Team-based Teaching Clinic (TBTC) SOAP note

Student name: James Kaan Date: 05-29-2015Student 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 appointmentb. 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 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)

Temp 98.9 FBP 142/88Weight 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 masses3. CV: Regular rhythm w/ no murmurs4. Resp: Normal breath sounds5. Abdominal: Normal bowel sounds, no renal bruits, no masses, soft and nontender, no hepatosplenomegaly6. Ext: No pitting edema, 2+ pedal pulses7. Skin: No rashes, discoloration, lesions8. Neuro: Sensation in feet was normal9. Psych: no obvious signs of depression or anxiety10. 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) Increase Novolog 2 units with meals (up to 50 units) If blood sugar above 200, increase another 2 units Meet with Dr. Kirk to address diabetes control and fine-tune medication 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 Continue Prozac 2 capsules by mouth every morning

5. Tobacco use: Continue decreasing tobacco use 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