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Name: Erika Payne

SOAP NOTE 3

Subjective Information

Identification (ID): D.P.

Date of visit: 2/10/2020

Age: 55 y/o

DOB: 10/31/1964

Gender: Female

Advanced directives: No

Insurance: Blue Cross Blue Shield

Ethnicity: Caucasian

Source: Self, reliable historian; husband present.

Chief Complaint:

“Hypertension follow up and lab review”

History of Present Illness (HPI):

D.P. is a 55-year-old female that presents for hypertension follow up. She was evaluated at

Physicians Care on 2/2/20 and went to Parkridge hospital for further evaluation due to elevated

blood pressure (200’s/120’s). She was discharged from the hospital on Lisinopril and Clonidine

daily. She notes that her blood pressure has been elevated for years. She explained that she

“doesn’t feel good” and “passes out” when her blood pressure is normal (120’s/80’s). She denies

chest pain, shortness of breath, vision changes, or headache. She explained that she did not have

insurance and did not see a provider for nearly 10 years. She is interested in establishing care.

She was previously diagnosed with diabetes and was prescribed Metformin but stopped taking it
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when she lost insurance. In addition, she is requesting medication for gastroesophageal reflux as

Omeprazole is expensive over the counter. She has a history of chronic back pain and is

requesting to see pain management now that she has insurance. She currently denies pain at this

time.

Past Medical History (PMH):

General health: Fair

Surgeries: 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. Denies history of hyperlipidemia or cardiac

events.

Musculoskeletal: Denies history of arthritis or fibromyalgia.

Endocrine: Reports history of diabetes. Denies history of thyroid disorders.

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

Gastrointestinal: Reports history of GERD. Denies IBS.

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

Psychiatric: Denies history of attention deficit disorder, insomnia, or mood disorders.

Health Maintenance:

Last PE: >10 years ago

- Mammogram – Never
- Colonoscopy - Never
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Specialists: None

Immunizations: Pt reports up to date. Will need booster of Tdap.

- Refuses influenza this year.

Social History:

Personal History:
Marital status: Married

Sexual orientation: Heterosexual

Religious preferences: Deferred

Occupation: None

Safety or abuse issues: None

Health Habits:

Tobacco use: Current smoker. 1ppd x 40 years.

Alcohol use: Denies

Drinks per day: Denies

Illicit drugs: Denies

Diet: Fair.

Exercise: Occasional.

Exposure to toxins: Deferred

Family History:

Mother, unknown

Father, unknown

Medications:

Clonidine 0.1mg tablet. Take 1 tablet by mouth once daily.

Class: Antihypertensive; Alpha2-Adrenergic Agonist

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Adverse Effects: Drowsiness, headache, fatigue, dizziness

Contraindications: Hypersensitivity to clonidine hydrochloride or any component of the

formulation (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)

Allergies:

Denies any drug allergies, allergies to food, latex, or stinging insects.

Review of Systems (ROS):

General:

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

Diet:

Reports eating a well-balanced diet.

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.
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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:

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

syncope.

Gastrointestinal:

Reports intermittent “heart burn” after meals. Denies abdominal pain, nausea, vomiting, or

diarrhea.

Genitourinary:

Denies urinary frequency, urgency, hematuria, or dysuria.

Musculoskeletal:

Reports chronic low back pain without radiation to legs. Denies change in range of motion,

weakness, heat, or swelling.

Neurologic:

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

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Objective Information:

Physical Exam:

Vital Signs:

Temperature: 98.9F

Heart Rate: 90

Respirations: 18

BP: 175/129

Height: 5’1”

Weight: 147lbs

BMI: 27.7% (Overweight)

Pain Scale: 0/10 currently

Focused exam:

General Appearance

Patient is a 55-year-old female who is well groomed, wearing appropriate dress for season, and

cooperative. She is alert and talking to husband 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 fair, warm, dry. Hair is blonde and clean. No bruising, abrasions, redness, lesions, or

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

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

Head
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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. Conjunctiva is pink and sclera is white. Extraocular

movements intact. Orbits and eyelids are atraumatic.

Ears

Symmetrical. Bilateral ear canals are patent. Tympanic membranes are pearly, gray with cone of

light present bilaterally.

Nose

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

palpation of frontal and maxillary sinuses. Nares are patent.

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 1+.

Chest and Lungs

Chest is symmetrical in shape. Symmetrical, bilateral movement of chest expansion. 18

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

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

posterior lung fields bilaterally. Intermittent dry cough. No wheezes, crackles, rubs or rhonchi.
SOAP NOTE 3 8

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 fair. 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.

Musculoskeletal

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

size, symmetrical, and contour. No ecchymosis, erythema, or changes in the skin integrity. No

guarding, discoloration, pallor, or cyanosis of 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.

Reports bilateral lower back pain with bending and rotation.

Diagnostic Tests or Labs:

Labs on 2/10/20

CBC – WDL

CMP – WDL except glucose was 218

Hemoglobin A1C – 6.6%

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Lipid Panel – Total Cholesterol: 124, LDL: 52, HDL: 39, Triglycerides: 164

TSH – 2.1

Vitamin D – 14.7

No previous labs to compare.

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

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, however, stopped seeking

medical care due to loss of medical coverage years ago. She explained that she is asymptomatic

and therefore did not think that her elevated blood pressure was significant. 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). This patient started

taking Lisinopril, an ACE inhibitor, last week after she was discharged with a prescription from

the emergency department. In addition, she was prescribed Clonidine once a day. These

medications have helped decrease her blood pressure, but she still remains hypertensive. She is
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reluctant to take any more medication for her blood pressure because she explains that she does

not feel well when her blood pressure is around target.

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, 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 has a hemoglobin A1C of 6.6% and fasting blood glucose of 215. Despite

knowing that she has diabetes mellitus type 2, she did not know what the condition is or

treatment. She took Metformin years ago but stopped taking it when she lost insurance coverage

and could no longer see her provider. We discussed the diagnosis of diabetes and the potential

long-term effects of the disease including macrovascular and microvascular effects.

According to Zuckerman and Carrion (2019), gastroesophageal reflux disease (GERD) is

diagnosed clinically. A trial of proton-pump inhibitors can provide both diagnosis and initial

treatment of this condition (Zuckerman & Carrion, 2019). “Heartburn" and regurgitation are the

most common symptoms, which usually occur after meals (Zuckerman & Carrion, 2019).
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Symptoms are typically worse if the patient is lying down or bending over (Zuckerman &

Carrion, 2019). Treatment goals aim to control symptoms and prevent complications

(Zuckerman & Carrion, 2019). This patient has an established diagnosis of GERD and has been

talking over the counter omeprazole with improvement in her symptoms.

Approximately 84% of adults will experience low back pain at some point in their lives

(Knight et al., 2020). The majority of patients in primary care have nonspecific back pain that is

self-limiting. This patient has an established diagnosis and has had intermittent low back pain for

several years. Nonpharmacologic treatment for low back pain includes heat, massage, exercises,

acupuncture, and more (Knight et al., 2020). Recommended pharmacotherapy includes

nonsteroidal anti-inflammatory drugs which may be in combination with muscle relaxants if

necessary (Knight et al., 2020). This patient explained that she has been on narcotic pain

medication in the past and completed therapy without improvement in her symptoms. She was in

a pain management program in the past for her pain, but it became too expensive. She is

requesting a referral back to pain management.

Vitamin D deficiency is the most common nutritional deficiency in the world among

children and adults (Holick, 2019). Risk factors for vitamin D deficiency include inadequate

sunlight exposure, using sun protection, increased skin pigmentation, inadequate dietary intake,

malabsorption syndromes, obesity, and medication use (Holick, 2019). According to Holick

(2019), most patients with vitamin D deficiency are asymptomatic. Diagnostic criteria for

vitamin D deficiency includes a serum 25-hydroxyvitamin D level of <20 nanograms/mL

(Holick, 2019). Vitamin D insufficiency is defined as serum 25-hydroxyvitamin D between 21-

29 nanograms/mL (Holick, 2019).  The goal of treatment is to maintain a level of 30-100

nanograms/mL in both children and adults (Holick, 2019).  Treatment includes Vitamin D2
SOAP NOTE 3 12

(ergocalciferol) and D3 (cholecalciferol) supplements which are equally effective (Holick, 2019).

In addition, it is recommended to stay on a maintenance dose of Vitamin D3 of 1500-2000 IU

per day (Holick, 2019). Sensible sun exposure is recommended for treatment and prevention of

vitamin D deficiency (Holick, 2019). Exposure of arms and legs for 5 to 30 minutes per day can

stimulate vitamin D production (Holick, 2019). Caution is advised as the face needs sun

protection and we do not want patients having too much exposure due to risk of a sunburn or

increased risk for skin cancer (Holick, 2019). It is important to make sure the patient is having

adequate calcium intake as this can contribute to vitamin D insufficiency or deficiency. We

discussed taking cholecalciferol (Vitamin D3) 2000 IU orally once daily for 6 to 8 week and then

we will repeat her labs. She was informed that she can purchase this supplement over the

counter, but she preferred a prescription to see if it is cheaper with insurance.

DIAGNOSES:

ICD 10 codes:

I10 – Hypertension

E11.9 – Type 2 diabetes mellitus without complications

K21.9 – Gastroesophageal reflux disease (GERD)

M54.5 – Low back pain

E55.9 – Vitamin D deficiency, unspecified

CPT codes:

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

Examination; Medium Decision, Moderate Complexity

PLAN:
SOAP NOTE 3 13

- Discussed hypertension and potential complications if the condition remains uncontrolled

including heart disease, stroke, kidney disease, and retinopathy. I recommended she

purchases a blood pressure cuff and document results in a daily log. If this is not

practical, then she can go to a grocery store that has a blood pressure monitor and do spot

checks to record for next visit.

- Prescribe: Lisinopril 20mg tablet. Take one tablet by mouth daily. Dispense: 30 (thirty)

Refill: 0 (zero). Discussed monitoring for reactions including angioedema, hypotension,

dizziness, or cough.

- Prescribed: Clonidine 0.1mg tablet. Take one tablet by mouth daily. Dispense: 30 (thirty).

Refill: 0 (zero). Discussed adverse effects including hypotension, bradycardia, syncope,

headache, or fatigue. If any of these occur, stop taking and notify provider.

- I expressed that it is crucial that she takes these medications consistently so we can

accurately evaluate her blood pressure and determine the need for changes.

- Referral to cardiology. A referral to cardiology was sent to help manage the patient's

hypertension. She reports chronic hypertension that has not been treated for several years

and that she does not tolerate lower blood pressure (120/80’s) due to episodes of syncope.

The patient is reluctant to increase her blood pressure medication. It is best that her

hypertension is managed by a specialist as further testing may be necessary. If she does

not receive a call within 7 days to schedule her appointment, call the office to check on

the referral process.

- Discussed diabetes mellitus type 2 and the importance of lifestyle modifications for

glycemic control. A diabetic diet was discussed as well as limiting sodium due to

hypertension.
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- Prescribe: Metformin 500mg tablet ER. Take one tablet by mouth daily. Dispense:

30(thirty). Refill: 0 (zero) Discussed that this medication can cause GI upset including

nausea, vomiting, flatulence, and diarrhea.

- Prescribe: Omeprazole 40mg tablet. Take one tablet by mouth daily. The patient was

instructed to take every day in the morning before eating to improve her symptoms of

gastric reflux. I discussed eating smaller portions and remaining in an upright position for

at least 30 minutes after eating to prevent reflux.

- Prescribe: Cholecalciferol (Vitamin D3) 2,000 unit capsule. Take one capsule by mouth

daily. Dispense: 30 (thirty). Refill 0 (zero). Do not eat or drink anything within 30

minutes of taking this medication.

- I discussed that I am only prescribing a one-month supply on her medications so that I

can see her back in 4 weeks to reassess.

- Referral to pain management. A referral to pain management was ordered to address the

patient's chronic low back pain which has interfered with activities of daily living and

prevented her from working. She has seen pain management in the past but stopped due

to loss of insurance.

- I discussed that due to the patient not having medical care for several years, it will take

several visits and steps to organize her health care needs and get everything addressed. It

can be very over whelming and we will take one step at a time, but her blood pressure is a

priority. We also need to work on scheduling her mammogram, Pap smear, colonoscopy,

and consider statin therapy due to ASCVD risk of 18.5%. These topics were not

addressed at this visit but will be at the follow up.

- Follow up in 4 weeks, or sooner if necessary.

SOAP NOTE 3 15

- Advance directive planning was not discussed at this visit but will be at next visit.

- All questions answered.

SOAP NOTE 3 16

References

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

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

Holick, M.F. (2019). Vitamin D Deficiency. Epocrates. Retrieved from

https://online.epocrates.com/diseases/64142/Vitamin-D-deficiency/Treatment-Options

Knight, C., Deyo, R., Staiger, T., & Wipf, J. (2020). Treatment of acute low back pain.

UpToDate. Retrieved from https://www-uptodate-

com.proxy.lib.utc.edu/contents/treatment-of-acute-low-back-pain?search=low%20back

%20pain

%20treatment&source=search_result&selectedTitle=1~150&usage_type=default&displa

y_rank=1

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

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search=clonidine&source=search_result&selectedTitle=1~148&usage_type=panel&kp_t

ab=drug_general&display_rank=1#F153448

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=panel&kp_tab

=drug_general&display_rank=1#F189191

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

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

2-diabetes-mellitus?search=diabetes%20mellitus%20type
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%202&sectionRank=1&usage_type=default&anchor=H6&source=machineLearning&sel

ectedTitle=3~150&display_rank=3#H6

Zuckerman, M.J. and Carrion, A.F. (2019). Gastroesophageal reflux disease. Epocrates.

Retrieved from https://online.epocrates.com/diseases/8241/Gastroesophageal-reflux-

disease/Treatment-Approach