Artificial Intelligence
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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.