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