What would a SOAP note look like for a 65-year-old male with type 2 diabetes, hypertension, and hyperlipidemia, presenting with polyuria, polydipsia, hypertension, and hyperglycemia, and currently on metformin, lisinopril, and atorvastatin?

SOAP Note Example: 65-Year-Old Male with Type 2 Diabetes, Hypertension, and Hyperlipidemia

Subjective

Chief Complaint: "I've been urinating more frequently and feeling very thirsty for the past 2 weeks."

History of Present Illness:

• Patient reports polyuria (urinating every 1-2 hours, including 4-5 times nightly) and polydipsia (drinking 3-4 liters of water daily) for 14 days 1
• Denies dysuria, fever, or weight loss 1
• Reports fatigue and occasional blurred vision 1
• No chest pain, shortness of breath, or lower extremity edema 1
• Medication adherence: Takes metformin 1000 mg twice daily, lisinopril 20 mg daily, and atorvastatin 40 mg nightly as prescribed 1

Past Medical History:

• Type 2 diabetes mellitus (diagnosed 8 years ago) 1
• Hypertension (diagnosed 10 years ago) 1
• Hyperlipidemia (diagnosed 10 years ago) 1

Medications:

• Metformin 1000 mg PO BID 1
• Lisinopril 20 mg PO daily 1, 2
• Atorvastatin 40 mg PO nightly 1
• Aspirin 81 mg PO daily 1

Social History:

• Non-smoker 1
• Occasional alcohol use (1-2 drinks per week) 1
• Sedentary lifestyle, walks 10 minutes 2-3 times weekly 3

Family History:

• Father: Type 2 diabetes, myocardial infarction at age 62 1
• Mother: Hypertension, stroke at age 70 1

Objective

Vital Signs:

• Blood pressure: 152/88 mmHg (seated, repeated after 5 minutes: 148/86 mmHg) 1, 3
• Heart rate: 78 bpm, regular 1
• Temperature: 98.4°F 1
• Respiratory rate: 16 breaths/min 1
• Weight: 220 lbs (BMI 32.1 kg/m²) 3

Physical Examination:

• General: Alert, oriented, appears well-nourished but obese 1
• HEENT: No retinopathy on fundoscopic exam (last dilated exam 11 months ago) 1
• Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops 1
• Respiratory: Clear to auscultation bilaterally 1
• Extremities: No edema, pedal pulses 2+ bilaterally, monofilament testing intact 1

Laboratory Results (today):

• Fasting plasma glucose: 248 mg/dL 1
• HbA1c: 9.2% 1, 3
• Serum creatinine: 1.1 mg/dL (eGFR 72 mL/min/1.73m²) 1
• Serum potassium: 4.2 mEq/L 1
• Lipid panel (3 months ago): LDL 118 mg/dL, HDL 38 mg/dL, triglycerides 210 mg/dL 1
• Urine albumin-to-creatinine ratio: 45 mg/g (microalbuminuria) 1, 2

Assessment

1. Type 2 diabetes mellitus, uncontrolled (HbA1c 9.2%, fasting glucose 248 mg/dL) with symptomatic hyperglycemia (polyuria, polydipsia) and microalbuminuria 1, 3

2. Hypertension, uncontrolled (BP 152/88 mmHg, not at goal <130/80 mmHg for diabetic patient) 1, 3

3. Hyperlipidemia, suboptimal control (LDL 118 mg/dL, not at goal <100 mg/dL for diabetic patient with cardiovascular risk factors; low HDL 38 mg/dL; elevated triglycerides 210 mg/dL) 1, 3

4. Obesity (BMI 32.1 kg/m²) contributing to insulin resistance 3

5. Diabetic nephropathy, early stage (microalbuminuria 45 mg/g with preserved eGFR) 1, 2

6. Increased cardiovascular risk (diabetes >10 years, hypertension, dyslipidemia, family history of premature coronary disease, microalbuminuria) 1

Plan

Diabetes Management:

• Intensify glycemic control with target HbA1c <7.0% 1, 3
• Add SGLT2 inhibitor (empagliflozin 10 mg PO daily) to metformin for additional glucose lowering, cardiovascular protection, and renal protection 1
• Continue metformin 1000 mg PO BID (eGFR >30, safe to continue) 1
• Educate patient on SGLT2 inhibitor: maintain hydration, monitor for genital mycotic infections, discontinue if ketoacidosis symptoms develop 1
• Recheck HbA1c in 3 months 3
• Self-monitoring blood glucose: fasting and 2-hour postprandial readings 3 times weekly initially 3

Hypertension Management:

• Increase lisinopril to 40 mg PO daily (ACE inhibitor is first-line for diabetic patient with microalbuminuria) 1, 2
• Target BP <130/80 mmHg 1, 3
• Recheck serum creatinine and potassium in 2 weeks after dose increase 1
• Home blood pressure monitoring: measure twice daily (morning and evening) for 1 week, bring log to next visit 3
• Sodium restriction to <2,300 mg/day 1, 3

Lipid Management:

• Increase atorvastatin to 80 mg PO nightly (high-intensity statin for diabetic patient with multiple cardiovascular risk factors and LDL >100 mg/dL) 1, 3
• Target LDL <100 mg/dL 1, 3
• Recheck lipid panel in 3 months 1, 3
• Continue aspirin 81 mg daily for cardiovascular protection 1

Lifestyle Modifications:

• Weight loss goal: 5-10% body weight reduction (11-22 lbs) over 6 months through caloric restriction 1
• Physical activity: Increase to 150 minutes moderate-intensity aerobic exercise weekly (30 minutes, 5 days/week) plus resistance training 2 days/week 1, 3
• Dietary counseling: Referral to registered dietitian for medical nutrition therapy focusing on carbohydrate counting, portion control, and sodium restriction 1
• Smoking cessation: Reinforce continued abstinence 1, 3
• Alcohol moderation: Continue current limited intake 1

Monitoring and Follow-up:

• Return visit in 2 weeks for blood pressure recheck and laboratory monitoring (creatinine, potassium) after lisinopril dose increase 1
• Return visit in 3 months for HbA1c, lipid panel, and comprehensive diabetes assessment 1, 3
• Annual screening: Dilated retinal exam (due in 1 month), comprehensive foot exam today (completed, monofilament intact), urine albumin-to-creatinine ratio annually 1
• Cardiovascular risk assessment: Calculate 10-year ASCVD risk score at next visit 1

Patient Education:

• Explained hyperglycemia symptoms and importance of medication adherence 1
• Reviewed hypoglycemia recognition and treatment (glucose tablets, 15-15 rule) 1
• Discussed cardiovascular risk factor modification and importance of multidrug therapy 1
• Provided written materials on diabetes self-management, dietary modifications, and exercise recommendations 1
• Encouraged questions; patient verbalized understanding of plan 1