SOAP Note Template_2023-1 (1)
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School
University of South Florida *
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Course
3712
Subject
Medicine
Date
Apr 3, 2024
Type
docx
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3
Uploaded by ChancellorFangMole45
Date: October 5,2023. Group: 2 Member Initials: SH, WS, NH, SP Course: _APC-III
Pt Initials: SW Age: 45 Sex: woman Reason for visit: follow up for blood pressure check and cough
S
O
S
ubjective: CC:
“I have come in for a follow-up blood pressure check and this cough and tickle in my throat is
killing me”. HPI: Sam Washington is a 45-year-old African American woman who presents to her family
medicine clinic for evaluation of her blood pressure. She was seen by her primary care provider
almost 6 weeks ago when she was diagnosed with hypertension when her BP reading was 146/88
with no dizziness, no headaches, no blurry vision. Her follow-up BP one week later was 142/88. At
that time the PCP started her on BP medication and ordered a battery of baseline labs and referred
her to an ambulatory care pharmacist for management of her chronic conditions. PMH: Hypertension × 6 weeks ago Type 2 DM × 1 year Hyperlipidemia x 1 year SH: Unknown FH: Father died of lung cancer at age 71, mother died of MI at age 73.
ROS: Appears older than stated age otherwise feels fine. Dry, tickly cough started a few weeks ago.
But reports it happens every season. It is aggravated by seasonal allergies. The OTC medication (gets cheapest one) usually helps, but not this time. Denies joint pain or weakness. O
bjective: Medication list: Lisinopril 10 mg PO daily Metformin 1000 mg PO BID Pseudoephedrine Hydrochloride 30 mg
VS:
BP 145/85 mm Hg
P 85 bpm
RR 22
T 37.2°C
Wt 75 kg
Ht 5 4″
′
Andrews
Date: October 5,2023. Group: 2 Member Initials: SH, WS, NH, SP Course: _APC-III
Pt Initials: SW Age: 45 Sex: woman Reason for visit: follow up for blood pressure check and cough
A/P
Labs:
1.
Uncontrolled Second Stage Hypertension A:
Patient’s Blood pressure is 145/85 mmHg, second stage hypertension. The goal is for to decrease her blood pressure to 130/80 mmHg, which is the goal, as per mentioned by AHA guidelines. P:
Discontinue the Lisinopril 10mg due to the patient being African American and ACE inhibitor aren’t as effective in this ethnicity. Recommend switching Lisinopril 10mg PO daily to Amlodipine 2.5mg PO daily for 2-4 weeks and follow up with PCP. Advise patient to reduce salt intake, increase physical activity and weight loss. 2.
Uncontrolled Hyperlipidemia A: The laboratory results indicate hyperlipidemia. Her LDL level is 180 mg/dL, ideally less than 100 mg/dL; Triglycerides are at 225 mg/dL, with the target being 150 mg/dL; and HDL is 28 mg/dL, falling
short of the desired level of 50 mg/dL or higher. The goal is to decrease the LDL to be less than 100 mg/dL., as mentiones by ADA guidelines. P: Start Colesevelam 3.75 g/day PO in 1 or 2 divided doses, with a meal. Monitor the Triglyceride levels since this drug can increase triglyceride levels. Advise patient to exercise regularly, lose weight
and take fish oil. Follow up with PCP. 3.
Cough/ throat pain A: Patient mentions experiencing throat discomfort, typically dealing with seasonal allergies, and using over-the-counter allergy medication, which, at the moment, isn't providing relief. The goal is for eliminate the coughing discomfort. P: Discontinue Pseudoephedrine Hydrochloride 30 mg PO due to her having hypertension and start Cetirizine HCl 10mg PO daily. Advise the patient to start cough drops, increase fluid intake and to invest on a humidifier. Andrews
Date: October 5,2023. Group: 2 Member Initials: SH, WS, NH, SP Course: _APC-III
Pt Initials: SW Age: 45 Sex: woman Reason for visit: follow up for blood pressure check and cough
4.
Controlled Diabetes Type 2 A: Patient has controlled diabetes, no need to change it. A
ssessment: Provide problem list
(listed from highest to lowest priority), include supportive evidence
from S/O for each
problem. Also, include treatment goals
for each problem: P
lan: Provide detailed recommendations for each problem. You must include rationale
for recommendation, monitoring parameters
, and follow-up
. Also, you must include evidence-based guidelines and/or other resources used in the plan
:
Andrews
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