1. Soap Note 2 Chronic Conditions
Soap Note 2 Chronic ConditionsSoap Note Chronic Conditions (15 Points)Pick any Chronic
Disease from Weeks 6-10Soap notes will be uploaded to Moodle and put through TURN-It-
In (anti-Plagiarism program) Follow the MRU Soap Note Rubric as a guideTurn it in Score
must be less than 50% or will not be accepted for credit, must be your own work and in
your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy
paste from websites or textbooks will not be accepted or tolerated. Please see College
Handbook with reference to Academic Misconduct Statement Please use one of the
templates provided to format your soap note. Keep these templates for future clinical
rotations. SAMPLE Block format Soap Note Template.docx Sample Soap Note
Template.docxPATIENT INFORMATIONName: Mr. W.S.Age: 65-year-oldSex: MaleSource:
PatientAllergies: NoneCurrent Medications: Atorvastatin tab 20 mg, 1-tab PO at
bedtimePMH: HypercholesterolemiaImmunizations: Influenza last 2018-year, tetanus, and
hepatitis A and B 4 years ago.Surgical History: Appendectomy 47 years ago.Family History:
Father- died 81 does not report informationMother-alive, 88 years old, Diabetes Mellitus,
HTNDaughter-alive, 34 years old, healthySocial Hx: No smoking history or illicit drug use,
occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives
alone.SUBJECTIVE:Chief complain: “headaches” that started two weeks agoSymptom
analysis/HPI:The patient is 65 years old male who complaining of episodes of headaches
and on 3 different occasions blood pressure was measured, which was high (159/100,
158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and
sometimes it is accompanied by dizziness. He states that he has been under stress in his
workplace for the last month.Patient denies chest pain, palpitation, shortness of breath,
nausea or vomiting.ROS:CONSTITUTIONAL: Denies fever or chills. Denies weakness or
weight loss. NEUROLOGIC: Headache and dizzeness as describe above. Denies changes in
LOC. Denies history of tremors or seizures. HEENT: HEAD: Denies any head injury, or
change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies
pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion.
THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.Respiratory: Patient
denies shortness of breath, cough or hemoptysis.Cardiovascular: No chest pain, tachycardia.
No orthopnea or paroxysmal nocturnaldyspnea.Gastrointestinal: Denies abdominal pain or
discomfort. Denies flatulence, nausea, vomiting ordiarrhea.Genitourinary: Denies
hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping
stream of urine or incontinence.MUSCULOSKELETAL: Denies falls or pain. Denies hearing a
2. clicking or snapping sound.Skin: No change of coloration such as cyanosis or jaundice, no
rashes or pruritus.Objective DataCONSTITUTIONAL: Vital signs: Temperature: 98.5 °F,
Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25.
Report pain 0/10.General appearance: The patient is alert and oriented x 3. No acute
distress noted. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and
time. Sensation intact to bilateral upper and lower extremities. Bilateral UE/LE strength
5/5.HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no
tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye
movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema,
edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of
light. Maxillary sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa
moist without lesions,.Lids non-remarkable and appropriate for race.Neck: supple without
cervical lymphadenopathy, no jugular vein distention, no thyroid swelling or
masses.Cardiovascular: S1S2, regular rate and rhythm, no murmur or gallop noted.
Capillary refill < 2 sec.Respiratory: No dyspnea or use of accessory muscles observed. No
egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath sounds presents
and clear bilaterally on auscultation.Gastrointestinal: No mass or hernia observed. Upon
auscultation, bowel sounds present in all four quadrants, no bruits over renal and aorta
arteries. Abdomen soft non-tender, no guarding, no rebound no distention or organomegaly
noted on palpationMusculoskeletal: No pain to palpation. Active and passive ROM within
normal limits, no stiffness.Integumentary: intact, no lesions or rashes, no cyanosis or
jaundice.Assessment Essential (Primary) Hypertension (ICD10 I10): Given the symptoms
and high blood pressure (156/92 mmhg), classified as stage 2. Once the organic cause of
hypertension has been ruled out, such as renal, adrenal or thyroid, this diagnosis is
confirmed.Differential diagnosis:Ø Renal artery stenosis (ICD10 I70.1)Ø Chronic kidney
disease (ICD10 I12.9)Ø Hyperthyroidism (ICD10 E05.90)PlanDiagnosis is based on the
clinical evaluation through history, physical examination, and routine laboratory tests to
assess risk factors, reveal identifiable causes and detect target-organ damage, including
evidence of cardiovascular disease.These basic laboratory tests are:· CMP· Complete blood
count· Lipid profile· Thyroid-stimulating hormone· Urinalysis· ElectrocardiogramØ
Pharmacological treatment: The treatment of choice in this case would be:Thiazide-like
diuretic and/or a CCB· Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once
daily. Ø Non-Pharmacologic treatment: · Weight loss· Healthy diet (DASH dietary pattern):
Diet rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced
content of saturated and trans l fat· Reduced intake of dietary sodium: <1,500 mg/d is
optimal goal but at least 1,000 mg/d reduction in most adults· Enhanced intake of dietary
potassium· Regular physical activity (Aerobic): 90–150 min/wk· Tobacco cessation·
Measures to release stress and effective coping mechanisms.Education· Provide with
nutrition/dietary information.· Daily blood pressure monitoring at home twice a day for 7
days, keep a record, bring the record on the next visit with her PCP· Instruction about
medication intake compliance. · Education of possible complications such as stroke, heart
attack, and other problems.· Patient was educated on course of hypertension, as well as
warning signs and symptoms, which could indicate the need to attend the E.R/U.C.
3. Answered all pt. questions/concerns. Pt verbalizes understanding to allFollow-
ups/Referrals· Evaluation with PCP in 1 weeks for managing blood pressure and to evaluate
current hypotensive therapy. Urgent Care visit prn.· No referrals needed at this
time.ReferencesDomino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Clinical
Consult 2017 (25th ed.). Print (The 5-Minute Consult Series).Codina Leik, M. T. (2014).
Family Nurse Practitioner Certification Intensive Review (2nd ed.). ISBN 978-0-8261-3424-
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