SOAP template - VA (Clone)

1. Diabetes mellitus:
- Reports feeling okay, actively trying to keep blood glucose under control
- Adheres to metformin regimen daily with no side effects
- No known drug allergies
- Reports recent diagnosis of diabetes in younger brother
- Monitors blood glucose at home approximately three times per week, usually in the morning

2. Hypertension:
- Reports actively trying to keep blood pressure under control
- Adheres to ramipril regimen daily with no side effects
- No known drug allergies
- Seeks dietary advice regarding sodium intake

O/
Well NAD
Vital signs: Blood pressure 138/84 mmHg, weight 84 kg, body mass index 28.3
Fasting glucose 7.8 mmol/L, hemoglobin A1c 7.2%
Lipid panel: low-density lipoprotein 2.4 mmol/L, triglycerides 1.8 mmol/L
CV: S1/S2, regular
Resp: AE=AE, no adventitious sounds
Abdomen: soft, no tenderness
No ankle swelling
No foot ulcers or skin issues
Foot sensation intact

Assessment and Plan:
A/P
1. Type 2 diabetes mellitus:
- Continue metformin as prescribed
- Reinforce dietary modifications: high-fibre, low-glycemic foods, avoid sugary drinks
- Encourage regular physical activity: walking and light strength training twice weekly
- Refer to dietitian for personalized nutrition guidance
- Repeat laboratory investigations in 3 months
- Maintain home glucose monitoring and bring log to next visit
- Educate on importance of glycemic control to reduce risk of complications
- RTC prn

2. Essential hypertension:
- Continue ramipril as prescribed
- Advise limiting sodium intake to approximately 1 teaspoon per day, including processed and restaurant foods
- Educate on reading food labels and using herbs for flavor instead of salt
- Reinforce importance of blood pressure control to reduce cardiovascular and renal risk
- RTC prn

3. Dyslipidemia:
- Monitor lipid profile, target low-density lipoprotein under 2.0 mmol/L
- Reinforce dietary and lifestyle modifications
- RTC prn