Rwh soap 2 different notes

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SOAP Note _______

NU___:_________

Herzing University

Name:_________________________

Typhon Encounter #: _____________________

Comprehensive:____Focused:____

S: SUBJECTIVE DATA
CC:	"I've been feeling more tired than usual, and my blood sugar readings have been higher lately."
HPI:	• O (Onset): Increased fatigue, polyuria, and occasional blurred vision started 1 week ago. • L (Location): N/A • D (Duration): Symptoms have been present for the last 7 days. • C (Characteristics): Fatigue, increased thirst, frequent urination. • A (Associated/aggravating factors): History of poor adherence to diet and medications in the past month. Increased stress due to financial constraints. • R (Relieving factors): N/A • T (Treatment): The patient has been on Metformin but confides that he has missed the doses over the last month.
PMH:	Type 2 Diabetes Mellitus(diagnosed 8 years ago). • Hypertension diagnosed 3 years ago • Hyperlipidemia(diagnosed 4 years ago). • No history of cardiovascular events.
ALLERGIES	NKDA.
MEDICATIONS	Metformin 1000 mg, PO, bid for diabetes. • Lisinopril 20 mg, PO, daily for hypertension. • Atorvastatin 10 mg, PO, daily for hyperlipidemia
SH	Nonsmoker • ETOH (socially, 1-2 drinks per week). • Sedentary. • Lives with spouse; office manager. • Stress related to financial concerns impeding medication compliance • Cultural influence on food choices; wants culturally sensitive diabetes education
FH	• Father: Age 68, Coronary artery disease • Mother: Age 72, Stroke
HEALTH PROMOTION & MAINTENANCE	• Immunizations: Current • Diet: The patient is aware of dietary recommendations for the control of diabetes but admits to spotty adherence. • Exercise: The patient has little exercise and is sedentary. • Recent eye and dental exams: Last eye exam 6 months ago, no problems noted. Last dental exam 1 year ago.
ROS (put N/A in sections not completed day of exam)	Constitutional	Fatigue, weight gain
	Head	Blurred vision at times
	Eyes
	Ears, Nose, Mouth, Throat
	Neck
	Cardiovascular/Peripheral Vascular	No chest pain, palpitations, or edema
	Respiratory	Denies shortness of breath or cough
	Breast
	Gastrointestinal	No nausea or vomiting
	Genitourinary	Polyuria
	Musculoskeletal	Denies joint pains
	Integumentary
	Neurological	No vertigo, no headaches
	Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7)	No depression or anxiety (PHQ-9: 6)
	Endocrine	No polyuria or heat intolerance
	Hematologic/Lymphatic
	Allergic/Immunologic
	Other

O: OBJECTIVE DATA
VITALS:	HR: 88 bpm	RR: 18 breaths/min	BP: 145/90 mmHg	Temp: 98.6°F
	SpO2%: 98% on room air	Ht: 5'10"	Wt: 215 lbs	BMI: 32.5
	Age: 56	LMP:	PAIN: None reported
PHYSICAL EXAM (Pertinent data related to presenting problem or visit type. Put N/A in sections not completed day of exam)	General Appearance:	The patient was an overweight male who appeared alert, oriented to person, place, and time
	Head:	Atraumatic, normocephalic
	Eyes	No conjunctival pallor, Visual acuity intact
	ENT, Mouth	There were no oral lesions present
	Neck	No lymphadenopathy or JVD
	Cardiovascular/Peripheral Vascular	Regular rate, regular rhythm, no murmurs, no gallops
	Respiratory	Clear to auscultation bilaterally, no wheezes or crackles
	Breast
	Gastrointestinal	Abdomen soft, non-tender, no hepatosplenomegaly
	Genitourinary Male
	· External Exam
	· Internal Exam
	Genitourinary Female
	· External Exam
	· Internal Exam
	Musculoskeletal	No joint pain, full range of motion
	Integumentary	Skin intact, no ulcers or wounds
	Neurological	Alert and oriented, no focal neurological deficits
	Psychiatric	No evidence of anxiety or depression
	Endocrine	With no evidence of thyroid or any other hormonal abnormalities
	Hematologic/Lymphatic
	Allergic/Immunologic
	Other

A: ASSESSMENT AND DIAGNOSIS
	DIAGNOSIS	ICD-10 CODES
PRIORITIZE DIAGNOSIS	1. Type 2 Diabetes Mellitus – poorly controlled	(ICD-10: E11.9)
	2. Hypertension – poorly controlled	(ICD-10: I10)
	3. Hyperlipidemia – suboptimally controlled	ICD-10: E78.5

VISIT CODES

CPT BILLING CODES

CPT Code: 99214 (Established patient, moderate complexity).

DIAGNOSTICS

POC TESTING

TESTS REVIEWED

• Recent HbA1c: 9.2% (elevated)

• Fasting blood glucose: 190 mg/dL

• Lipid panel: LDL elevated to 140 mg/dL; total cholesterol: 230 mg/dL

• Creatinine: 1.0 mg/dL (normal)

P: PLAN
ACTIONS	1.	Diagnosis: Type 2 Diabetes Mellitus Diagnostics Order: o HbA1c q 3 months o Self-monitoring of blood glucose daily Therapeutic: o Increase metformin to 1500 mg po bid. o May add glipizide or GLP-1 receptor agonist if blood glucose continues to be poorly controlled. Education o Plan for the management of diabetes: diet and exercise and self-management. o Adherence to medication: solution to economic problem, such as generics or patient assistance programs. Consultation/Collaboration: o Diabetes Educator, for nutrition counseling and diabetic management. o Social Worker: resources for financial aid
	2.	Problem: Hypertension • Diagnostic Order: o Home BP monitoring. o Re-check BP in 2 weeks. Therapeutic: o Increase the dose of Lisinopril to 40 mg a day. o Decrease salt intake and lose weight. Education: o Counsel about lifestyle changes: nutrition and exercise. o Monitor BP at home and bring a log for follow-up. Consultation/Collaboration: o Foll up with a primary care physician for further evaluation and management.
	3.	Diagnosis: Hyperlipidemia • Diagnostics Order: o Repeat lipid panel in 6 months. • Therapeutic: o Increase the dose of Atorvastatin to 20 mg daily if the improvement in the lipid control is not seen. • Education: o low-fat diet, increase in fiber intake. o Review the use of statins in regard to the reduction of cardiovascular risk. • Consultation/Collaboration: o Refer to cardiologist if there is a concern regarding cardiovascular risk
PREVENTITIVE (Used for comprehensive exams)	Health Promotion Exercise: at least 150 minutes of moderate activity/week. Dietary teaching of a low-glycemic, balanced diet. Discussion of USPSTF recommended guidelines for screenings, blood pressure, cholesterol
FOLLOW UP	• Next visit: Return in 2 weeks- blood pressure check and review current medications for compliance. • Phone call in one week to review patient blood glucose logs for progress and to address compliance with therapy prescribed. • HbA1c Follow-up in 3 months.