SOAP Note Case Study

SOAP Note Case Study

Complete a focused SOAP note for the case study as noted below and address the additional discussion questions. For the SOAP note section only, you do not need to use complete sentences and must use approved nursing/medical abbreviations. You may copy and paste information from the case scenario.

For the discussion questions you must use Harvard format, using correct sentence structure and spelling. Include a written cover sheet as noted in the example posted on the module wall. Be succinct on both sections of the paper. No copying of any information is allowed on the discussion answers and will be considered plagiarism. Base your answers on appropriate evidence with citations as required.

The rubric is attached at the end of this document, be sure to review the rubric as you are writing so that you will have a well written, scholarly paper.

Case Scenario

CC: “I have been having heartburn every evening for the past 3 weeks”

45-year-old Saudi man presents for complaints of heartburn and to follow-up on yearly labs. He was diagnosed with hypertension 5 years ago. Currently he is prescribed losartan 100 mg and hydrochlorothiazide 25 mg by mouth every morning. Medical history includes dyslipidemia diagnosed 5 years ago for which he takes Atorvastatin 40 mg by mouth at bedtime. He reports that he takes all medication as ordered and experiences no side effects. He eats a standard Saudi diet except that he and his wife go out to eat at least 4-3 times each week for dinner and travel to Dubai at least 2 times each year where they eat 3 meals per day in restaurants. When he eats in restaurants, he does not follow a low salt diet as he does at home. He is employed as a chemical engineer at an oil refinery.  He reports his job requires a lot of sitting and he does not have much opportunity for exercise. He is married with 3 healthy teen-age children. He lives in his owned home with his wife and their 3 children. His widowed mother also lives with him.  He is comfortable in his home and has a happy relationship with his wife, children, and mother. He denies any symptoms of depression. His father and grandfather both died in their early 50’s from myocardial infarction. His mother is age 75 and has hypertension and T2DM. His maternal grandfather died due to colon cancer at age 50. He has 3 siblings. His brothers both have T2DM.  His sister was diagnosed with colon cancer last year at age 40. His oldest brother had an MI at age 50 but is doing well post stent placement one year ago. Denies pain except for some numbness and tingling in his toes, with pain at 3/10.  Denies any foot ulcers. Denies nausea/vomiting/diarrhea/constipation/black/bloody stools. He reports the heartburn usually occurs in the evenings after dinner and are reduced by chewing calcium carbonate tablets. He has not tried anything else for his heartburn symptoms. He reports that he has experienced similar heartburn symptoms several times in the past, but the symptoms have not lasted this long before. Denies shortness of breath, cough or wheezing, dizziness, difficulties with balance, or falls. Denies chest pain or palpitations. Denies joint pain, stiffness, or swelling. Denies rashes or dry skin. He is sexually active with his wife and states he has no difficulty. He sees the ophthalmologist every 2 years for eye exam due to astigmatism, last exam was 6 months ago, and his vision was unchanged, per patient report. He has declined colonoscopy at a previous visit.

Appears well groomed and is oriented to person, place, and time. Skin is warm, no open lesions. Conjunctivae white, moist, without drainage.  Red reflex present. Optic disc round well defined bilaterally. Macula is without visible lesions. No A-V nicking noted. Oropharynx is pink, moist without lesions, dentition is in good repair. Trachea is midline, thyroid is palpable and within expected limits, no nodules palpated. Lungs clear to auscultation bilaterally, anterior and posterior, without adventitious sounds. Heart with regular rate and rhythm, no murmurs, gallops, or rubs. Abdomen soft, bowel sounds active x 4. No abdominal tenderness with palpation. No CVP pain on percussion bilaterally. MSK not examined. LOPS (loss of protective sensation) 4/10 bilaterally including plantar surface distal 1/3 of foot and 10 toes, PS (protective sensation) 6/10 for remainder of foot by microfilament examination.  Lung sounds:

Vital signs: Weight 113 kg, Ht. 1.83 m, BMI 33.7, B/P 150/92 with repeat after 20 minutes 138/80, HR 89, RR 18, Temp 36.7 C, PO2 97% on room air.

Laboratory Results

These results were obtained fasting 2 days prior to this appointment:

TestResultAdult Reference Range
Glucose108Fasting: 70 – 110 mg/dL
Calcium9.18.2 – 10.6 mg/dL
Albumin4.53.5 – 5.0 gm/dL
Total Protein7.16.0 – 8.4 gm/dL
Sodium139133 – 146 mEq/L
Potassium4.83.5 – 5.4 mEq/L
CO23423 to 29 mEq/L
Chloride10298 – 106 mEq/L
BUN167 – 18 mg/dL
Creatinine1.30.6 – 1.2 mg/dL
GFR62> 60 mL/min/1.73m2
ALP8744 to 147 IU/L
ALT181 – 21 units/L
AST227 – 27 units/L
Total Bilirubin0.6Up to 1.0 mg/dL
HgA1c6.55.7 %
TestResultAdult reference Range
Red blood cell count           5.14.2 – 6.9 million/µL/cu mm
Hematocrit            48%Male: 45% to 52%
Platelet count      280,000150,000 – 350,000/mL
Hemoglobin 15Male: 13 – 18 gm/dL
Female: 12 – 16 gm/dL
WBC84.3-10.8 × 103/mm3
TestPatient ValueNormal Range
Total Cholesterol220< 200 mg/dL
Triglycerides150<150 mg/dL
HDL Cholesterol4560 mg/dL
LDL Cholesterol14560-130- mg/dL
Cholesterol/HDL Ratio4.94.0
TG/HDL Ratio3.3<2
LDL/HDL Ratio3.23.3-4.4

SOAP Note

Write a complete focused SOAP note. Use this format for your SOAP note:

This is the SOAP note format you are to use to complete the SOAP note.  Please use the word document copy posted with the assignment so you can type directly into the form.

Discussion: Answer the following questions:

  1. Based on the patient’s history, family history, and the lab values provided, what is your rationale for changing or not changing the cholesterol medications? Include a discussion of either a or b, based on your plan.
    1. If you changed the medications and /or dosages,what is your rational for choosing the drug(s) and doses you chose?
    1. If you chose not to change the medications and/or dosages, what is your rationale for continuing the same medication regimen?
  2.  What should this patient’s blood pressure, weight, and HgA1c goals be? Give the rational for each goal, specific to this patient.
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