Can you create a mock SOAP note for a 67‑year‑old female presenting for a same‑day sick visit with streptococcal pharyngitis (positive rapid strep test), who has a history of bronchitis, hyperlipidemia, diverticulitis, and type 2 diabetes mellitus (A1c increased from 9.9% to 11.8% despite metformin 1000 mg), is on metformin and mojarro 15 mg (statin), received a vitamin B12 injection, and requires diet and lifestyle counseling as well as preventive‑screening recommendations?

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Last updated: September 11, 2026 • View editorial policy

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Mock SOAP Note: 67-Year-Old Female with Streptococcal Pharyngitis and Uncontrolled Type 2 Diabetes

SUBJECTIVE

Chief Complaint: Sore throat

History of Present Illness:
67-year-old female presents for same-day sick visit with acute onset sore throat. Rapid antigen detection test (RADT) performed in office was positive for Group A Streptococcus.

Past Medical History:

  • Type 2 Diabetes Mellitus (on metformin 1000 mg)
  • Hyperlipidemia (on statin therapy)
  • History of bronchitis
  • Diverticulitis

Current Medications:

  • Metformin 1000 mg PO daily
  • Mounjaro (tirzepatide) 15 mg subcutaneous weekly
  • [Statin - specific agent/dose not specified]

Review of Systems:
Denies cough, rhinorrhea, hoarseness, or oral ulcers. No fever documented today. Denies dysphagia, dyspnea, or neck mass.

OBJECTIVE

Vital Signs: [Document actual vitals]

Physical Examination:

  • HEENT: Pharyngeal erythema with tonsillar exudates present. No peritonsillar abscess. Tender anterior cervical lymphadenopathy.
  • Cardiovascular: Regular rate and rhythm
  • Respiratory: Clear to auscultation bilaterally
  • Abdomen: Soft, non-tender

Laboratory Results:

  • Rapid Strep Test: Positive
  • Hemoglobin A1c: 11.8% (increased from 9.9% three months ago)

Procedures Performed Today:

  • Vitamin B12 injection administered

ASSESSMENT

  1. Acute Group A Streptococcal Pharyngitis
  2. Type 2 Diabetes Mellitus, poorly controlled (A1c 11.8%, worsening from 9.9%)
  3. Hyperlipidemia, stable
  4. History of diverticulitis, inactive
  5. Vitamin B12 monitoring (on long-term metformin therapy)

PLAN

1. Streptococcal Pharyngitis

Penicillin remains the treatment of choice for Group A streptococcal pharyngitis due to proven efficacy, safety, narrow spectrum, and low cost 1, 2, 3.

Treatment Options:

  • First-line: Penicillin V 500 mg PO twice daily × 10 days OR Amoxicillin 500 mg PO twice daily × 10 days
  • If penicillin allergic (non-anaphylactic): First-generation cephalosporin × 10 days 3
  • If anaphylactic penicillin allergy: Azithromycin 500 mg day 1, then 250 mg days 2-5 OR Clindamycin 300 mg PO three times daily × 10 days 3

Prescribed: Cephalexin [specify dose] PO for 10 days

Patient Education:

  • Complete full 10-day antibiotic course to eradicate streptococci and prevent complications (acute rheumatic fever, suppurative complications) 1
  • Symptomatic relief with acetaminophen or NSAIDs as needed 3
  • No follow-up throat culture needed if asymptomatic after treatment 2, 3
  • Return if symptoms worsen or new symptoms develop (neck swelling, difficulty breathing, inability to swallow)

2. Type 2 Diabetes Mellitus - Poorly Controlled

This patient's A1c has increased significantly from 9.9% to 11.8% over three months despite metformin 1000 mg and Mounjaro 15 mg, indicating inadequate glycemic control and requiring immediate intensification of therapy 4.

Current Regimen Assessment:

  • Metformin 1000 mg daily (suboptimal dosing - maximum effective dose is 2000 mg/day) 5, 6
  • Mounjaro (tirzepatide) 15 mg weekly (already at maximum dose) 7

Immediate Actions:

A. Optimize Metformin Dosing:

  • Increase metformin to 1000 mg PO twice daily (2000 mg total daily dose) to achieve maximal glucose-lowering efficacy 5, 6
  • Titrate gradually if GI side effects occur
  • Continue metformin when adding other agents 5, 4

B. Consider Additional Glucose-Lowering Agent:

Given A1c ≥10%, consider initiating insulin therapy with or without additional agents 5, 4, 8. However, since patient is already on maximum-dose GLP-1RA (Mounjaro), first optimize metformin dosing and reassess in 3 months.

Alternative approach if insulin not initiated now:

  • Add SGLT2 inhibitor for additional glucose-lowering and potential cardiovascular/renal benefits 9, 6, 4
  • SGLT2 inhibitors provide 0.7-1.0% A1c reduction when added to existing therapy 5

C. Lifestyle Modifications (Critical):

Dietary Counseling:

  • Implement heart-healthy dietary pattern (Mediterranean, DASH, or vegetarian/vegan diet) focusing on glycemic control and weight management 9
  • Reduce total caloric intake for weight loss if BMI ≥25 kg/m² 9
  • Limit refined carbohydrates and added sugars
  • Increase fiber intake

Physical Activity:

  • Prescribe at least 150 minutes per week of moderate-intensity physical activity OR 75 minutes of vigorous-intensity activity 9
  • Supervised exercise programs improve A1c more than advice alone 6
  • Combination of dietary change and exercise improves hyperglycemia more than either alone 6

D. Vitamin B12 Monitoring:

Long-term metformin use is associated with vitamin B12 deficiency; periodic measurement of vitamin B12 levels should be considered, especially in patients with anemia or peripheral neuropathy 5, 6, 8, 6, 10, 11.

  • B12 injection administered today (appropriate)
  • Schedule periodic B12 level monitoring (every 1-2 years or sooner if symptoms develop) 5, 6, 10
  • Risk factors for deficiency include: higher metformin dose, longer treatment duration, older age 12, 13, 14
  • Monitor for symptoms: anemia, peripheral neuropathy, cognitive changes 5, 6

E. Follow-up:

  • Recheck A1c in 3 months after metformin dose optimization
  • If A1c remains ≥9% after 3 months, do not delay insulin initiation 5, 4
  • Consider referral to diabetes educator/nutritionist for intensive lifestyle counseling

3. Preventive Screening

Cardiovascular Risk Assessment:

  • Patient has multiple ASCVD risk factors: diabetes, hyperlipidemia, age 67
  • Continue statin therapy (already on Mounjaro/statin regimen)
  • Measure waist circumference at next visit (recommended for all patients with BMI <35 kg/m² for cardiovascular risk assessment) 9
  • Blood pressure monitoring
  • Consider lipid panel if not recently checked

Diabetes-Related Screening:

  • Annual comprehensive foot examination
  • Annual dilated eye examination (retinopathy screening)
  • Annual urine albumin-to-creatinine ratio and eGFR (nephropathy screening)
  • Consider screening for diabetic neuropathy

Age-Appropriate Cancer Screening:

  • Mammography (if not up to date)
  • Colonoscopy status (given history of diverticulitis)
  • Other age-appropriate screenings per USPSTF guidelines

Immunizations:

  • Influenza vaccine (annual)
  • Pneumococcal vaccine (if not up to date)
  • COVID-19 vaccination status
  • Tdap/Td booster if needed

4. Hyperlipidemia

  • Continue current statin therapy
  • Recheck lipid panel at next visit if not recently done
  • Reinforce lifestyle modifications (diet, exercise) for cardiovascular risk reduction

5. History of Diverticulitis

  • Currently inactive, no acute issues
  • Counsel on high-fiber diet for prevention
  • Return precautions for abdominal pain, fever, change in bowel habits

PATIENT EDUCATION & COUNSELING

Diabetes Management:

  • Explained significant worsening of diabetes control (A1c 9.9% → 11.8%)
  • Discussed importance of medication adherence, dietary changes, and regular physical activity
  • Emphasized that uncontrolled diabetes increases risk of heart disease, kidney disease, vision loss, and neuropathy 15
  • Provided written materials on heart-healthy eating patterns and exercise recommendations

Metformin & B12:

  • Explained association between long-term metformin use and vitamin B12 deficiency 5, 6, 11
  • Discussed need for periodic B12 monitoring
  • Instructed to report symptoms of deficiency (numbness, tingling, weakness, memory problems)

Strep Throat:

  • Explained importance of completing full antibiotic course
  • Discussed prevention of transmission to household contacts
  • Provided return precautions

PRESCRIPTIONS

  1. Cephalexin [specify dose] PO for 10 days (for streptococcal pharyngitis)
  2. Metformin 1000 mg PO twice daily (increased from 1000 mg once daily)
  3. Continue Mounjaro 15 mg subcutaneous weekly
  4. Continue current statin therapy

FOLLOW-UP

  • Return in 3 months for A1c recheck and diabetes management reassessment
  • Sooner if: strep symptoms worsen, new diabetes symptoms (polyuria, polydipsia, weight loss), or other concerns
  • Schedule preventive screening appointments as discussed
  • Consider referral to diabetes educator/nutritionist for intensive lifestyle intervention

Time spent: [Document time for billing purposes]
Counseling: >50% of visit time spent on diabetes education, lifestyle counseling, and medication management

Physician Signature: ___________________________
Date: ___________________________

References

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