Question

Directions: Write a SOAP note for the patient scenario described below. A complete S, O and A section addressing all problems should be written. Only those problems that are primary or secondary priority need to be addressed in the plan (P section). Be sure to include references for recommendations.

Date of encounter: 5/25/20

CC: Post-discharge follow-up

Patient “Paul” is a 54 year-old Caucasian male being seen in the clinic following a recent hospital discharge 1 week ago for acute myocardial infarction. During his admission, he underwent a heart catheterization and subsequent drug-eluting stent placement to the left anterior descending coronary artery. He was initiated on atorvastatin, aspirin, and clopidogrel therapy in the hospital and discharged on these medications in addition to his previous home regimen.

Upon presentation to the clinic, the patient was noticeably limping and when asked, he stated that his hip pain has gotten much worse over the past few months. He was previously able to control the pain with OTC naproxen and acetaminophen, however he says that these medications have not been working as well lately. Additionally, he states that his legs have been swollen since he was discharged from the hospital. The swelling seems to be better in the morning, but gets worse the longer he is on his feet, so he has been spending a lot of time in his recliner. He is worried that it may interfere with him going back to work as an elementary school 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 week and half ago

Social History:

                Lives at home with wife, 5 year old son, and 6 months old daughter

                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 in hospital

                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 during hospitalization showed LVEF of 30%

Labs:

Drawn as outpatient – 2 days prior to clinic visit
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 all primary and secondary problems fully within the plan.

Answer 1

Date of encounter: 5/25/20

CC: Post-discharge follow-up

Subjective (S) -

Patient “Paul” is a 54 year-old Caucasian male visited to the clinic for follow up with

Chief complaints of - Limpping and worsening of hip pain since few months

- Swelling of the foot since last 1 week

History of present illness --  

C/o hip pain which has gotten much worse over the past few months. initially pain was relived by with OTC naproxen and acetaminophen, Now No relief at present.

C/o Swollen legs since he was discharged from the hospital. The swelling seems to be better in the morning, but gets worse the longer he is on his feet, so he has been spending a lot of time in his recliner.

Paul was admitted a week ago in the hospital for acute myocardial infarction. During his admission, he underwent a heart catheterization and subsequent drug-eluting stent placement to the left anterior descending coronary artery. He was initiated on atorvastatin, aspirin, and clopidogrel therapy in the hospital and discharged on these medications in addition to his previous home regimen.

Past medical history:

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, T2D

Mother – alive, age 78, COPD, hypothyroidism

Sister – alive, age 46, HTN

Surgical History:

              Heart catherization with LAD stent placement approximately a week and half ago

Social History:

                Lives at home with wife, 5 year old son, and 6 months old daughter

                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 in hospital

                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

Objective (O)-

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 during hospitalization showed LVEF of 30%

Labs:

Drawn as outpatient – 2 days prior to clinic visit
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%

Assesment (A) ---Patient Paul who is suffering from complaints of Hip pain since few months and swelling of foot since 1 week is having clinical diagnosis of

1.? Fracture Neck femur due to analgesis abuse

2. Left ventricular failure secondary to Acute Myocardial infarction

Plan (P)

Primary Problem - .? Fracture Neck femur due to analgesis abuse

- Obtain a x ray hip and SOS MRI Hip to look for fracture Neck of femur

- Refer to orthopaedician for the same

- Avoid taking OTC for hip pain

Secondary problem - Continue medication for Post myocardial infarction

-- Refer to cardiologist

Life style changes --- Avoid prolong standing or sitting with feet hanging,

-- keep legs elevated while sleeping using a pillow under the legs

Diet changes -- Avoid taking exces salt and sugar in diet