SU_NSG6420_W6_A4_Taylor_A.docx - SOAP NOTE Name DP Date Age 49 Time 11:03 Sex M SUBJECTIVE CC \u201cHere for my blood sugar check\u201d HPI DP is a

SU_NSG6420_W6_A4_Taylor_A.docx - SOAP NOTE Name DP Date Age...

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SOAP NOTE Name: DP Date: 11/28/18 Time: 11:03 Age: 49 Sex: M SUBJECTIVE CC: “Here for my blood sugar check” HPI: DP is a 49-year-old African-American male who comes in for follow-up of his type 2 diabetes. Since his last appointment 6 months ago, pt states that his blood sugars have been running in the 200s to 300s with his highest blood glucose reading at 320. Pt checks his BS 3 times per day. Pt states that he has been eating a lot of carbs and that his diet habits have been poor. No c/o chest pain, dizziness/lightheadedness, SOB, polyuria, polydipsia. He occasionally drinks liquor but states that he drinks Crown Royal “which has no carbs and uses diet coke with the liquor”. His last eye exam was in Aug. 2018 Medications: Linzess 145mcg daily – IBS Lantus 30U at night – Type 2 DM Humulin Regular Insulin 15U TID w/meals – Type 2 DM Zocor 10mg at night – Hyperlipidemia Neurontin 100mg TID – Diabetic neuropathy Lisinopril 10mg daily – HTN Cialis 20mg as needed – ED ASA 81mg – Heart health
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  • Summer '16
  • ANDREWCLARK
  • Blood sugar, Diabetic neuropathy

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