Detailed SOAP Note

Subjective

• 58 yo M (Arthur MacDonald, DOB: 14/05/1966, HCN: 902-481-7729) presents at 10:30 for initial MNT consult re: newly diagnosed T2DM and hyperlipidaemia. Reports unintentional wt gain of 5 kg over past 12 mos, mild daytime fatigue, and polyuria. Diet recall reveals skipped breakfasts, processed convenience lunches, large evening meals, and 2–3 sugar-sweetened beverages/day. No GI complaints.
• PMHx: HTN (dx 2019), T2DM (dx 02/10/2024), dyslipidaemia. PSHx: Laparoscopic cholecystectomy (2015).
• Meds: metformin (Glucophage®) 500 mg PO BID; ramipril (Altace®) 5 mg PO daily; rosuvastatin (Crestor®) 10 mg PO daily; colecalciferol (vitamin D3) 1,000 IU PO daily.
• SHx: Long-haul truck driver; sedentary lifestyle with irregular meal schedules and frequent fast-food intake. Lives with spouse. Ex-smoker (quit 2010), EtOH 3–4 beers/wk.
• Allergies: Penicillin (urticaria); no known food allergies or intolerances.

Objective

• Vitals: BP 138/84 mmHg, HR 76 bpm, RR 16/min, Temp 36.8 °C, SpO2 98 % on RA. Anthropometrics: Ht 178 cm, Wt 102.5 kg, BMI 32.3 kg/m², Waist circumference 108 cm.
• Physical Exam: General: Alert, NAD. HEENT: Mucous membranes moist. Skin: Acanthosis nigricans noted at posterior neck; no lower extremity oedema. Nutrition-Focused Physical Exam (NFPE): Central adiposity present; no evidence of micronutrient deficiencies or muscle wasting.
• Labs (01/10/2024): HbA1c 8.2 %, FBG 9.4 mmol/L, Total Cholesterol 5.8 mmol/L, Triglycerides 2.6 mmol/L, LDL-C 3.5 mmol/L, HDL-C 0.9 mmol/L, eGFR 82 mL/min/1.73m², Urine ACR 1.8 mg/mmol.
• Imaging: RUQ US (05/10/2024) demonstrates mild hepatic steatosis; surgical absence of gallbladder.

Assessment

• Nutrition Diagnosis (PES): Excessive carbohydrate intake (NI-5.8.2) related to frequent consumption of sugar-sweetened beverages and fast food while working on the road, as evidenced by 24-hour diet recall, HbA1c of 8.2 %, and TG of 2.6 mmol/L. Class I obesity (BMI 32.3 kg/m²) and T2DM.
• Pt demonstrates high readiness to change but faces occupational barriers to consistent meal timing and food preparation.

Plan

• Nutrition Rx: Target consistent CHO intake of 45–60 g per meal and 15–30 g per snack. Aim for gradual wt loss of 0.5 kg/wk via a 500 kcal/day deficit (estimated requirement: 2,100 kcal/day, 100 g protein/day). F/u in RD clinic in 4 wks (15/11/2024 at 14:00).
• Provided counselling on the Diabetes Canada plate method, nutrition label reading (focusing on total CHO, fibre, and saturated fat), and portable, non-perishable meal/snack options suitable for truck cab storage (e.g., unsalted nuts, tinned fish, whole grain crackers, Greek yoghurt in 12V cooler). Advised substituting sugar-sweetened beverages with water or zero-calorie flavoured sparkling water. Reinforced taking metformin with meals to minimise GI side effects.
• Referred to local Diabetes Education Centre (DEC) for SMBG training and glucometer provision, and to community exercise physiologist for a tailored physical activity regimen.
• Instructed pt to keep a 3-day food and blood glucose log prior to next visit. Reviewed s/sx of hypoglycaemia and treatment protocol (15 g fast-acting CHO), though risk is low on current regimen.