Provide a SOAP evaluation for the Endocrinology Case

Case Information:
CC/PMI: GB is a 65 year-old male who comes in for a check-up on the request of his
spouse. His last check-up was 10 years ago. He has no complaints other than some leg
numbness and tingling from time-to-time, increased urination, and feeling thirsty and tired
most of the time.
SH: no smoking or alcohol consumption
PMH: hypertension
Physical Examination:
GEN: well-nourished, slightly obese male
VS: BP 170/100, HR 70, RR 12, T 98.7, Wt 89kg, Ht 5’8″
HEENT: PERRLA
COR: RRR, NMRG
CHEST: CTA
NEURO: monofilament test shows decreased peripheral sensation
EXT: normal
Laboratory (fasting):
Na 140
Cl 100
BUN 28
BG 250
K 4.3
HCO3 24
SCr 1.9
ALT 35
AST 40
Ca 9.0
Cholesterol 250
Triglycerides 300
HDL 35
LDL 155
Urine microalbumin/creatinine: 100 mcg/mg
Important considerations for creating a SOAP note:
1. What major problems can you identify with this patient?
2. What subjective/objective information in the case supports each of those
problems? Pl

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