Create a Note either FARM or SOAP based on the given clinical case SOAP Note Components Notes Subjective Objective Assessment
**SOAP Note**
**Subjective:**
- Patient: Sarah Martin, a 43-year-old female
- Chief Complaint: “I think that my blood sugar is running low because I have a terrible headache.”
- History of Present Illness: Diagnosed with Type 2 diabetes mellitus 6 months ago. Attempts to control blood sugar with diet and exercise have been unsuccessful. Currently on glyburide 5 mg BID. Reports daily monitoring with blood sugar levels ranging from 215-260 mg/dL. Fasting blood sugar averages 170 mg/dL. Complains of nocturia, polyuria, and polydipsia. Denies symptoms of hypoglycemia.
- Past Medical History: Type 2 DM, hypertension, bipolar disorder, dyslipidemia, morbid obesity.
- Family History: Father with history of hypertension and bipolar disorder; mother with dyslipidemia; brother with alcohol-related DM.
- Social History: Married for 21 years, has two teenage children. Works as a delivery driver for a floral shop. Denies tobacco use, drinks alcohol occasionally (5 beers/wine per week).
- Current Medications: Glyburide, Lisinopril, Zyprexa, Carbamazepine, Lorazepam, Fluoxetine, EC ASA, Pravastatin.
- Allergies: Morphine (hives).
**Objective:**
- Vital Signs: BP 165/90, HR 98, RR 18, Temp 38.6°C
- Weight: 109 kg, Height: 5'8", Waist circumference: 38 in
- Physical Examination:
- General: Well-developed, well-nourished, severely obese Caucasian female in no acute distress.
- HEENT: Pupils equal, round, reactive to light and accommodation; extraocular movements intact; fundus exam without retinopathy.
- Cardiovascular: Regular rate and rhythm; no murmurs, rubs, or gallops.
- Respiratory: Clear to auscultation and percussion.
- Abdomen: Non-tender, non-distended.
- Extremities: Weak pulse in left dorsalis pedis (1+), calluses on metatarsophalangeal joints.
- Neurological: Deep tendon reflexes 2+ throughout; normal sensation (5.07 monofilament) and vibration in feet.
- Laboratory: UA shows 1+ protein, positive microalbuminuria.
**Assessment:**
- Type 2 Diabetes Mellitus: Poor glycemic control, evidenced by high daily blood glucose readings and a previous A1C of 8.9%. Patient shows signs of diabetes-related complications (microalbuminuria).
- Hypertension: Elevated blood pressure (165/90) not at goal.
- Morbid obesity: Weight gain of 15 lb over the past year complicates diabetes management.
- Dyslipidemia: Current drug therapy not effectively controlling cholesterol levels.
- Psychiatric Conditions: Bipolar disorder moderately controlled with current medications; potential for food-related behaviors during mood episodes.
**Plan (Recommendations/Resolutions):**
1. **Diabetes Management:**
- Increase frequency of blood glucose monitoring to 2-3 times daily.
- Referral to a dietitian for personalized meal planning, considering the nature of her job.
- Consider medication adjustment: evaluate the need for higher doses of glyburide or addition of a second agent (e.g., metformin or GLP-1 receptor agonist).
- Schedule follow-up A1C test in 3 months.
2. **Hypertension Management:**
- Continue Lisinopril; consider an increase or addition of a thiazide diuretic if BP remains uncontrolled.
- Lifestyle modifications: dietary sodium reduction and regular physical activity as tolerated.
3. **Weight Management:**
- Address weight with dietary intervention and consider discussing weight loss medications or programs if lifestyle changes are insufficient.
4. **Dyslipidemia Management:**
- Review current PRAVASTATIN dose; consider increasing to optimize lipid control.
5. **Bipolar Disorder:**
- Continue current medications (Zyprexa, Carbamazepine, Fluoxetine). Monitor for mood stability and effects on eating habits.
- Collaborate with a psychiatrist to assess the effectiveness of the current plan.
6. **Follow-Up:**
- Schedule follow-ups in 1 month to assess blood glucose logs, weight, and general health progress. Encourage regular appointments with the primary care physician for comprehensive management of chronic conditions.