Pediatric Soap Note #6

Please provide the requested information on the template and enter the information on the template form attached.

-Patient:

12year old white female

an already established patient at the clinic

-chief complaint:

review labs

A1C 5.9, ALT 25

-history of patient illness (please add more information to cover OLDCARTS format):

pt obese, counseled in the past on making diet adjustments and exercise

-diagnosis:

prediabetes

-Diagnostic test

A1C

-Education:

– diabetic diet

– stop drinking sodas

– limit processed foods

-decrease caloric intake

-If labs continue to be elevated, consider starting low dose metformin

-exercise

-A1C and CMP recheck in 3 months

Patients Primary Language:

English

Ordered medication

none

No know food, medication, and seasonal allergies

Denies surgical history

Denies hospitalizations

Denies traumas

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