SOAP Note
Subjective Data
Patient claims father and uncle died of heart attacks in their late 50s. Patient is sedentary
during the week and claims to exercise on weekends. Patient may not get adequate sleep as
he reports working late during the week. Patient is not on any supplements or medications.
Patient claims his doctor said he has elevated LDL levels and is pre-diabetic. Patient takes no
medications, supplements, or vitamins. Dietary recall reveals he consumes 3,798 kcals. If this
dietary recall is accurate, he exceeds his energy intake for the day. He is also over his limit
for added sugar, saturated fat, and sodium. He consumes almost double the amount of
recommended sodium.
Objective Data: measurements/lab data
The patient is 511, 260 pounds, with a of BMI 36.3 (obese). The patient is a 38 year old
male.
Assessment/Plan
The patient is obese and over his IBW and consumes too many calories of processed food.
The patient does not exercise adequately for his calorie consumption. Patient is at risk of
becoming diabetic and gaining more weight. The patient should begin replacing refined
grains with whole grains, increasing fruit and vegetable intake, decreasing processed food
intake, and decrease portion sizes. Follow up with patient in 1 month to assess dietary
changes and see if pre-diabetes has progressed or reversed.