Focused SOAP Note
Student’s Name
Institutional Affiliation
Course
Professor’s Name
Date
Focused SOAP Note
Patient Information:
Initials IHD, Age 70 y.o, Sex F,
S (subjective)
CC (chief complaint): Follow up care for hypertension and home health care needs.
HPI (history of present illness):
Dickson, Irava Haggerty is a 70 year-old female who is on a follow up televideo care for hypertension.
Current Medications:
05/21/2019NovoLOG FlexPen Subcutaneous 100 UNIT/ML 20 Three times a day with meal-Subq
Antidiabetics03/04/2019ozempic (0.25 Or 0.5 Mg/Dose) Subcutaneous 2 Mg/1.5ml 2 Once Weekly Till Sample Pen Completed Then Start Ozempic 1mg Sub Q Weekly
Antidiabetics(Ls) Amlodipine Besylate Oral 10 Mg 1 Tab(S) Daily By Mouth
Calcium Channel Blockers(Ls) Aspirin Oral 81 Mg 1 Tab(S) Daily By Mouth
Analgesics – Nonnarcotic(Ls) Carvedilol Oral 12.5 Mg 1 Tab(S) Twice Daily. By Mouth
Beta Blockers(Ls)Furosemide Oral 40 Mg 1 Tab(S) Twice Daily. By Mouth
Diuretics(Ls)Losartan Potassium-Hctz Oral 100-25 Mg 1 Tab(S) Daily By Mouth
Antihypertensives(Ls) Tresiba Flextouch Subcutaneous 100 Unit/Ml 100ml Take Am And Pm 100u Subcutaneous(Sq)
Antidiabetics(Ls)Potassium 20mg/By Mouth/1(Tab) Twice Daily
Minerals & Electrolytes(Ls) Celecoxib Oral 200 Mg 1 Cap(S) Daily By Mouth
Analgesics – Anti-Inflammatory(Ls) Cholecalciferol Oral 125 Mcg (5000 Ut) 1 Cap(S) Daily By Mouth
Vitamins(Ls)Meloxicam Oral 15 Mg 1 Tab(S) Daily By Mouth
Analgesics – Anti-Inflammatory(Ls) Rosuvastatin Calcium Oral 40 Mg 1 Tab(S) Daily By Mouth
Antihyperlipidemics
Allergies:
Neumovax 23, Naproxen, and penicillin.
PMHx:
OA – affecting multiple joints causing mobility issues due to the arthritis in bilateral knees. Chronic pain 2/2 DJD. She takes Aleve to help her sleep.
DM2
HTN
HFpEF
Allergic
Arthritis
Hyperlipidemia
Hypertension
Obesity
Polyneuropathy
Type 2 diabetes mellitus
Soc and Substance Hx: The patient is single. The details of the children and education are not in the file. Information on occupational history is not available. The file has no information on financial needs, food security, worry, anxiety, and inability. Information on transport needs, medical, non-medical, and substance use. The patient is a former smoker. The file has no information on physical activity and social connections. She never had a sexual encounter.
Fam Hx: The mother has a history of arthritis, diabetes, heart failure, heart attack, hypertension, kidney disease, learning disabilities, obesity, and vision loss. The sister has asthma.
Surgical Hx: No prior surgical procedures.
Mental Hx: Diagnosis and treatment. Current concerns (anxiety and/or depression). History of self-harm practices and/or suicidal or homicidal ideation.
Violence Hx: Concern or issues about safety (personal, home, community, sexual (current and historical).
Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse (oral, anal, vaginal, other, any sexual concerns).
ROS
GENERAL: Negative for body weight changes, chills, diaphoresis, or fever.
HEENT: Negative results for nasal congestion, postnasal drip, and sore throat.
SKIN: Negative for lesions, rash or itching.
RESPIRATORY: Negative for cough, or shortness of breath.
CARDIOVASCULAR: Negative results for tightness or chest pain, palpitation, and leg swelling.
MUSCULOSKELETAL: Positive for arthralgias, back pain, and gait problem (2/2 chronic arthritis pain), negative for myalgias.
NEUROLOGICAL: Negative for dizziness and headaches.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating.
REPRODUCTIVE: Not pregnant and no recent pregnancy. No reports of vaginal or penile discharge. Not sexually active.
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
Vital signs: There were no vital signs taken during the visit. During the next visit, there is a need to take the vital signs to establish high blood pressure severity.
O (objective)
Physical exam:
General: She is not in critical illness.
Appearance: She is appearing sick.
Pulmonary: Normal pulmonary condition. No breathing problems.
Neurological: No focal deficit present.
Mental status: AO*3.
Physical examination is limited due to the televideo encounter.
Differential Diagnosis
Primary diagnosis: Hypertension
Hypertension is an illness that triggers high blood pressure. The symptoms include headache, fatigue, and breathing problems (Ong et al., 2019). People develop high blood pressure due to various reasons. Some of them include genetic factors or traumatic experiences in life. Blood pressure require monitoring and adherence to treatment to ensure the condition do not deteriorate into severe levels.
Aortic coarctation:
Aortic coarctation is the narrowing or constriction of the aorta. The condition prompts the heart to pump harder to get sufficient blood through the arteries and other parts of the body. The condition is not evident until adulthood (Bruse et al., 2017). One of the common symptoms of the disease is high blood pressure. Diagnosis involves EKG or chest X-ray.
Malignant hypertension:
Malignant hypertension is a type of high blood pressure that causes organ damage. Malignant high blood pressure is typically above 180/120mm/hg. The condition should be treated as an emergency (Rubin et al., 2019). It can cause significant damage to essential organs such as the kidney or brain. Damage of the essential organs can undermine the health of an individual. Failure to treat the condition can lead to fatalities. Statistics indicate that patients are at a high risk of death if malignant hypertension is not treated.
Assessment/Plan
Circulatory – essential hypertension, current assessment, and plan, continue the current medication regime.
Relevant medications: Carvedilol (COREG) 12.5mg tablet.
Losartan (COZAAR) 25mg tablet
Other orders: Ambulatory to home health.
HFpEF (heart failure with preserved injection fraction) CMS/HCC
Current assessment and plan
Continue with f/up with Dr. Wayhs.
Continue losartan, carvedilol, and BP control.
Relevant medications
Carvedilol (COREG) 12.5mg tablet
Losartan (COZAAR) 25mg tablet
Other orders
Ambulatory referral to home health
Digestive
Morbid obesity (CMS/HCC)
Current assessment and plan
Discussed the patient’s BMI with her
The discussed DASH diet, continue f/up with endocrinology.
Relevant orders
Ambulatory referral to home health
Musculoskeletal:
Osteoarthritis of multiple joints
Current assessment and plan
Long hx of chronic arthritis in knees, back
Continue ice/heat PRN – planning to star using heat pad again.
Voltaren gel RX sent today
Relevant medication
Diclofenac sodium (Voltaren) 1% gel
Relevant orders:
Ambulatory referral to home health
Others – limited mobility
Current assessment and plan
Would continue to benefit from HHC services, including skilled RN and home health aide – referral sent to HHC today.
Return in about 3 months (around) 10/16/2020 for HTN and OA.
I have reviewed the history, exam, assessment, and plan with the resident and agree with conclusions, exceptions to the elements will be noted.
The information shows that the patient should contact the hospital or visit the facility for further analysis. The analysis, including vital signs and physical examination, is crucial in making conclusions about a patient’s health condition. During the visit, the patient should report the progress since the last medical analysis. The patient should continue with a balanced diet. It is important to continue adhering with the current medication to eliminate the risks associated non-compliance with the medication. The patient should have blood pressure tool kit to assess their blood pressure to ensure their health condition do not deteriorate without their knowledge.
References
Bruse, J. L., Khushnood, A., McLeod, K., Biglino, G., Sermesant, M., Pennec, X., … & De Leval, M. (2017). How successful is successful? Aortic arch shape after successful aortic coarctation repair correlates with left ventricular function. The Journal of Thoracic and Cardiovascular Surgery, 153(2), 418-427.
Ong, M. S., Abman, S., Austin, E. D., Feinstein, J. A., Hopper, R. K., Krishnan, U. S., … & Mandl, K. D. (2019). Racial and ethnic differences in pediatric pulmonary hypertension: an analysis of the pediatric pulmonary hypertension network registry. The Journal of Pediatrics, 211, 63-71.
Rubin, S., Cremer, A., Boulestreau, R., Rigothier, C., Kuntz, S., & Gosse, P. (2019). Malignant hypertension: diagnosis, treatment and prognosis with experience from the Bordeaux cohort. Journal of Hypertension, 37(2), 316-324.
