SOAP 8
nikkyvuSUBJECTIVE: This is a 72-year-old female
2 years ago
8
files (2)SOAP8_TODO.docx
SAMPLE_ME_TO_USE.docx
SOAP8_TODO.docx
CC:
O: VS BP: 134/72 mmHg (right arm, seated), Heart Rate: 89 bpm, Respiratory Rate: 18 bpm, Temperature: 97.7 °F, Spo2: 99%, Room air, Weight: 237 lbs. (BMI: 42.0 kg/m2) (dressed), Height 5ft. 3in. (Without shoes).
A: Patient has bilateral ear irrigation at clinic. right ear was irrigated successfully, left ear requires further evaluation with ENT. Patients always feel fatigue, SOB in exertion NYHA III. can only walk a few feet before needing to rest.
9/26/24 US ABD: Fatty infiltration of the liver s/p cholecystectomy with evidence of biliary duct dilation
9/27/24 Breast US Bilateral benign breast lesions
OBJECTIVE: make change when necessary
Vital Signs: Ht(without shoes) 172 cm (5’8”). Wt. (dressed) 58.51 kg (184 lbs.) (BMI: 28.0 kg/m2) BP 120/60 mmHg (right arm seated); 125/62 mmHg (left arm, seated); with wide cuff. Heart rate (HR) 70 bpm and regular. Respiratory rate (RR) 18 bpm. Temperature (oral) 97. 9°F, Spo2: 100% Room air.
HEENT : Positive for runny nose, watery eyes, and sore throat. Denies earache or dizziness.
Eyes: Vision 20/20 in both eyes. Visual fields full by confrontation. Conjunctive pink; sclera white. Pupils 4 mm constricting to 2 mm. PERRLA. EOMI. Disc margins are sharp, without hemorrhage or exudate: no arteriolar narrowing or A-V nicking.
Ears: Ear canal clear bilaterally. TM clear bilaterally; bilaterally Ear good cone of light. The cone of light is at 5 o'clock in the right ear and 7 o'clock in the left ear. Rinne test: Positive bilaterally (AC > BC). Weber midline: No lateralization. Mastoid process: No tenderness noted bilaterally.
Nose Mucosa pink, septum midline. No sinus tenderness. No polyps, turbinate intact, no evidence of bleeding.
Mouth: Oral mucosa pink. The dentition is good. Tongue midline. Tonsils 1+. Pharynx without exudates.
Neck: Neck Supple. Trachea midline. The thyroid isthmus is palpable, and lobes are not felt.
Lymph Nodes: No cervical, axillary, or epitrochlear nodes.
Thorax and Lungs: Thorax Symmetric with good expansion. Lungs resonant on percussion. Breath sounds vesicular with no added sounds. Diaphragms descend 4 cm bilaterally.
Respiratory : Positive for a productive cough with yellowish sputum. Denies shortness of breath (SOB).
Cardiovascular: Regular rate and rhythm, heart rate 70 bpm. Crisp S1 and S2. At the base, S2 is louder than S1. At the apex, S1 is louder than S2. There are no murmurs or extra sounds.
Abdomen: soft, non-tender + BS, no guarding.
Diagnostics: Obtained before the diagnosis, examples: would be CBC or BMP, CXR or TSH etc.
Assessment:
Plan:
Any diagnostics ordered / planned (this would be diagnostics needed)
· Pharmacologic and Nonpharmacologic: The patient was prescribed Polymyxin B/Trimethoprim solution 1 drop q 4 hours while awake x7 days. (also enter quantity # here if controlled substance or antibiotics)
Pharmacologic:
NEOMYCIN-POLYMYXIN-HC EAR SOLN 1 DROP in each ear for 5 days
PROTONIX DR 40 MG TABLET (take 1 tablet (40 mg) by oral route once daily)
METOPROLOL SUCC ER 25 MG TAB (take 1 tablet (25 mg) by oral route once daily)
CRESTOR 10 MG TABLET (take 1 tablet (10 mg) by oral route once daily)
ONETOUCH ULTRA TEST STRIPS (Check blood sugar tid)
Albuterol Sulfate HFA 90 mcg/puff AEROSOL (2 puffs qid prn sob)
SHINGRIX 0.5 ML SUSPENSION (one as directed)
CONTOUR METER SYSTEM (to check sugar tid)
PREP EASE ALCOHOL PADS (use twice daily)
LISINOPRIL 30 MG TABLET (TAKE ONE TABLET ONCE DAILY)
VITAMIN B-12 1,000 MCG TABLET (one once a day)
CLOTRIMAZOLE 1% CREAM (Apply on affected region twice a day)
BREZTRI 160-4.8-9 mcg/puff AEROSOL, METERED (2 puff bid)
ONETOUCH DELICA PLUS 30G LANCETS (to check blood sugar three times a day
FARXIGA 5 MG TABLET (1 t po daily)
CHLORTHALIDONE 25 MG TABLET (TAKE ONE TABLET BY MOUTH ONCE DAILY)
DICLOFENAC SODIUM 3% GEL (apply to knees by topical route 2 times per day)
KEPPRA 500 MG TABLET (take 1 tablet (500 mg) by oral route 2 times per day)
ARTIFICIAL TEARS DROPS (2 drops bid)
METFORMIN HCL 1,000 MG TABLET (TAKE ONE TABLET BY MOUTH IN THE MORNING WITH BREAKFAST)
PLAVIX 75 MG TABLET (take 1 tablet (75 mg) by oral route once daily)
VENTOLIN HFA 90 MCG INHALER (inhale 2 puffs (180 mcg) by inhalation route every 4-6 hours as needed)
Medications:
Education:
Nonpharmacologic
follow-up
referral
NOTE
· Any diagnostics ordered/planned (this would be diagnostics needed)
· The patient was prescribed Polymyxin B/Trimethoprim solution one drop q 4 hours while awake x7 days. (also enter quantity # here if controlled substance or antibiotics)
NO REFERENCE NEEDED
SAMPLE_ME_TO_USE.docx
CC: Follow up post-hospital discharge.
SUBJECTIVE: This is a 66-year-old black male with a PMH of HTN, IDDM2, and prostate cancer s/p prostate radiation therapy. Surgical Hx: Prostate surgery and last radiation May 2022, FMHx: is significant for DM, HTN in his grandmother, Social Hx: denies alcohol and tobacco use, allergies: NKDA. The patient presents for a follow-up visit after being hospitalized for hyperglycemia. Hospital admission was from 9/5-10/2024 at SJH with a blood glucose level of 800 mg/dl upon admission. He was not in diabetic ketoacidosis (DKA) and tested negative for ketones. HBA1C was >14% per the hospital discharge summary. The patient admits to being non-compliant with insulin and oral glycemic medication. He endorses not using insulin Novolin R and Lantus for the past eight months before hospital admission. During the assessment, the patient endorsed symptoms of polyphagia, polyuria, and polydipsia. He denies tingling and numbness in the lower extremities, unintentional weight loss, cough, chest pain, SOB, dizziness, blurry vision, palpitation, or headaches. Fingerstick blood glucose was 220 mg/dl in the office, and he reported consuming old-fashioned oatmeal without added sugar three hours prior.
Vital Signs: Ht(without shoes) 178 cm (5’10”). Wt. (dressed) 89.34 kg (197 lbs.) (BMI: 28.3 kg/m2) BP 132/96 mmHg (right arm seated); 135/90 mmHg (left arm, seated); with wide cuff. Heart rate (HR) 96 bpm and regular. Respiratory rate (RR) 18 bpm. Temperature (oral) 97. 6°F, Spo2: 98% Room air.
Eyes; Vision 20/20 in both eyes. Visual fields full by confrontation. Conjunctive pink; sclera white. Pupils 4 mm constricting to 2 mm. PERRLA. EOMI. Disc margins sharp, without hemorrhage, exudate. No arteriolar narrowing or A-V nicking.
Ears: Ear canal clear bilaterally. TM clear bilaterally; bilaterally Ear good cone of light. The cone of light is at 5 o'clock in the right ear and 7 o’clock in the left ear. Rinne test: Positive bilaterally (AC > BC). Weber midline: No lateralization. Mastoid process: No tenderness noted bilaterally.
Nose Mucosa pink, septum midline. No sinus tenderness. No polyps, turbinates intact, no evidence of bleeding.
Mouth: Oral mucosa pink. The dentition is good. Tongue midline. Tonsils 1+. Pharynx without exudates.
Neck: Neck Supple. Trachea midline. Thyroid isthmus palpable, lobes not felt.
Lymph Nodes: No cervical, axillary, or epitrochlear nodes.
Thorax and Lungs: Thorax Symmetric with good expansion. Lungs resonant on percussion. Breath sounds vesicular with no added sounds. Diaphragms descend 4 cm bilaterally.
Cardiovascular: Regular rate and rhythm, heart rate 96 bpm. Crisp S1 and S2. At the base, S2 is louder than S1. At the apex, S1 is louder than S2. There are no murmurs or extra sounds.
Abdomen: soft, non-tender + BS no guarding
Diagnostics:
Blood Glucose Monitoring:
· In-office fingerstick blood glucose: 220 mg/dl.
· HBA1C: >14% (from hospital discharge summary), indicating poorly controlled diabetes.
· Basic Metabolic Panel (BMP): To assess kidney function, electrolyte levels, and glucose.
· Fasting Lipid Panel: To assess cholesterol levels and cardiovascular risk.
· Urine Microalbumin: To check for early signs of diabetic nephropathy.
· Blood Pressure readings in-office 132/96 mmHg (right arm) and 135/90 mmHg (left arm).
Assessment: 66-year-old male with poorly controlled IDDM2, non-compliance with insulin therapy, recent hospital admission for hyperglycemia, hypertension, and prostate cancer (s/p radiation therapy). Hyperglycemia is likely secondary to medication non-compliance.
Elevated HBA1C >14%, indicating severely uncontrolled diabetes.
Blood pressure is slightly elevated diastolic blood pressure (DBP) >90.
· Metformin HCL 500 mg tablet, take one tablet by mouth three times daily
· Novolin 70-30, 100-unit insulin pen, inject six units subcutaneously three times daily before each meal
· Lantus 100 units insulin pen, inject 24 units subcutaneously at bedtime
· Norvasc 10 mg tablet, take one tablet (10 mg) by oral route once daily
· lisinopril 2.5 mg tablet, take one tablet (2.5 mg) by oral route once daily
· Continues Glucose monitoring (CGM) Dexcom-G7 sensor/reader change every ten days.
· Procedures: None at this time
· Education:
The risks of uncontrolled diabetes, including potential complications, were discussed. Educate on recognizing symptoms of hyperglycemia and hypoglycemia.
The importance of a balanced diet and consistent carbohydrate intake using my plate meal planner to plan my diet.
Encourage increased physical activity, such as 150 minutes of brisk walking three times weekly.
Emphasize the importance of medication adherence, including regular insulin use (Novolin R and Lantus).
Schedule education sessions with a diabetes educator to improve understanding of insulin use, diet, and monitoring.
Encourage frequent home blood glucose monitoring (at least three times per day). Before breakfast, lunch, and two hours after dinner. The target goal of FS is between 120-130 mg/dl before breakfast and 160-180 mg/dl two hours after dinner.
Encourage home blood pressure monitoring with the goal of <130/80 mmHg.
· Follow-up: Return to the office in one week to review the blood glucose logbook, blood pressure logbook, and diet diary.
Recheck HBA1C in 3 months with a target goal of < 7%
Referral:
· Nutritionist for meal and diet planning
· Endocrinology for uncontrolled diabetes,
· Ophthalmologist to assess any diabetic retinopathy,
· Podiatry for any nerve damage.
· Dentist for any gun disease associated with poorly controlled DM.
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