SOAP Note week 6

Name: F.O

Pt. Encounter Number:

Date: 08/21/2020

Age: 38

Sex: Male

SUBJECTIVE

CC:

“I came to review my labs from last week”

HPI:

This patient was seen at the office last week for a general checkup and to conduct blood lab tests. He has no current health complaints; however, he is overweight in BMI and states that he eats unhealthy foods. Blood tests conducted include CBC, CMP, Lipid Panel, HbA1c, and Urinalysis. Additionally, the patient wanted STD panel screenings because he is sexually active without protection.

Medications: (List with reason for med )

No currently taking any medication.

PMH

Allergies: NKDA; No reported food or environmental allergies.

Medication Intolerances: None

Chronic Illnesses/Major traumas: Overweight BMI

Hospitalizations/Surgeries: None

Family History

Father: 68 years old, HTN, T2DM, Osteoarthritis

Mother: 66 years old, HTN T2DM

Brother: 35 years old, Healthy

Social History

Highest level of education: High school

Occupation: Construction Worker

Current living: Lives alone in an apartment.

Marital status: Single

Substance use/abuse: Denies use of any recreational drug, denies smoking tobacco or e-cigarettes

ETOH: Drinks moderately, 5 drinks once a week

Safety Status: Works construction jobs in high-rise apartments, follows all safety precautions. Reports feeling safe at work.

ROS

General

Denies fever, chills, fatigue, or pain.

Cardiovascular

Denies Chest pain, denies palpitations.

Skin

Non-contributory

Respiratory

Denies cough, denies wheezing, denies hemoptysis, and denies dyspnea.

.

Eyes

Non-contributory

Gastrointestinal

Non-contributory

Ears

Non-contributory

Genitourinary/Gynecological

Non-contributory

Nose/Mouth/Throat

Non-contributory

Musculoskeletal

Non-contributory

Breast

Non-contributory

Neurological

Non-contributory

Heme/Lymph/Endo

Non-contributory

Psychiatric

Non-contributory

OBJECTIVE

Weight 187 lbs. BMI 29.3

Temp 98.5

BP 136/83

Height 67 inches

Pulse 79

Resp 19

General Appearance

Overweight male, in no acute distress. Alert and oriented; answers questions appropriately.

Skin

Deferred.

HEENT

Deferred

Cardiovascular

S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs. Capillary refills two seconds. Pulses 3+ throughout. No edema.

Respiratory

Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.

Gastrointestinal

Deferred.

Breast

Deferred

Genitourinary

Deferred

Musculoskeletal

Full ROM seen in all four extremities as the patient moved about the exam room.

Neurological

Speech clear. Good tone. Posture erect. Balance stable; gait normal.

Psychiatric

Alert and oriented. Dressed in clean slacks, shirt, and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.

Lab Tests

Abnormal Results:

Triglycerides: 184 MG/DL

Cholesterol: 214 MG/DL

Glucose: 120 MG/DL

HbA1c: 6.2%

STD Panel: Negative

Special Tests

Repeat HbA1c test to confirm diagnosis.

Diagnosis

Final Diagnosis: Prediabetes (R73.03) According to the American Diabetes Association (ADA) an HbA1c value of between 5.7% and 6.4% is indicative of pre-diabetes (Beulens, et al., 2019).

Differential: Overweight (E66.3) According to the Centers for Disease Control and Prevention (CDC), this patient has a BMI that is indicative of overweight. A person is classified as overweight if their BMI is between 25.0 and 30 (Adult Body Mass Index (BMI), 2020).

Differential: Metabolic Syndrome (E88.81) Metabolic syndrome is marked by increased blood pressure, increased glucose in blood, increased triglycerides, and cholesterol, and excess body fat around the waist. It is linked to overweight and obesity and is becoming increasingly common in the United States (Metabolic Syndrome, 2019).

Plan/Treatment

The patient’s HbA1c will need to be re-evaluated at a separated occasion in order to confirm the diagnosis of prediabetes. The most important plan in treatment of prediabetes is management of the condition in order to prevent progression towards Type 2 Diabetes Mellitus. This involves healthy lifestyle changes that must be made by the patient in order to reduce risk. The patient is classified as being overweight. This is a risk factor for developing T2DM (Beulens, et al., 2019). We will refrain from prescribing any medication until we confirm the diagnosis and determine if the patient can make the necessary lifestyle changes to reduce his risk.

· Exercise more frequently and focus on cardiovascular exercise such as walking, jogging, and aerobic exercises.

· Practice healthy eating reduce sodium in diet and reduce fat intake.

· Drink plenty of water every day.

· Practice safe sexual practices.