KING KHALID UNIVERSITY

COLLEGE OF PHARMACY
DEPT. OF CLINICAL PHARMACY

CPH –611 IPPE- 1

Instructions:

 Prepare a SOAP notes as power point presentation using the template attached
on blackboard and refer to the SOAP component file posted on blackboard and
present it during the practical hours.
 You can increase the number of slides depending on your content`s requirement.
 You can refer to the medical abbreviations and lab values posted on the
blackboard.
 Send the PowerPoint presentation through course message in black board on or
before the day of presentation.
 You will be asked questions after you finish the presentation

TYPE 2 DIABETES MELLITUS

CHIEF COMPLAINT
“I have had diabetes for about six months and would like to have my blood sugar tested. I think
that my blood sugar is running low because I have a terrible headache.”
HPI
Sarah Martin is a 45-year-old woman who comes to the pharmacy for a diabetes education class
taught by the pharmacist. She would like for the pharmacist to check her blood sugar before the
class begins. She was diagnosed with type 2 DM about 6 months ago. She had been attempting
to control her disease with diet and exercise, but had no success. Her physician started her on
metformin 1000 mg twice daily with food about 3 months ago. She has gained 10 lb over the
past year. She monitors her blood sugar once a day, and her results have ranged from 215 to 280
mg/dL. Her fasting blood sugars have averaged 200 mg/dL.
PMH
Type 2 DM × 6 months
HTN × 17 years
Bipolar disorder × 25 years
Dyslipidemia × 12 years
Morbid obesity × 20 years
FH
Father has a history of HTN, dyslipidemia, and bipolar disorder. Mother has a history of
dyslipidemia and hypothyroidism. Brother has DM thought to be secondary to alcoholism.
SH
Has been married for 23 years. She has two children who are teenagers and one child in college.
She works as a sales associate in the electronics department of a local mass merchandiser. She
denies any use of tobacco products after stopping smoking 10 years ago, but does drink alcohol
occasionally (three beers or glasses of wine per week).
Meds
Metformin 1000 mg PO BID with food
Lisinopril 20 mg PO once daily
Zyprexa 5 mg PO QHS
Carbamazepine ER 200 mg PO BID
Lorazepam 1 mg PO TID PRN
Fluoxetine 20 mg PO Q AM
Pravastatin 40 mg PO once daily
All
Penicillin—hives
ROS
Complains of nocturia, polyuria, and polydipsia on a daily basis. Denies nausea, constipation,
diarrhea, signs or symptoms of hypoglycemia, paresthesias, and dyspnea.
Physical Examination
Gen
WDWN severely obese, white woman in NAD
VS
BP 154/90 mm Hg, P 98 bpm, RR 18, T 37.0°C; Wt 109 kg, Ht 5′8″, waist circ 38 in
HEENT
PERRLA, EOMI, R & L fundus exam without retinopathy
Neck/Lymph Nodes
No LAN
Lungs
CTA & P
CV
RRR, no m/r/g
Abd
NT/ND
Genit/Rect
Deferred
MS/Ext
Carotids, femorals, popliteals, and right dorsalis pedis pulses 2+ throughout; left dorsalis pedis
1+; feet show mild calluses on MTPs

Lab Value Lab Value

Na 138 mEq/L A1C 10.0
K 3.7 mEq/L AST 16 IU/L
 Cl 103 mEq/L ALT 19 IU/L
CO2 31 mEq/L Alk phos 62 IU/L
BUN 16 mg/dL Fasting lipid profile
SCr 0.9 mg/dL T. chol 244 mg/dL
Glu (random) 243 mg/dL LDL 141 mg/dL
Ca 9.4 mg/dL HDL 58 mg/dL
Phos 3.3 mg/dL Trig 225 mg/dL
T. bili 0.4 mg/dL TC/HDL ratio 4.2

UA
1+ protein, (+) microalbuminuria