WEEK 4 SOAP NOTE NU623
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School
Herzing University *
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Course
623
Subject
Medicine
Date
Feb 20, 2024
Type
docx
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SOAP Note: Week 4
NU623: Adult Health
Herzing University
Name: Amanda Lee
Typhon Encounter #: Comprehensive:____Focused:__X__
S: SUBJECTIVE DATA
CC: “My anxiety medicine is not working anymore.”
HPI: 41-year-old white male presented to clinic today with complaints of “extreme anxiety” lasting for one month. Patient states he is having “full-
blown panic attacks” that are happening 2-3 times per week and worse at night. Patients states he only slept two hours last night due to the anxiety. Attacks are lasting anywhere from 30 minutes to 4 hours, and normally do
not subside until he is home and able to lay down and force himself to go to sleep. Patients describes attacks as a gradual onset, with an elevated heart rate, mild palpitations, and an elevated blood pressure which he feels is related to the anxiety. Patient states there is nothing in particular that brings them on, but they usually happen when he is away from home. Patient states he had panic attacks similar to this years ago, but has not had them this bad in quite some time. Patient reports taking Zoloft 50mg daily for the last 10 years. Patient stated when he felt an increase in anxiety 1 month ago, his usual provider here increased dose to 100 mg daily, however, the anxiety did not improve. Patient reports that he decreased the dose himself 2 weeks ago back down to 50 mg and the anxiety has only gotten worse. Patient also reports “ringing in his ears” that started when his dose was increased 1 month ago and has not stopped since decreasing it. Patient states BP is normally controlled with meds; however, it has been elevated the last 2 weeks.
PMH:
HTN (diagnosed in 2018), Anxiety/depression (diagnosed in 2014), DM2 (diagnosed in 2021)
ALLERGIES
No known allergies
MEDICATIONS
Lisinopril 10 mg PO daily, Zoloft 50 mg PO daily, Metformin 500 mg PO
BID
SH
Patient lives at home with wife and 2 small sons and works shiftwork at a local warehouse. Patient reports a 20-pack-year history of smoking, quit in 2015. Denies alcohol or illicit drug use. Patient reports he drinks caffeine “occasionally” but not every day. Denies any newly added stressors, just the normal stress of work, family, kids. FAMILY HISTORY
Maternal – HTN, DM
Paternal – HTN, Hyperlipidemia
Maternal grandmother – DM, died at the age of 78 (Colon cancer)
Paternal grandfather – HTN, MI (died at 72 of heart attack)
HEALTH Patient reports receiving the Moderna primary series of COVID vaccine
SOAP Note: Week 4
NU623: Adult Health
Herzing University
Name: Amanda Lee
Typhon Encounter #: Comprehensive:____Focused:__X__
PROMOTION & MAINTENANC
E
in September 2020; has not received any of the boosters. Did not take flu vaccine this year and doesn’t wish to receive it. Education provided. Patient reports lifestyle modifications when he was diagnosed with HTN in 2018 and continues to try and stick to a low-sodium, low fat diet. Patients states he packs a lunch for work and only eats out a couple times a week. Diabetic foot exam performed at last visit and was negative. Last eye exam 4 months ago. Positive GAD-7 assessment at today’s visit. Last A1c was1 month ago (6.1). Last cardio visit 5 years ago. ROS (put N/A in sections not completed day of exam)
Constitutional
Denies fever, chills, recent wt loss/gain
Head N/A
Eyes
N/A
Ears, Nose, Mouth, Throat
N/A
Neck
N/A
Cardiovascular/Peripheral Vascular
Reports palpitations. Denies chest pain, LE swelling/edema, orthopnea Respiratory
Denies SOB, cough, wheezing
Breast
N/A
Gastrointestinal
N/A
Genitourinary
N/A
Musculoskeletal
N/A
Integumentary
N/A
Neurological Reports tinnitus Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7)
Denies suicidal ideation, denies any thoughts of harm or harming others
Endocrine N/A
Hematologic/Lymphatic N/A
Allergic/Immunologic Denies food/medication/environmental allergies
Other N/A
O: OBJECTIVE DATA
VITALS:
HR: 89
RR: 18
BP: 150/80
Temp: 98.1
SpO2%: 99%
Ht: 70”
Wt: 221lb
BMI: 31.7
SOAP Note: Week 4
NU623: Adult Health
Herzing University
Name: Amanda Lee
Typhon Encounter #: Comprehensive:____Focused:__X__
Age: 41
LMP: N/A
PAIN: 0
PHYSICAL EXAM (Pertinent data related to presenting problem or visit type. Put N/A in sections
not completed day of exam)
General Appearance
Pt appears calm, well-
nourished, answers questions appropriately
Head N/A
Eyes
N/A
ENT, Mouth
N/A
Neck
N/A
Cardiovascular/Peripheral Vascular
Regular rate/rhythm, S2, S3 audible, no murmurs or gallop,
negative for edema, cap refill <3 sec
Respiratory
Lungs clear bilaterally, no wheezing, cough, SOB
Breast
N/A
Gastrointestinal
N/A
Genitourinary Male
External Exam
N/A
Internal Exam
N/A
Genitourinary Female
External Exam
N/A
Internal Exam
N/A
Musculoskeletal
N/A
Integumentary
N/A
Neurological N/A
Psychiatric Pt scored 18 on GAD-7, appears quiet/calm Endocrine N/A
Hematologic/Lymphatic N/A
Allergic/Immunologic N/A
Other
N/A
A: ASSESSMENT AND DIAGNOSIS
DIAGNOSIS
ICD-10 CODES PRIORITIZE DIAGNOSIS
1.
Generalized Anxiety Disorder
F41.1
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SOAP Note: Week 4
NU623: Adult Health
Herzing University
Name: Amanda Lee
Typhon Encounter #: Comprehensive:____Focused:__X__
2.
Primary Essential Hypertension
3.
Tinnitus I10
H93.19
VISIT CODES
CPT BILLING CODES
99213
DIAGNOSTICS
POC TESTING
(+) GAD-7 assessment, pt scored 18, EKG r/t palpitations, (NSR)
TESTS REVIEWED
N/A
P: PLAN
ACTIONS
1.
Diagnosis: Generalized Anxiety Disorder
Diagnostics Order:
EKG done in office today due to reported palpitations and showed NSR. Therapeutic:
D/C Zoloft. Start Paroxetine 10mg PO qam x 1 week, then 20mg PO qam x 1week. Plan is to continue to increase until we get to a therapeutic dose and the panic attacks are under control. Discussed the option of Buspar, however, pt states he has taken this before with no success. Started Metoprolol 12.5mg PO PRN as needed for acute panic attack resulting in physical symptoms such as rapid HR.
Education:
Education provided on side effects of both new medications such as bradycardia, fatigue, weakness, nausea, constipation (Metoprolol) and to with Paxil, to report any signs of rash (SJS), nausea, insomnia, headache, suicidality or mania. Patient
was also instructed to never stop an antidepressant abruptly. . Patient instructed to go to ER if he experiences any chest pain or SOB.
Consultation/Collaboration:
Patient referred to mental health NP for increased anxiety, panic attacks management 2.
Diagnosis: Primary Essential Hypertension
Diagnostics Order: Thyroid function, lipid panel, kidney function labs ordered today.
Therapeutic: Continue with 10mg Lisinopril PO daily. Education: Monitor BP at home 2-3 times daily and keep diary of this and we will look at next visit. Diet/exercise counseling provided
SOAP Note: Week 4
NU623: Adult Health
Herzing University
Name: Amanda Lee
Typhon Encounter #: Comprehensive:____Focused:__X__
Consultation/Collaboration:
Consult cardiology for med management and f/u testing if needed.
Diagnosis: Tinnitis
Diagnostics Order: N/A
Therapeutic: D/C Zoloft as could be contributing factor. If tinnitus has not subsided by f/u in 2 weeks, will discuss further options. Instructed patient to try distracting sounds such as a fan or radio to help with noise. Education: Instructed patient to seek medical attention immediately if he experiences sudden dizziness or hearing loss
Consultation/Collaboration: Will f/u in 2 weeks, if tinnitus has not
resolved, will refer to ENT
PREVENTITIVE (Used for comprehensive exams)
N/A
FOLLOW UP
Patient to follow up at this clinic within 2 weeks to monitor effectiveness of new medication. Will continue to go up on Paroxetine if not therapeutic in 2 weeks. Will discuss lab results and
outcome of mental health consult in order to better manage conditions.