1 Running head: SOAP NOTE ONE. Patient Encounter SOAP Note #1. M. Michelle Piper, MSN, RN. Submitted in Partial Fulfillment of the Requirements for GNRS 5568 Older Adult Chronic Illness The University of Texas Medical Branch School of Nursing Fall 2013. 2. SOAP NOTE ONE. SUBJECTIVE. Ms. KH is a 47-year-old Caucasian female who presented to the Magnolia Healthcare clinic October 11, 2013 alone to review abnormal lab work. History of Present Illness & Analysis of Symptom Pt reports that she had labwork drawn one week ago as part of her six-month follow-up appointment. She reports feeling well and healthy today. She states that she thinks her cholesterol labs were probably high.
2 Current Health Status Pt has no known allergies. She is currently taking: Metoprolol 50 mg PO twice daily Aspirin 81 mg PO daily Atorvastatin 80 mg PO daily Metformin ER 500 mg PO twice daily Fluoxetine 20 mg PO daily Robaxin 750 mg PO at bedtime as needed for migraine pain Sumatriptan 6 mg SC injection as needed for migraine Restoril 30 mg PO at bedtime as needed for insomnia All immunizations UTD. Pt reports no EtOH, no recreational drugs, (+) smoking (1 pack/day x 25 years), and 2 caffeine/day. Last physical exam 1 week ago. Does not walk or perform other exercise. Upon questioning, pt states that she takes Fluoxetine every day, but only takes other medications 4-5 days/week.
3 Past Medical History Pt reports being in good general health. Pt denies past major illnesses or injuries. Past surgery . C-section x2; TAH 10 years ago for heavy menstrual flow. No blood transfusions. Current Dx include: HTN. Hypercholesterolemia NIDDM. Depression with Anxiety Migraine Headaches Pt performs own ADLs. 3. SOAP NOTE ONE. Social History Pt is divorced and lives alone in apartment in town within 10 minutes drive of twin sister, mother, 2 adult children, and extended safe home environment. Pt reports that she is active at work. Works as retail clerk. No previous military service. No religious or cultural considerations. Pt lives in rural community.
4 Family History Pt's children well & healthy. Pt's mother w/ HTN, hyperlipidemia, Type 2 DM. Pt's father deceased at age 60 w/ MI. Pt's twin sister w/ HTN & hypercholesterolemia. Review of Systems General: Pt denies fatigue, weakness, unintentional weight loss or syncope. CV: No c/o chest pain, dyspnea, dizziness. Resp: Denies dyspnea, SOB, cough. GI: Denies anorexia, N/V/D/C. denies change in bowel habits or incontinence. No c/o numbness to LE. OBJECTIVE. VS: HR 66 BP 120/72. Ht 66 , Wt 133 lb. BMI Pt is alert & oriented. Pt interactive. Head normocephalic, atraumatic. Features symmetrical. Neck supple, without thyromegaly. No carotid bruit noted.
5 Heart w/ RRR, no gallop or murmur. Lungs sounds CTAB. No wheezes noted. BS clear in Extremities warm, 2+ pulses, <3 sec cap refill. No swelling noted. Diabetic foot exam normal with intact monofilament sensation bilaterally. Diagnostic: CBC normal w/ H&H CMP normal w/ fasting glucose 102, Cr , AST/ALT 25/21. Lipids elevated w/ total cholesterol 230, HDL 36, LDL 162, triglycerides 160. TSH normal at HbA1c normal at 4. SOAP NOTE ONE. ASSESSMENT. Hypercholesterolemia (Rosenson, 2013b). 1. Total cholesterol >200 (High classification per ATP III). 2. LDL >= 160 (High classification). 3. HDL <40 (Low classification). 4. Pt has 1 CHD equivalent w/ NIDDM.
6 5. Framingham risk 4 Major risk factors (Smoking, treated HTN, low HDL, family hx premature CHD). 6. Per Framingham calculator, pt has risk of MI in next 10 years (heart age >80). 7. For 10 year risk >20%, LDL goal is 100 mg/dL (Rosenson, 2013b). Differential diagnoses: Nonfasting lab draw 1. Nonfasting state will elevate triglycerides and total cholesterol (false positive). 2. BUT, Patient was fasting Hypertriglyceridemia (Rosenson, 2013a). Tobacco abuse 1. Pt smokes 1 pack/day x 25 years. Hypertension 1. Systolic BP 120 on metoprolol Impaired fasting glucose 1. Glucose 99, HbA1c , on metformin 2. Previous A1c PLAN. Therapeutic: 1. Continue current regimen atorvastatin (Lipitor) 80 mg PO daily a.
7 Unable to determine if current dosage is ineffective f pt isn't taking meds b. LDL goal <=130. 2. Continue current metoprolol 50 mg PO BID. a. BP at today visit acceptable 3. Continue current ASA 81 mg PO daily a. Low dose ASA significantly reduces risk of first MI (Hennekens, 2013). 5. SOAP NOTE ONE. 4. Continue current metformin 500 mg PO daily(McCulloch, 2013). 5. Start Chantix a. mg daily x 3 days, then mg BID x 4 days, then 1 mg BID x 12 weeks (Rennard, Rigotti, & Daughton, 2013). Diagnostic Tests: 1. Recheck lipids in 3 months a. If not at goal, consider changing atorvastatin to rosuvastatin for low HDL/high LDL. b. If not at goal for triglycerides, consider adding fish oil, gemfibrozil, or Niaspan Education: 1.
8 Discuss Framingham Risk & demonstrate (using Framingham risk App) current risk of MI & lowered risk with improved control of lipids, BP, smoking cessation a. Framingham Risk App available in Apple App Store 2. Reinforce lifestyle modifications (Hennekens, 2013). a. Exercise 30 min most days of week b. Limit concentrated sources of carbohydrates/sugars to decrease triglycerides 3. Discuss importance of taking medications daily as prescribed. Medications cannot improve health when they remain in prescription bottle. 4. Importance of smoking cessation (Hennekens, 2013). a. Use of Chantix (Rennard et al., 2013). i. Choosing quit date 3 weeks after beginning Chantix has better success rate than 1 week after beginning medication 5.
9 Tight glycemic control reduces microvascular complications Follow-up: 1. Return to clinic in 1 month to follow-up on Chantix & evaluate effectiveness 2. Return too clinic in 3 months to recheck lipid panel D'Agostino, R. B., Vasan, R. S., Pencina, M. J., Wolf, P. A., Cobain, M., Massaro, J. M., & Kannel, W. B. (2008). General cardiovascular risk profile for use in primary care. Circulation, 117, 743-753. doi: Hennekens, C. H. (2013). Overview of primary prevention of coronary heart disease and stroke. UpToDate. McCulloch, D. K. (2013). Overview of medical care in adults with diabetes mellitus. UpToDate. Rennard, S. I., Rigotti, N. A., & Daughton, D.
10 M. (2013). Overview of smoking cessation management in adults. UpToDate. 6. SOAP NOTE ONE. Rosenson, R. S. (2013a). Approach to the Patient with hypertriglyceridemia. UpToDate. Rosenson, R. S. (2013b). ATP III guidelines for treatment of high blood cholesterol. UpToDate. Research Article Summary D'Agostino, R. B., Vasan, R. S., Pencina, M. J., Wolf, P. A., Cobain, M., Massaro, J. M., &. Kannel, W. B. (2008). General cardiovascular risk profile for use in primary care. Circulation, 117, 743-753. doi: The selected article analyzes data from the Framingham data set of 8491 individuals to create risk groups of men and women with specific characteristics in order to predict risk of coronary vascular events.