Comprehensive Family Medicine New Patient SOAP Note

Subjective

• 58 yo M (Robert Miller, DOB: 14/05/1966, MRN: 849-204-11) presents to establish care at 09:30 after relocating to the area.
• Establish primary care and routine management of HTN, T2DM, and HLD.
• Reports mild intermittent bilateral plantar foot numbness (2/10 severity) x 3 months. Otherwise asymptomatic.
• Tolerating lisinopril 20 mg PO daily, metformin (Glucophage®) 1,000 mg PO BID, and atorvastatin (Lipitor®) 40 mg PO daily without GI upset, myalgias, or cough.
• Concerned about peripheral neuropathy progression; admits to inconsistent dietary adherence during recent move.
• Home BP readings average 138/84 mmHg; fasting fingerstick blood glucose ranges 130–155 mg/dL; home weight 94 kg.

Labs

• External records (10/03/2025): HbA1c 7.4 %, FBG 142 mg/dL, Cr 1.0 mg/dL, eGFR 82 mL/min/1.73m², K 4.3 mmol/L, Total Chol 175 mg/dL, LDL 92 mg/dL, HDL 44 mg/dL, TG 195 mg/dL.
• HbA1c increased from 6.8 % on 05/09/2024; LDL improved from 118 mg/dL.
• Urine microalbumin-to-creatinine ratio, TSH, and Vitamin B12 level ordered today are pending.

Objective

ROS

• Denies fever, chills, fatigue, or unintentional weight change.
• Denies vision changes, blurred vision, hearing loss, tinnitus, or sore throat.
• Denies chest pain, palpitations, orthopnea, or PND.
• Denies SOB, cough, or wheezing.
• Denies nausea, vomiting, diarrhea, constipation, or abdominal pain.
• Denies dysuria, hematuria, urgency, or nocturia.
• Denies arthralgias, myalgias, or back pain.
• Reports mild bilateral plantar paresthesias; denies focal weakness, dizziness, or syncope.
• Denies depression, anxiety, or insomnia.

Assessment

• Alert, oriented, well-nourished male in NAD. Vitals (09:35): BP 142/86 mmHg, HR 76 bpm, RR 14/min, Temp 36.8 °C, SpO2 98 % RA, BMI 29.8 kg/m².

• Mood and affect appropriate; intact judgment and insight.

• Normocephalic, atraumatic.

• PERRLA, EOMI, conjunctivae clear, no scleral icterus.

• TMs pearly grey bilaterally, nares patent, oropharynx clear with moist mucous membranes.

• Supple, no JVD, no thyromegaly, no lymphadenopathy or carotid bruits.

• CTAB, no wheezes, rales, or rhonchi; normal respiratory effort.

• RRR, normal S1/S2, no murmurs, rubs, or gallops; 2+ DP/PT pulses, no peripheral edema.

• Deferred.

• Soft, non-tender, non-distended, normoactive bowel sounds, no hepatosplenomegaly.

• Normal gait and station; 5/5 strength and full ROM in all extremities.

• CN II–XII intact, DTRs 2+ symmetric; decreased sensation to 10 g monofilament at bilateral plantar 1st MTP joints.

• Warm, dry, intact; no foot ulcers, calluses, or rashes; normal toenails.

• Normal spinal curvature, no CVA tenderness or paraspinal spasm.

• Patient attended visit alone; no caregiver present.

• Type 2 diabetes mellitus with diabetic polyneuropathy (ICD-10: E11.42 | ICD-9: 250.60 | SNOMED: 421893009)

• Essential hypertension (ICD-10: I10 | ICD-9: 401.9 | SNOMED: 59621000)

• Mixed hyperlipidemia (ICD-10: E78.2 | ICD-9: 272.2 | SNOMED: 267434003)

Plan Note

Assessment & Plan

• 1. Type 2 diabetes mellitus with diabetic polyneuropathy
  • Suboptimally controlled (HbA1c 7.4 %) with new mild distal symmetric polyneuropathy.
  • Counselled on low-glycemic diet, daily foot inspections, and proper footwear; ordered urine microalbumin/Cr ratio and Vitamin B12 level to rule out concurrent deficiency; referred to Ophthalmology for annual dilated eye exam.
  • Continue metformin (Glucophage®) 1,000 mg PO BID; add empagliflozin (Jardiance®) 10 mg PO daily; defer neuropathic pain pharmacotherapy per patient preference given mild symptoms.
  • Recheck HbA1c and BMP in 3 months.
• 2. Essential hypertension
  • Above goal (< 130/80 mmHg) both in clinic and on home logs.
  • Advised DASH diet, sodium restriction (< 2,000 mg/day), and continued home BP monitoring.
  • Increase lisinopril from 20 mg to 40 mg PO daily.
  • Recheck BMP in 2 weeks to monitor renal function and potassium; review BP log at next visit.
• 3. Mixed hyperlipidemia
  • Controlled on current high-intensity statin therapy.
  • Continue lifestyle modifications and regular aerobic exercise (150 min/week).
  • Continue atorvastatin (Lipitor®) 40 mg PO daily.
  • Repeat fasting lipid panel in 12 months.

• RTC in 3 months for routine follow-up, lab review, and blood pressure check; return sooner or seek urgent care for chest pain, severe shortness of breath, focal weakness, or foot ulceration.