium intake to approximately 1 teaspoon per day, including processed and restaurant foods.
- Read food labels and choose low-sodium or no added salt products.
- Engage in regular physical activity, including walking and light strength training twice weekly if possible.

3. Dyslipidemia:
- Continue current management and dietary recommendations.
- Reinforce importance of lipid control to reduce cardiovascular risk.

4. Follow up in 3 months with repeat laboratory evaluation.

Dr. Emily Carter
Regional Medical Center