Running head: SOAP NOTE 1 1

Name: Erika Payne

SOAP NOTE 1

Subjective Information

Identification (ID): F.M.

Date of visit: 1/23/2020

Age: 52 y/o

DOB: 3/7/1967

Gender: Female

Advanced directives: No

Insurance: United Healthcare

Ethnicity: African American

Source: Self, reliable historian

Chief Complaint:

“Follow up and lab review.”

History of Present Illness (HPI):

F.M. is a 52-year-old female that presents for a follow up visit and lab review. She had lab work

completed on 1/17/20 in order to review at this visit. She was last evaluated in May 2019 but did

not follow up three months later due to insurance coverage issues. She explained that she has not

been taking her medications as prescribed because she often falls asleep before taking her nightly

dose. In addition, she has not been checking her blood sugar regularly because her meter broke

about 3 months ago. She denies any changes in her health or pain. She explains that she now has

better insurance and would like to schedule her mammogram and colonoscopy.

Past Medical History (PMH):

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General health: Fair

Surgeries: Cholecystectomy, tubal ligation, hysterectomy (dates unknown)

Past Illnesses: None

Hospitalizations: None

Past Medical Problems:

Neurologic: Denies history of seizures or tremors.

HEENT: Denies allergic rhinitis and recurrent sinusitis.

Respiratory: Denies history of asthma, pneumonia, COPD, sleep apnea, or bronchitis.

Cardiovascular: Reports history of hypertension and hyperlipidemia. Denies history of cardiac

events.

Musculoskeletal: Denies history of arthritis or fibromyalgia.

Endocrine: Reports history of diabetes mellitus type 2. Denies history of thyroid disorders.

Dermatologic: Denies history of psoriasis, atopic dermatitis, rosacea, skin cancer, and urticaria.

Gastrointestinal: Reports history of irritable bowel disease. Denies history of GERD.

Genitourinary: Denies history of kidney stones, bladder infections, or kidney disease.

Psychiatric: Denies history of depression, anxiety, attention deficit disorder, insomnia, or mood

disorders.

Health Maintenance:

Last PE: May 2019

Diagnostic tests:
- Last colonoscopy in 2014. Recall 5 years.
- Last mammogram in 2017.

Specialists: None

Immunizations: Up to date
SOAP NOTE 1 3

- Influenza: 12/2019
- PPV23: 1/18/18
- Prevnar13: 2/2019

Social History:

Personal History:
Marital status: Divorced

Sexual orientation: Heterosexual

Religious preferences: Deferred

Occupation: Medical Records Department at hospital

Safety or abuse issues: None

Health Habits:

Tobacco use: Denies

Alcohol use: Denies

Drinks per day: Denies

Illicit drugs: Denies

Diet: Fair. 1 cup of coffee per day.

Exercise: Occasional

Exposure to toxins: Deferred

Family History:

Mother, living, hypertension

Father, living, hypertension and hyperlipidemia

Medications:

Glipizide 10mg tablet. Take 1 tablet by mouth twice a day.

Class: Sulfonylurea, Antidiabetic Agent

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Adverse Effects: Dizziness, nervousness, syncope, diaphoresis, diarrhea

Contraindications: Hypersensitivity to glipizide or sulfonamide derivatives, type 1 Diabetes Mellitus,

diabetic ketoacidosis (Lexicomp, 2020a)

Lisinopril 20mg tablet. Take 1 tablet by mouth once daily.

Class: Angiotensin-Converting Enzyme (ACE) Inhibitor; Antihypertensive

Adverse Effects: Hypotension, dizziness, increased creatinine, syncope, headache, hyperkalemia

Contraindications: Hypersensitivity to ACE inhibitors, angioedema related to ACE inhibitors, idiopathic

or hereditary angioedema (Lexicomp, 2020b)

Metformin ER 500mg tablet, extended release. Take 2 tablets by mouth twice daily.

Class: Biguanide, Antidiabetic Agent

Adverse Effects: Diarrhea, nausea, vomiting, flatulence, infection, headache, weakness

Contraindications: Hypersensitivity to metformin or any component of the formulation; severe renal

dysfunction, acute or chronic acidosis (Lexicomp, 2020c)

Simvastatin 10mg tablet. Take 1 tablet by mouth daily.

Class: Anti-lipid Agent, HMG-CoA Reductase Inhibitor

Adverse Effects: Atrial fibrillation, edema, headache, vertigo, eczema, abdominal pain, constipation,

upper respiratory infection, bronchitis

Contraindications: Active liver disease, concomitant use of strong CYP3A4 inhibitors (Lexicomp,

2020d)

Allergies:

Denies any drug allergies. Denies allergy to food, latex, or stinging insects.
SOAP NOTE 1 5

Review of Systems (ROS):

General:

Denies sleep disturbance, fatigue, fever, weight loss/gain, or chills.

Diet:

Reports eating a moderate amount of breads and fried or fatty foods.

Skin, Hair, & Nails :

Denies any bruising, redness, abrasions, lesions, or discoloration to skin. Denies changes in nails

or hair.

Eyes:

Denies vision disturbances, dry eye, watery eyes, discharge, and trauma. She wears glasses.

Ears:

Denies hearing loss, otalgia, discharge, or tinnitus.

Nose:

Denies nasal congestion, epistaxis, postnasal drip, or sneezing.

Throat and Mouth:

Denies sores in mouth, sore throat, or dry mouth.

Head and Neck:

Denies headaches or neck pain.

Chest and Lungs:

Denies cough, shortness of breath, dyspnea on exertion, wheezing, or night sweats.

Cardiovascular:
SOAP NOTE 1 6

Denies chest pain, palpitations, edema, claudication, exercise intolerance, varicosities, or

syncope.

Gastrointestinal:

Denies abdominal pain, nausea, vomiting, or diarrhea.

Musculoskeletal:

Denies change in range of motion, weakness, heat, or swelling.

Neurologic:

Denies loss of coordination, weakness, numbness, or tingling.

Objective Information:

Physical Exam:

Vital Signs:

Temperature: 98.4F

Heart Rate: 70

Respirations: 16

BP: 124/76

Height: 5’3”

Weight: 182lbs

BMI: 32.2% (Obese)

Pain Scale: 0/10

Focused exam:

General Appearance
SOAP NOTE 1 7

Patient is a 52-year-old female who is well groomed, wearing appropriate dress for season, and

cooperative. She is alert and sitting upright in a chair when I entered the room. No distress

noted.

Mental Status and Neurological

Oriented to person, place, and time. Speech is clear and understandable. Sensory and motor

function intact. Deep tendon reflexes of patella 2+ bilaterally.

Skin/hair/nails

Skin is brown, warm, dry. Hair is black and clean. No bruising, abrasions, redness, lesions, or

swelling noted. Nails are trimmed with no cracking, splitting, or discoloration. Nail beds are

pink, capillary refill is < 3 seconds, and no evidence of clubbing of the fingers is noted.

Head

Head is normocephalic, atraumatic.

Neck

No jugular vein distention noted. No bruits noted on auscultation of the carotid arteries. Trachea

is midline and freely mobile. Neck is supple with full range of motion. No nodules or masses

palpated on thyroid gland.

Eyes

Pupils are equal, round, and reactive to light and accommodation. Conjunctiva is pink and sclera

is white. Extraocular movements intact. Orbits and eyelids are atraumatic.

Ears

Symmetrical. Bilateral ear canals with scant amount of soft cerumen present. Tympanic

membranes are pearly, gray with cone of light present bilaterally.

Nose
SOAP NOTE 1 8

Mucosa is pink without discharge. Nasal septum appears midline. No tenderness noted upon

palpation of frontal and maxillary sinuses. Nares are patent, no erythema, or drainage noted.

Mouth and Throat

Lips are moist. Dentition is intact with no obvious caries. Buccal membranes are pink and moist.

Tongue is pink, midline, and moist. No erythema or exudate present on posterior pharynx.

Tonsils are 2+.

Chest and Lungs

Chest is symmetrical in shape. Symmetrical, bilateral movement of chest expansion. 16

respirations per minute. No visible use of accessory muscles. No crepitus, masses, lesions, noted

to anterior or posterior chest. Clear auscultated lung sounds throughout anterior and posterior

lung fields bilaterally. No wheezes, crackles, rubs or rhonchi.

Heart/Peripheral Vascular

No signs of acute distress. PMI is palpable at the left midclavicular line at the 5th intercostal

space. No heaves, lifts, thrills or thrusts at PMI. S1 and S2 are audible with regular rhythm. No

splitting, gallops, rubs, murmurs or snaps at the five cardiac points of auscultation. Dorsalis pedis

pulses are 2+, regular. No cyanosis or edema throughout body.

Gastrointestinal

Abdomen is rounded, symmetrical. Skin color is brown. Active bowel sounds in all four

quadrants. No aortic bruits. Tympany percussed in all four quadrants. Liver not palpable.

Abdomen is soft to light and deep palpation. No masses, tenderness, or presence of

organomegaly with palpation.

Genitourinary

Examination deferred.
SOAP NOTE 1 9

Musculoskeletal

Patient is able to walk around room and change positions independently. Joints are appropriate

size, symmetrical, and contour. No unusual skin markings, ecchymosis, erythema, or changes in

the skin integrity. No guarding, discoloration, pallor, cyanosis or bleeding in joints throughout.

No warmth or crepitus of joints. No edema, masses, atrophy, hypertrophy, increased tone

irregularities noted in any muscle groups bilaterally. No scoliosis or deformities palpated of

spine. No pain with palpation of spine.

Diagnostic Tests or Labs:

Labs on 1/17/20

CBC – WDL

CMP – WDL except glucose was 188

Hemoglobin A1C – 8.8%

Lipid Panel – Total Cholesterol: 203, LDL: 125, HDL: 46, Triglycerides: 206

Microalbumin/random urine w/creatinine: WDL

Labs on 5/9/19

Hemoglobin A1C – 8.9%

Lipid Panel – Total Cholesterol: 192, LDL: 118, HDL: 47, Triglycerides: 153

Assessment Information:

Diagnostic Criteria

Hypertension is often diagnosed through screening of an asymptomatic individual (Brettler,

2019). Hypertension is diagnosed by obtaining an average of two or more seated blood pressures

on two separate office visits (Brettler, 2019). According to Brettler (2019), the diagnostic criteria
SOAP NOTE 1 10

for hypertension is as follows:

* Pre-hypertension: 120-139/80-89 mmHg

* Hypertension: ≥140/90 mmHg

* Stage 1: 140-159/90-99 mmHg

* Stage 2: ≥160/100 mmHg

This patient has an established diagnosis of hypertension. Lifestyle modifications are

crucial in the treatment of hypertension. She was educated on the importance of exercise, a well-

balanced diet, and the importance of achieving a healthy weight. First line drug therapy for

hypertension is a thiazide diuretic, an angiotensin-converting-enzyme inhibitor (ACE inhibitor),

or an angiotensin II receptor blocker (ARB) (Brettler, 2019). The patient has been taking

Lisinopril, an ACE inhibitor, and appears to be well controlled. She reports she occasionally

checks her blood pressure when she visits her mother and it is usually approximately 120

systolic. In addition, an ACE inhibitor is recommended for diabetic patients as it helps lower

blood pressure and preserves renal function (Brettler, 2019).

Patients with hyperlipidemia are often asymptomatic and diagnosed on routine screening

examinations (Santos, 2019). Diagnostic criteria for hyperlipidemia is based on the following lab values

(Santos, 2019):

LDL:

* Optimal: <70mg/dL

* Desirable - Above Desirable: 70 - 129mg/dL

* Borderline high: 130-159mg/dL

* High: 160-189mg/dL

* Very high: >190mg/dL

Total Cholesterol:
SOAP NOTE 1 11

* Optimal: <170mg/dL

* Desirable: <200mg/d

* Borderline high: 200 - 239mg/dL

* High: >240mg/dL

HDL:

* Low: <40mg/dL

Triglycerides:

* Ideal: <100mg/dL

* Desirable: 100-<150mg/dL

* Borderline high: >150mg/dL

* High: 200 - 499mg/dL

* Very high: > 500mg/dL

This patient was previously diagnosed with hyperlipidemia. Recommendations for drug therapy is

based on age, comorbidities, and cardiovascular risk (Santos, 2019). The patient’s total cholesterol, LDL,

and triglyceride level are elevated and have increased since her last visit. I spoke with the patient

regarding her lab results. She explained that she was prescribed Simvastatin in May 2019 but stopped

taking it because it made her urine “smell bad”. The patient’s atherosclerotic cardiovascular disease

(ASCVD) risk score was calculated in the office and resulted as 10.3%. We discussed these results with

the patient and explained that it is very important for her to be on a lipid lowering agent. She expressed

that she did not try the Simvastatin for very long and is willing to retry a statin medication. In addition,

nonpharmacologic treatment of hyperlipidemia including dietary modifications and physical activity is

crucial.

Diabetes mellitus type 2 affects nearly 8 percent of the United States population (McCullouch &

Hayward, 2019). Risk factors include age greater than 45 years, obesity, family history, sedentary

lifestyle, hyperlipidemia, hypertension, polycystic ovary syndrome, and history of vascular disease

(McCullouch & Hayward, 2019). Screening tests for type 2 diabetes include a fasting plasma glucose,
SOAP NOTE 1 12

hemoglobin A1C, and an oral glucose tolerance test (McCullouch & Hayward, 2019). According to

McCullouch & Hayward (2019), diagnosis of diabetes mellitus is based on the following test findings and

must be confirmed on a subsequent day by repeating the same test:

* Fasting plasma glucose >126 mg/dL

* Hemoglobin A1C > 6.5%

* Two-hour plasma glucose > 200mg/dL during oral glucose tolerance test

* Random plasma glucose > 200mg/dL with symptoms

This patient was diagnosed with diabetes mellitus type 2 several years ago and has been on various

medications to try to manage her blood glucose levels. Patients with diabetes have a high risk for both

microvascular and macrovascular disease, therefore, it is crucial to closely manage their condition. She

explained that she only takes Metformin and Glipizide in the morning because she often falls asleep

before taking her medication at night. In addition, she explains that she hasn’t been able to check her

blood glucose because her meter stopped working.

Irritable bowel syndrome (IBS) is a gastrointestinal disorder that causes abdominal pain and

altered bowel habits (Lehrer, 2018). This condition is often diagnosed after other pathological conditions

are excluded (Lehrer, 2018). Rome IV criteria is used to diagnose IBS (Lehrer, 2018). According to

Lehrer (2018), diagnostic criteria for IBS includes recurrent abdominal pain on average at least one day

per week during the previous three months that is associated with two or more of the following:

* Related to defecation (may be increased or unchanged by defecation)

* Associated with a change in stool frequency

* Associated with a change in stool form or appearance

Irritable bowel syndrome can be associated with four different bowel patterns: diarrhea

predominantly, constipation predominantly, mixed diarrhea and constipation, or unclassified (Lehrer,

2018). She was previously diagnosed with irritable bowel syndrome with diarrhea. She is not currently

taking any medications for this condition and reports her condition is stable when she monitors her diet.
SOAP NOTE 1 13

DIAGNOSES:

ICD 10 codes:

I10 – Hypertension

E11.9 – Type 2 Diabetes Mellitus without complications

E78.5 – Hyperlipidemia

K58.0 – Irritable bowel syndrome with diarrhea

CPT codes:

99214 – Office Visit, Established Patient, 2 Key Components: Detailed History; Detailed

Examination; Medium Decision, Moderate Complexity

PLAN:

- Labs reviewed with patient. Discussed increased cholesterol levels and elevated

hemoglobin A1C. Discussed long term health risk associated with uncontrolled diabetes,

hypertension, and hyperlipidemia including stroke, heart disease, poor kidney function,

and vision issues.

- Patient notified that her ASCVD risk score is 10.3%, therefore, it is recommended that

she is on a statin medication. Since she did not tolerate Simvastatin and self-discontinued

it, we will try Rosuvastatin 10mg tablet by mouth once a day. We would prefer that she

takes it at bedtime, however, due to compliance issues if she will remember to take it in

the morning then that is okay. Discussed monitoring for muscle pains or cramps and dark

urine. She must notify her provider if this occurs.

SOAP NOTE 1 14

- Discussed continuing Lisinopril 20mg by mouth once daily. Monitor blood pressure at

home and document it in log for next visit.

- Lifestyle modifications including diet and exercise discussed with patient. Patient given

diabetic diet handout which provided in depth information about carbohydrates and

serving sizes. In addition, she was encouraged to limit her sodium intake.

- Due to poor compliance with twice a day dosing of diabetic medications, she was

instructed to stop taking her Metformin and Glipizide. Start taking Synjardy XR

(Empagliflozin and Metformin) 12.5mg -1000mg tablet – two tablets by mouth once a

day. She was notified that this drug is a combination of Metformin and a SGLT2

inhibitor. The SGLT2 inhibitor will help her excrete glucose in her urine. Therefore, she

was instructed to increase her water intake and monitor for symptoms of a urinary tract

infection or yeast infection, which would include dysuria, blood in urine, urinary

frequency, urinary urgency, vaginal itching, or vaginal discharge. She was given a 7-day

sample of Synjardy XR in case her pharmacy did not have it readily available. A new

glucose meter was prescribed. Patient instructed to monitor her blood sugar daily and

document it in a log for next visit.

- Referral for mammogram and colonoscopy sent. Patient notified that she will be

receiving a call within 7 days to schedule an appointment.

- Routine eye exam scheduled for March.

- She was instructed to follow up in 3 months, or sooner if necessary, to assess how she is

doing with her medication changes and check a hemoglobin A1C. Advance directives not

discussed at this visit but will be reviewed at her next visit. All questions were answered.
SOAP NOTE 1 15

References

Brettler, J. (2019). Essential Hypertension. Epocrates. Retrieved

from https://online.epocrates.com/diseases/2611/Essential-hypertension/Key-Highlights

Lehrer, J. (2018). Irritable Bowel Syndrome. Medscape. Retrieved from

https://emedicine.medscape.com/article/180389-overview

Lexicomp. (2020a). Glipizide: Drug Information. UpToDate. Retrieved from

https://www-uptodate-com.proxy.lib.utc.edu/contents/glipizide-drug-

information?search=glipizide&source=search_result&selectedTitle=1~36&usage_type=p

anel&kp_tab=drug_general&display_rank=1#F176326

Lexicomp. (2020b). Lisinopril: Drug Information. UpToDate. Retrieved from

https://www-uptodate-com.proxy.lib.utc.edu/contents/lisinopril-drug-

information?search=lisinopril&source=search_result&selectedTitle=1~82&usage_type=p

anel&kp_tab=drug_general&display_rank=1#F189191

Lexicomp. (2020c). Metformin: Drug Information. UpToDate. Retrieved from

https://www-uptodate-com.proxy.lib.utc.edu/contents/metformin-drug-

information?search=metformin&source=search_result&selectedTitle=1~148&usage_type

=panel&kp_tab=drug_general&display_rank=1#F193858

Lexicomp. (2020d). Simvastatin: Drug Information. UpToDate. Retrieved from

https://www-uptodate-com.proxy.lib.utc.edu/contents/simvastatin-drug-

information?search=simvastatin&source=search_result&selectedTitle=1~148&usage_typ

e=panel&kp_tab=drug_general&display_rank=1#F221302

McCulloch, D. & Hayward, R. (2019). Screening for type 2 diabetes mellitus. UpToDate.
SOAP NOTE 1 16

Retrieved from https://www-uptodate-com.proxy.lib.utc.edu/contents/screening-for-type-

2-diabetes-

mellitus?search=diabetes%20mellitus%20type%202&sectionRank=1&usage_type=defau

lt&anchor=H6&source=machineLearning&selectedTitle=3~150&display_rank=3#H6

Santos, R.D. (2019). Hypercholesterolemia. Epocrates. Retrieved

from https://online.epocrates.com/diseases/17011/Hypercholesterolemia/Key-Highlights