(Student Name)
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor:
Soap Note # Main Diagnosis Diabetes Mellitus type 2
PATIENT INFORMATION
Name: Mr. ET
Age: 56-year-old
Gender at Birth: Female
Gender Identity: Female
Source: Patient
Allergies: Penicillins
Current Medications:
· Multi-Vitamin Centrum Silver
· Lisinopril 10 mg daily
· PMH: HTN
Diabetes mellitus type 2
Immunizations:
Preventive Care: Coloscopy 3 years ago (Negative)
Surgical History: laparoscopic cholecystectomy
Family History: Father alive
Mother-alive, 90 years old, Diabetes Mellitus, HTN
Daughter-alive, 21 years old, healthy
Social History: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, she lives alone.
Sexual Orientation: Straight
Nutrition History: Diets off and on