Directions: Write a SOAP note forthe patient scenario described below. A complete S, O and A sectionaddressing all problems should be written. Only those problems thatare primary or secondary priority need to be addressed in the plan(P section). Be sure to include references forrecommendations.
Date of encounter: 5/25/20
CC: Post-discharge follow-up
Patient “Paul†is a 54 year-old Caucasian male being seen in theclinic following a recent hospital discharge 1 week ago for acutemyocardial infarction. During his admission, he underwent a heartcatheterization and subsequent drug-eluting stent placement to theleft anterior descending coronary artery. He was initiated onatorvastatin, aspirin, and clopidogrel therapy in the hospital anddischarged on these medications in addition to his previous homeregimen.
Upon presentation to the clinic, the patient was noticeablylimping and when asked, he stated that his hip pain has gotten muchworse over the past few months. He was previously able to controlthe pain with OTC naproxen and acetaminophen, however he says thatthese medications have not been working as well lately.Additionally, he states that his legs have been swollen since hewas discharged from the hospital. The swelling seems to be betterin the morning, but gets worse the longer he is on his feet, so hehas been spending a lot of time in his recliner. He is worried thatit may interfere with him going back to work as an elementaryschool teacher.
PMH:
T2DM diagnosed 5 years ago
HTN diagnosed 10 years ago
OA diagnosed 5 years ago
Family History:
               Father – alive, age 80, HTN, MI x 2, T2DM
               Mother – alive, age 78, COPD, hypothyroidism
               Sister – alive, age 46, HTN
Surgical History:
               Heart catherization with LAD stent placement approximately a weekand half ago
Social History:
               Lives at home with wife, 5 year old son, and 6 months olddaughter
               Works as an elementary school teacher
               Tobacco: 15 pack-year smoking history; quit 2 months ago
               Alcohol: 1-2 drinks/day with dinner
               Negative illicit drug use
               Compliant with prescribed medication regimens
Allergies: NKDA
Medication List:
               Metformin 500 mg PO BID with meals
               Lisinopril 10 mg PO daily
               Metoprolol tartrate 50 mg PO BID
               Acetaminophen ER 650 mg PO every 8 hours as needed for hip pain(OTC)
               Naproxen sodium 220 mg PO BID (OTC)
               Atorvastatin 20 mg PO daily – new medication started inhospital
               Aspirin EC 81 mg PO daily – new medication started in hospital
               Clopidogrel 75 mg PO daily – new medication started in hospital
Vaccinations:
               PPSV23 in 2015
               Yearly flu vaccine
               Td in 2016, never received Tdap
Height: 72 inches
Weight: 224 pounds
Vitals:
BP 162/98 mmHg
HR 76; RR 18
Temp 98.9°F
O2 sat 97% on RA
Physical Assessment: WNL aside from 3+bilateral lower extremity edema
Diagnostic studies: TTE completed duringhospitalization showed LVEF of 30%
Labs:
Drawn as outpatient – 2 days prior to clinicvisit |
Na – 138mEq/L | WBC – 7.5x 103 cells/mm3 |
K – 3.6 mEq/L | Hgb – 13.4 g/dL |
Cl – 104 mEq/L | Hct – 41.0 % |
CO2 – 30 mEq/L | Plt – 265 x 103 cells/mm3 |
BUN – 19 mg/dL | Bilirubin, total – 0.68 mg/dL |
SCr – 1.1 mg/dL | AST – 38 IU/L |
Glucose – 168 mg/dL | ALT – 44IU/L |
Ca – 9.2 mg/dL | Alkaline phosphatase – 92 IU/L |
HbA1c – 8.2% | |
Develop a thorough SOAP note for this patient, addressing allprimary and secondary problems fully within the plan.
