Case study endocrinology
CC/PMI: GB is a 65-year-old Caucasian male who comes in for a check-up on the request of his spouse. His last check-up was 10 years ago. He has no complaints other than some leg numbness and tingling from time-to-time, increased urination, and feeling thirsty and tired most of the time.
SH: no smoking or alcohol consumption
PMH: hypertension
Physical Examination:
GEN: well-nourished, slightly obese male
VS: BP 158/89, HR 70, RR 12, T 98.7, Wt 89kg, Ht 5’8″
HEENT: PERRLA
COR: RRR, NMRG
CHEST: CTA
NEURO: monofilament test shows decreased peripheral sensation
EXT: normal
Laboratory (fasting):
Na 140
Cl 100
BUN 28
BG 250
K 4.3
HCO3 24
SCr 1.9
ALT 35
AST 40
Ca 9.0
Cholesterol 250
Triglycerides 300
HDL 35
LDL 155
Urine microalbumin/creatinine: 100 mcg/mg
Important considerations for creating a SOAP note:
- What major problems can you identify with this patient?
- What subjective/objective information in the case supports each of those problems? Please list only information that pertains to each problem under each problem.
- What is your assessment and plan for each problem?
- Provide pharmacological and non-pharmacological care (don’t forget to be specific). Will you discontinue any medication that the patient is currently taking and/or add any new medications?
- Include your therapeutic goals for each problem (use the subjective and objective information listed above to help you)
- How will you monitor each problem and each medication included in your plan?
- When will you suggest following up with the patient?
- Is there any laboratory monitoring that will need to be conducted to assure the safety of the patient?
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