You are seeing a 62-year-old white female for her annual visit.

  Presented below are

some pertinent subjective and objective data that you elicited during your
comprehensive assessment session with the patient (note – this is not the entire
subjective and objective data set for this office visit).
PMH:  HTN, Hyperlipidemia
Social History:  divorced, employed full time as a graduate nursing program professor,
no smoking history, reports on a rare occasion she may have 2 - 3 ounces of wine when
dining out [less than 6 times a year]
Health Maintenance Activities: 1 ½ to 2 hours of exercise every morning [45 – 60
minutes of yoga, 45 – 60 minutes of step aerobics]; low glycemic Pescatarian; has not
engaged with recommended colonoscopy, does not have screening mammograms,
does not get a flu shot and has not had any other recommended adult immunizations

Review of Systems
Cardiovascular: reports hypertension diagnosed at 27 years of age, controlled on 5mg
Lisinopril daily; reports elevated total cholesterol level for the last decade or so with no
pharmacologic treatment; denies chest pains, palpitations, lower extremity edema

Physical Exam
Constitutional – Ht. 64 inches, Wt. 127 pounds [BMI 21.8], BP 112/60, P 68, T 97.9
temporal, R 16, SpO2 99%
Integument – pink, warm, and dry to touch
Eyes – no arcus senilis
Cardiovascular – heart regular rate and rhythm, S1 and S2; no S3 or S4, murmur or
gallop; no carotid bruits; radial pulses palpable and pedal pulses 2+; no lower extremity
edema; capillary refill < 3 seconds bilateral
Lipid panel – Total cholesterol 302, HDL 117, Triglycerides 45
Please develop a discussion that responds to each of the following prompts.  Where
appropriate your discussion needs to be supported by scholarly literature.  Be sure to
include in-text citations in the context of the discussion and provide a full reference
citation at the end of the discussion.

Discussion Prompt
Utilize the information provided in the scenario to create your discussion post. 
Construct your response as an abbreviated SOAP note
(Subjective Objective Assessment Plan).
Structure your ‘P’ in the following format:  [NOTE:  if any of the 3 categories is not
applicable to your plan please use the ‘heading’ and after the ‘:’ input N/A]
Subjective:
Patient reports that she is 62 years old and identifies as a White female. She states that
she is here for her annual physical exam. She reports that she is divorced and
employed full time as a graduate nursing program professor. Patient reports no history
of smoking and endorses drinking 2-3 ounces of wine on rare occasions when dining
out (“less than 6 times a year”). Patient reports engagement in a very active lifestyle of
“1 ½ to 2 hours of exercise every morning; 45 – 60 minutes of yoga; and 45 – 60
minutes of step aerobics”. Patient reports that she eats a low glycemic Pescatarian diet.
Patient denies that she has received her recommended colonoscopy exam and has not
received her screening mammograms. Patient reports she does not get a flu shot and
has not had any other recommended adult immunizations. Patient reports history of
hypertension diagnosed at 27 years of age, and that it is controlled on 5mg Lisinopril
daily. Patient reports elevated total cholesterol level for the last decade or so with no
pharmacologic treatment. Patient denies chest pains, heart palpitations, and lower
extremity edema.
Objective:
Constitutional – Ht. 64 inches, Wt. 127 pounds [BMI 21.8], BP 112/60, P 68, T 97.9
temporal, R 16, SpO2 99%
Integument – pink, warm, and dry to touch
Eyes – no arcus senilis
Cardiovascular – heart regular rate and rhythm, S1 and S2; no S3 or S4, murmur or
gallop; no carotid bruits; radial pulses palpable and pedal pulses 2+; no lower extremity
edema; capillary refill < 3 seconds bilateral
Lipid panel – Total cholesterol 302, HDL 117, Triglycerides 45
Allergies: NKDA/NKA reported

Assessment: 62-year-old white female presents with history of hypertension, controlled by

lisinopril and extremely elevated cholesterol level indicating hyperlipidemia. Patient is at very
high risk for complications secondary to uncontrolled hyperlipidemia.
Diagnosis: Hypertension and uncontrolled hyperlipidemia

Plan: Begin patient on statin medication to gain control of hyperlipidemia. Recommend

adult booster immunizations and administer during this visit with patient consent.
Therapeutics: Patient’s total cholesterol level is 302 and the total recommended cholesterol
for adult women over 20 years of age is 200mg/dl. High total cholesterol, involving LDL, HDL, and
triglycerides, is greater than or equal to 240 mg/dL (Su et al., 2021). The patient is at risk for developing
atherosclerotic cardiovascular disease (ACVD), so initial treatment recommendation is to start patient on
a statin to lower LDL (Arcangelo, Peterson, Wilburn, & Reinhold, 2017). The 2018 Guideline on the
Management of Blood Cholesterol recognizes that although there is no ideal target blood level for LDL-
C, keeping these levels low is very important, as adults with LDL-C levels at or below 100 mg/dL are less
likely to have heart disease and stroke (Su et al., 2021).

Educational:
1. Educate patient about the importance of routine colonoscopy and mammogram.
2. Educate patient about how grapefruit juice can increase the potency of most statins, so drinking
it in conjunction with her medication can prove beneficial (Arcangelo et al., 2017).
3. Educate patient regarding importance of follow up appointments as these appointments will be
concerned with performing lab draws to ensure her medication(s) are working effectively and
monitoring of liver and other organs, and thyroid levels (Arcangelo et al., 2017).
4. Encourage patient to continue her active lifestyle as well as eating her
pescatarian diet as both can contribute to lowering her LDL levels.
Consultation/Collaboration: Refer patient out for colonoscopy and mammogram with
patient consent. Follow up with specialists regarding the results.

References

Arcangelo, V. & Peterson, A. (2021). Pharmacotherapeutics for advanced practice: A practical

approach. (5th ed.). Philadelphia: Wolters Kluwer

Su, L., Mittal, R., Ramgobin, D., Jain, R., & Jain, R. (2021). Current Management

Guidelines on Hyperlipidemia: The Silent Killer. Journal of lipids, 2021,

9883352. https://doi.org/10.1155/2021/9883352