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″
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:

  1. What major problems can you identify with this patient?
  2. What subjective/objective information in the case supports each of those problems? Please list only information that pertains to each problem under each problem.
  3. What is your assessment and plan for each problem?
  4. 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?
  5. Include your therapeutic goals for each problem (use the subjective and objective information listed above to help you)
  6. How will you monitor each problem and each medication included in your plan?
  7. When will you suggest following up with the patient?
  8. Is there any laboratory monitoring that will need to be conducted to assure the safety of the patient?

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