SOAP Note: Acute Asthma Exacerbation

ID:

Client’s Initials: W.D. | Age: 8 | Race: Caucasian | Gender: Male | Date of Birth: January 1, 2015 | Insurance: ABC Health | Marital Status: N/A

Subjective:

CC: “My son coughs a lot. He also seems to be gasping for breath.”

HPI: W.D. is an 8-year-old Caucasian male brought to the clinic with complaints of frequent coughs and shortness of breath. The symptoms began four days ago and has been present since. They manifest intermittently, often lasting a few minutes to hours. The patient describes the cough as dry and irritating. The cough is aggravated by cold and any physical activity. The mother notes that the cough and the shortness of breath were alleviated by inhaler medications during the initial days, but he has since stopped responding to the medication. The cough has since worsened, with the patient experiencing multiple episodes of coughs in a day. The patient also experiences frequent night awakenings and has been unable to sleep properly in the past two nights due to the cough and chest tightness. The symptoms are accompanied by nasal flaring and fatigue.

Past Medical History:

• Medical problem list

The patient is a known asthmatic. He was diagnosed with asthma four years ago and has been on medications to manage his asthmatic attacks. The patient was hospitalized one year ago for an acute asthmatic attack. He has never been involved in any accidents. He also denies having had any head injuries, psychiatric illnesses, or any other notable physical illness.

• Surgical:
  • The patient has never had any surgical procedures.
• Preventive Care:
  • The patient had a dental examination in August.
• Allergies: The patient has no known allergies.
• Medications:

Mucinex 5ml admisnistered orally every four hours. The patient started taking the medication yesterday to address the coughs.

Tylenol 500mg taken orally every 8 hours. The patient started taking the medication four days ago  to manage headaches.

Proventil® HFA administered at two puffs whenever the patient experiences an asthmatic attack.

• Immunizations:

The patient is up to date with all his childhood vaccines. He was scheduled to receive a COVID-19 vaccine next week. He has also received his annual flu vaccine shot.

Social History:

• Chemical history: The patient has no history of alcohol consumption or cigarette smoking. The father is a social smoker and alcohol drinker. He, however, denies smoking within the household. The mother also denies smoking within the household. She also denies smoking or using any substance of abuse during her pregnancy period.
• Other:

The patient is a school-going child currently in his second grade. He lives with both parents in a four-bedroom house with his two siblings. The family eats regular, balanced diets. The mother expresses a strong liking for seafood. Their living environment is clean, with a limited amount of dust. The family keeps a cat and a dog and has a small backyard flower garden. The patient is periodically involved in watering the garden.

• Safety:

The family does not own a gun. The patient and the family conform to safety practices such as wearing a safety belt and a head helmet whenever they are driving or performing outdoor activities. The patient also puts on a face mask whenever he is tending to the family’s garden.

• Family History:

Both parents are alive. The mother is a known asthmatic. Father has no known chronic illness, atopy, or history of respiratory illnesses.

Review of Systems

Constitutional: The patient is fatigued. He reports a low-grade fever. He, however, denies any recent changes in weight or chills.

Eyes: The patient reports periodic eye tearing, especially during the initial period of symptom onset. The tearing has since subsided. Denies visual loss or any changes in his vision. He also denies double vision, recent eye swelling, eye infection, or traumatic injury to the eye.

Ears/Nose/Mouth/Throat: Denies hearing loss or a ringing sensation in the ears. He also denies ear discharge. The patient reported experiencing nasal congestion, sneezing, and runny nose three days ago. Denies nasal polyps. The symptoms have improved since he was started on the antihistamine medication. He also reports experiencing facial pressure and intense coughing that sometimes wakes him up and delays his ability to induce sleep. The cough is mostly unproductive. Denies mouth sores, gum swelling, or using any dental applications. He reports a sore throat and difficulty swallowing. Denies hoarseness of voice.

Cardiovascular: Denies any irregularities in his heart rates or heart rhythms, palpitations, or chest pain. Also denies swelling in the extremities.

Pulmonary: The patient reports a chest tightness that started four days ago. He also reports periodic wheezing and labored breathing that sometimes awakens him during night sleep. The patient also coughs throughout the day. The cough worsens at night. Denies pleuritic pain or hemoptysis.

Gastrointestinal: Denies abdominal discomfort, distension, or tenderness. He also denies any irregularities in his bowel movements.

Genitourinary: Denies urinary frequency, urgency, or dysuria.

Musculoskeletal: Denies muscle pain, stiffness, or tenderness. He also denies joint swelling or restrictions in the range of motion of his joints.

Integumentary: The patient denies any inconsistencies in his skin color. He also denies rashes, hives, abnormal pigmentation, or any other lesions on his skin.

Neurological: The patient reports experiencing a headache with a pain scale of 5/10. The headaches preceded the complaints of cough and difficulty breathing. Denies dizziness or syncope.

Psychiatric: The patient denies depression or anxiety.

Endocrine: Denies heat or cold intolerance or diabetes.

Hematologic/Lymphatic: Denies lymph node swelling or splenomegaly.

Allergic/Immunologic: The patient has no known allergies.

Objective

Vital Signs: HR 122 beats per minute | BP 130/86 | Temp 99.7 F | RR 31 breaths per minute | SpO2 92%| Height -4’2 (50 percentile)| Weight – 70 lbs( 10^th percentile |BMI- 19.7 (85^th percentile. The child is at risk of being overweight).|

Labs, radiology, or other pertinent studies:

FEV1 – 1.8 L; FVC 3.0 L, FEV1/FVC 60%

Complete Blood Count for the patient: A CBC was necessitated to determine the presence of an infection or an inflammatory process. Viral infections are common triggers of acute asthmatic exacerbation among pediatric populations. Elevations in WBC counts are often suggestive of bacterial infections and can help distinguish viral infections from bacterial infections. Conversely, a decrease in WBC count, alongside elevated lymphocyte count, can be associated with viral infections (Pozdnyakova et al., 2020).

Hematology	Result	Normal range
Red cell count	5.5 x 1012/L	4.5–5.7
White cell count	8 x 109/L	4.0–10.0
Lymphocyte count	5.0 x 1012/L	1–4.8
Hemoglobin	160 g/L	133–167
Hematocrit	0.50	0.35–0.53
MCV	80 fL	77–98
MCH	27 pg	26–33
MCHC	332 g/L	330–370
RDW	10.5%	10.3–15.3

Physical Exam

General Survey: The patient is alert and responsive. He seems fatigued. He has difficulty completing phrases on a single breath. No signs of fever or chills. The patient assumed a sitting tripod position during the interview.

HEENT: The head is well-rounded and normocephalic. The hair is well distributed on the scalp, with no signs of alopecia or abnormal hair thickening. No signs of scars, head swelling, or any masses on the head. There are also no signs of facial scars or color inconsistencies. The eyes are symmetrical. There is a notable tearing. Vision functionalities are intact, with a 20/20 score. No signs of bloodshot, corneal dystrophy, or astigmatism. No sign of Dennie-Morgan lines below the lower eyelid or dark circles below the eye.

The ears are symmetrical and lined with hair. The tympanic membrane is clear. No signs of ear discharge or hearing loss. The nose is symmetrical and well-positioned on the face. No sign of nasal swelling or discharge. The patient had three episodes of sneezing during the interview. The nasal mucosal membranes are clear. No signs of pallor, bogginess, or nasal polyps. There is also a notable nasal flaring when the patient is gasping for breath. No sign of pharyngeal cobblestoning on examination of the throat.

Neck: The neck is symmetrical. No signs of skin color inconsistencies, scares, or lesions on the chest. The trachea is midline. No sign of jugular venous distension, swelling, or nodular enlargement on the lower front side of the neck.

CVS: The heart rate is rhythmic, but elevated as demonstrated in the vital signs. The S1 and S2 sounds were heard. No gallop or pericardial friction rub sounds were heard. An apical pulse was felt on palpation of the midclavicular fifth intercostal space.

Chest/Thorax: The chest wall is symmetrical. There is a notable sign of labored breathing and use of accessory muscles for respiration. No sign of any chest wall deformity or barrel chest. High-pitched wheezing sounds were heard bilaterally. No signs of respiratory stridor.

Abdominal: The abdomen is well-rounded and symmetrical. No sign of vein engorgement or scars. The abdomen is soft and non-tender. No palpable masses were found. Abdominal sounds were heard in all four quadrants.

Integumentary: No sign of skin color changes, scars, hives, swellings, or rash. No sign of finger clubbing, cyanosis, or pallor on the extremities. The capillary refill time on the lower and upper limbs was less than 2 seconds.

Neurological Examination: The patient is alert and cooperative. He answers the interview questions appropriately and is aware of his surroundings. His speech is normative in intonation, logical, and goal-directed. He has difficulty completing phrases in a single breath. No signs of slurred speech. His memory is intact. The patient also has a normal gait but occasionally assumes a sitting tripod position. His cranial nerves II-VII are intact.

Assessment

Differential Diagnoses

1. Acute asthmatic exacerbation ICD-10 code J45.901: Acute exacerbation of asthma is an acute or subacute condition characterized by a progressive escalation in asthmatic symptoms.

Rationale: The hallmark features of asthmatic exacerbation include shortness of breath, use of accessory muscles of respiration, wheezing, and chest tightness. Assessment findings often reveal patient inability to complete statements in a single breath, tachypnea above 30 breaths per minute, and a pulse rate above 120 beats per minute (Kostakou et al., 2019). The patient in the case presented had complaints of shortness of breath and frequent coughs. Assessment findings revealed tachypnea, elevated pulse rate of more than 120 bpm, wheezing, chest tightness, and a previous asthmatic exacerbation. This makes the asthmatic exacerbation diagnosis probable. Likewise, the FEV1/FVC values and the presence of an underlying infectious illness support this diagnosis.

2. Viral Pneumonia ICD-10 Code J12.9: Viral pneumonia Viral pneumonia is an infectious inflammatory condition affecting one or both lungs.

Rationale: Specific cues suggestive of viral pneumonia include lower temperature, flu symptoms, and a gradual onset. Likewise, physical examination findings of tachypnea and disproportionality between temperature elevation and the level of debility (American Lung Association, 2024). This differential was considered due to the presence of tachypnea and flu symptoms in the case presented. The patient, however, reported an acute onset of symptoms, with significant coughing, wheezing, and shortness of breath, making this diagnosis less probable.

3. Bronchiolitis ICD-10 Code J21.9:Bronchiolitis is an infectious respiratory disorder characterized by inflammation of the bronchioles.

Rationale: The hallmark features of bronchiolitis include cough, runny nose, and fever. Small airway obstruction with resultant shortness of breath and wheezing may also be apparent in patients with the disease (Manti et al., 2023). The presence of low-grade fever, shortness of breath, and wheezing makes bronchiolitis a probable diagnosis in the case presented. Unlike asthmatic exacerbation, where bronchoconstriction is prominent, the airway obstruction seen in bronchiolitis is due to airway edema (Pereira Filho et al., 2020). .The significant history of asthma in the case presented, coupled with the lack of evidence of exposure of the patient to persons with the disease or those with any other respiratory disease makes the diagnosis less probable.

4. Bronchiectasis ICD-10 Code J47.9: Bronchiectasis is an airway condition characterized by the widening of the airway and weakening functionalities of the mucociliary mechanisms.

Rationale:  The hallmark features of the disease include cough, sputum production, shortness of breath, wheezing, pleuritic chest pain, and hemoptysis (Talbot et al., 2024). The presence of shortness of breath and cough warranted the inclusion of this differential. However, the absence of pleuritic chest pain, hemoptysis, and sputum production made this diagnosis less probable.

Diagnosis: The presumptive diagnosis in the presented case is acute exacerbation of asthma. The presence of, severity, and frequency of coughs, shortness of breath, chest tightness, and wheezing pointed towards the diagnosis. An escalation of asthmatic symptoms often warranting multiple night awakenings, coupled with notable use of accessory muscles of respiration, tachypnea, and elevated pulse rate, is suggestive of an exacerbation (Ramsahai et al., 2019). Chest x-ray revealed bronchoconstriction, ruling out bronchiolitis or infection-induced wheezing. Likewise, the severity of the symptoms ruled out a normal asthmatic attack.

Plan

Acute Asthmatic Exacerbation

Diagnostics:

• Allergy testing: Allergy testing will be ordered to help determine any allergies the patient may have. Allergic testing is necessitated in patients with acute exacerbation, as allergic sensitization is a common cause of exacerbation. In this case, the child’s environment may be positive for animal dander and pollen that are allergenic and have the potential for triggering an asthmatic attack and exacerbation. Allergic testing for the allergens is thus paramount (Demoly et al., 2022).
• Peak flow assessment: Peak flow assessment will also be ordered. Peak flow measurement can help assess the severity of an asthmatic attack. In this case, peak flow measurement will reveal the severity of the exacerbation and inform management interventions such as oxygen therapy. A peak flow of less than 50% signifies very severe disease and the need for oxygen therapy (Pereira Filho et al., 2020).
• Chest X-ray is necessitated to rule out possible bronchiolitis and wheezing attributed to acute viral infections. The presence of bronchoconstriction often reveals the presence of asthma (Pereira Filho et al., 2020).

Treatment:

• Give two puffs of  Proventil HFA using a puffer and a spacer to ease the chest congestion and alleviate the shortness of breath. Repeat the dose every four hours while monitoring for a decrease in oxygen saturation and assessing dyspnea and respiratory rate. GINA guidelines recommend repeat SABA administration for children with acute asthmatic exacerbation while monitoring for deterioration in the vital signs.
• Start Pulmicort Flexhaler at 180 mcg every 12 hours. Pulmicort Flexhaler is effective in addressing shortness of breath and wheezing accustomed to airway inflammation. According to the GINA guidelines, a short course of inhaled corticosteroids is necessitated for all asthmatic children presenting with acute exacerbation of the disease. Inhaled corticosteroids are effective in preventing attacks (GINA, 2024).
• Refill  Proventil® HFA for 90 mcg per actuation when necessary to help address apparent subsequent asthmatic attacks. Inhaled short-acting beta-agonists such as albuterol ( Proventil® HFA) are effective in quick relief of asthmatic attacks. GINA recommends the use of two puffs of albuterol 2.5mg/2.5ml whenever a patient experiences an asthma attack for rapid opening of the airway (GINA, 2024).
• In case the oxygen saturation levels fall below 92%, oxygen therapy will be necessitated (Pereira Filho et al., 2020).

Education: 

• The patient and the family will be educated on the disease process and the likely therapeutic options available. In this respect, they will be informed that asthmatic exacerbations are life-threatening conditions and, if not managed promptly, may result in death.
• The patient will also be educated on the likely triggers for asthmatic exacerbation. In this case, they will be informed that environmental allergens and infections can trigger asthmatic exacerbation and should thus be avoided.
• They will also be educated on the symptoms of disease escalation to enhance their capacity to detect and report possible symptoms of escalation. In this case, the patient and his family will be informed that an increase in the frequency and intensity of the asthmatic symptoms is likely suggestive of an exacerbation and, therefore, require immediate medical intervention. Additionally, they should be advised to monitor the patient’s symptoms to enable them to detect any symptomatic escalation (Pereira Filho et al., 2020).
• The patient will also be educated on the significance of allergic testing to determine specific agents that the patient is allergic to. Selective allergic testing informs avoidance strategies for the patient (Pereira Filho et al., 2020).
• The patient will also be educated on the significance of controlling asthma. In this case, he will be advised to adhere to the prescribed medications. He will also be educated on the effective use of inhaler medication. Synchronization of breathing and the actuation of the inhaler can help maximize the dose of the medication administered and subsequently improve the effectiveness of the medication (Pereira Filho et al., 2020).

Follow-Up:

• The patient is expected to return for follow-up after one week. This will allow for assessment of the progress of the disease. It will also inform the need to escalate treatment (Pereira Filho et al., 2020). The patient is also expected to maintain contact with the clinic through the telehealth platforms notifying the clinician of any symptom escalation.

References

American Lung Association. (2024). Pneumonia symptoms and diagnosis. https://www.lung.org/lung-health-diseases/lung-disease-lookup/pneumonia/symptoms-and-diagnosis

Bousquet, J., Anto, J. M., Bachert, C., Baiardini, I., Bosnic-Anticevich, S., Walter Canonica, G., Melén, E., Palomares, O., Scadding, G. K., Togias, A., & Toppila-Salmi, S. (2020). Allergic rhinitis. Nature Reviews Disease Primers, 6(1). https://doi.org/10.1038/s41572-020-00227-0

Demoly, P., Liu, A. H., Rodriguez del Rio, P., Pedersen, S., Casale, T. B., & Price, D. (2022). A pragmatic primary practice approach to using specific IGE in allergy testing in asthma diagnosis, management, and referral. Journal of Asthma and Allergy, Volume 15, 1069–1080. https://doi.org/10.2147/jaa.s362588

Kostakou, E., Kaniaris, E., Filiou, E., Vasileiadis, I., Katsaounou, P., Tzortzaki, E., Koulouris, N., Koutsoukou, A., & Rovina, N. (2019). Acute severe asthma in adolescent and adult patients: Current perspectives on assessment and management. Journal of Clinical Medicine, 8(9), 1283. https://doi.org/10.3390/jcm8091283

Manti, S., Staiano, A., Orfeo, L., Midulla, F., Marseglia, G. L., Ghizzi, C., Zampogna, S., Carnielli, V. P., Favilli, S., Ruggieri, M., Perri, D., Di Mauro, G., Gattinara, G. C., D’Avino, A., Becherucci, P., Prete, A., Zampino, G., Lanari, M., Biban, P., … Baraldi, E. (2023). Update – 2022 Italian guidelines on the management of bronchiolitis in infants. Italian Journal of Pediatrics, 49(1). https://doi.org/10.1186/s13052-022-01392-6

Pereira Filho, F. de, Sarni, R. O., & Wandalsen, N. F. (2020). Evaluation of treatment of the exacerbation of asthma and wheezing in a pediatric emergency department. Revista Da Associação Médica Brasileira, 66(9), 1270–1276. https://doi.org/10.1590/1806-9282.66.9.1270

Pozdnyakova, O., Connell, N. T., Battinelli, E. M., Connors, J. M., Fell, G., & Kim, A. S. (2020). Clinical significance of CBC and WBC morphology in the diagnosis and clinical course of COVID-19 infection. American Journal of Clinical Pathology, 155(3), 364–375. https://doi.org/10.1093/ajcp/aqaa231

Ramsahai, J. M., Hansbro, P. M., & Wark, P. A. (2019). Mechanisms and management of asthma exacerbations. American Journal of Respiratory and Critical Care Medicine, 199(4), 423–432. https://doi.org/10.1164/rccm.201810-1931ci

Talbot, T., Roe, T., & Dushianthan, A. (2024). Management of acute life-threatening asthma exacerbations in the intensive care unit. Applied Sciences, 14(2), 693. https://doi.org/10.3390/app14020693

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Clinical Documentation Template

Directions: Students may use this general SOAP note template or their own.  Save a copy to your device to alter the document. Use APA when called for by the rubric or assignment prompt. The APA title page will be the first page, and the template will start on the second page. End with your APA formatted references. Keep in mind this template is structured for an average, problem-focused visit. This template will not be adequate for some special populations and situations (newborns/pregnancy visits/child wellness, etc.). Students need to use good clinical judgment and make additional headings and sections when needed and remove others as applies.

Consider viewing the EMS documentation guidelines from the US Department of Health and Human Services/CMS:

Documentation Guidelines – Reimbursement

Delete all text in red – these are instructions and not part of the SOAP document.

Student Name and clinical course: (If no title page): ______________________

ID:

Client’s Initials*:_______Age_____ Race__________Gender____________Date of Birth___________

Insurance _______________   Marital Status_____________

*It is recommended to include false initials and use Jan 1, XXXX (correct year) to protect client  confidentiality.  Include brief statement on whether the patient came to the clinic alone or accompanied, and if so by whom, and whether they are a reliable historian.

Subjective:

CC: Patient’s own words, a few words, a sentence or less. Example: “cough and fever”

HPI:

In paragraph format, including at the minimum OLDCARTS. Please start with demographics: AA, a 29 y.o. Asian female presents to the clinic alone with complaint of _____________.

Onset, Location, Duration, Characteristics/context, Aggravating factors or Associated symptoms,  Relieving Factors, Treatment, and Timing, Severity. Include any pertinent positives or negatives.

Past Medical History:

• Medical problem list
• Preventative care: (if applicable to the case – Paps, mammography, colonoscopy, dates of last visits, etc.)
• Surgeries:
• Hospitalizations:
• LMP, pregnancy status, menopause, etc. for women

Allergies:

Food, drug, environmental

Medications: include names, doses, frequency, and routes, and reason in parenthesis if off-label or secondary use

Family History:

Social History:

-Sexual history and contraception/protection (as applies to the case)

-Chemical history (tobacco/alcohol/drugs) (ask every pt about tobacco use)

Other: -Other social history as applicable to each case (diet/exercise, spirituality, school/work, living arrangements, developmental history, birth history, breastfeeding, ADLs, advanced directives, etc. Exercise your critical thinking here – what is pertinent and necessary for safe and holistic care)

ROS (write out by system): Comprehensive (>10) ROS systems for wellness exams or complex cases only. Do not include all 14 systems for every SOAP unless needed – review and document the pertinent systems. Do not include diagnoses – those belong in PMH. The below categories are per CMS guidelines.

### Constitutional:

– Fever

– Chills

– Weight loss or gain

– Fatigue

– Night sweats

– Weakness

### Eyes:

– Vision changes (blurry, double vision)

– Eye pain

– Redness or irritation

– Discharge

– Dryness or excessive tearing

– Floaters or flashes of light

### Ears/Nose/Mouth/Throat:

– Hearing loss or ringing in the ears (tinnitus)

– Ear pain or discharge

– Nasal congestion or discharge

– Sore throat

– Mouth sores or ulcers

– Difficulty swallowing

– Hoarseness

### Cardiovascular:

– Chest pain or discomfort

– Palpitations (irregular heartbeat)

– Shortness of breath (at rest or with exertion)

– Swelling in the legs or ankles

– Dizziness or lightheadedness

– History of hypertension or heart disease

### Pulmonary:

– Cough (dry or productive)

– Shortness of breath

– Wheezing

– Chest tightness

– Sputum production (color, amount)

– History of asthma or COPD

### Gastrointestinal:

– Nausea or vomiting

– Diarrhea or constipation

– Abdominal pain or discomfort

– Changes in appetite

– Heartburn or acid reflux

– Blood in stool or black stools

### Genitourinary:

– Urinary frequency or urgency

– Painful urination (dysuria)

– Blood in urine (hematuria)

– Incontinence

– Changes in menstrual cycle (for females)

– Sexual dysfunction

### Musculoskeletal:

– Joint pain or swelling

– Muscle pain or weakness

– Stiffness or limited range of motion

– History of arthritis or injuries

– Back pain

### Integumentary & Breast:

– Rashes or skin lesions

– Itching

– Changes in moles or skin color

– Breast lumps or tenderness

– Nipple discharge

### Neurological:

– Headaches

– Dizziness or vertigo

– Numbness or tingling

– Weakness or paralysis

– Seizures

– Memory changes or confusion

### Psychiatric:

– Depression or anxiety

– Mood swings

– Sleep disturbances (insomnia, hypersomnia)

– Changes in appetite

– Thoughts of self-harm or suicide

– Substance use

### Endocrine:

– Changes in weight

– Increased thirst or urination

– Heat or cold intolerance

– Changes in hair or skin texture

– Fatigue

– History of thyroid disease

### Hematologic/Lymphatic:

– Easy bruising or bleeding

– Swollen lymph nodes

– History of anemia

– Frequent infections

– Fatigue

### Allergic/Immunologic:

– Allergies (food, environmental, medication)

– History of asthma or allergic reactions

– Frequent infections

– Autoimmune disorders

Objective

Vital Signs:   HR        BP       Temp               RR       SpO2           Pain

Height             Weight             BMI    (be sure to include percentiles for peds)

Labs, radiology or other pertinent studies: be sure to include the date of labs – might be POC tests from today

Physical Exam (write out by system):

Start with a general survey:

Assessment

(you will often have more than one diagnosis/problem, but do the differential on the main problem)

Differentials (with a brief rationale for each):

1.

2.

3.

Diagnosis (may have more than one, include ICD-10 if rubric or as your instructor specifies)

Plan (4 pronged-plan for each problem on the problem list)

Diagnostics:

Treatment:

Education

Follow Up:

List plan under each Diagnosis.

Example

1: Hypertension (I10)

A: Lisinopril/HCT 20/12.5 Daily #90, refills 3

B: BMP in 6 months

C: Recheck BP in 2 Weeks

D: Low Sodium Diet and lifestyle modifications discussed

2: Morbid Obesity BMI XX.X (E66.01)

A: Goal of 5% weight reduction in 3 months

B: Increase exercise by walking 30 minutes each day

C: Portion Size Education

3: T2 Diabetes with diabetic neuropathy (E11.21)

A: Repeat A1C in 3 months

1. Increase Metformin to 1000mg BID #180, refills: 3

C: Annual referral to diabetic educator, ophthalmology, and podiatry (placed X/X)

D: Daily blood glucose check in the am and when sick

1. Return to clinic in 3-4 months to reassess