SOAP Note Template
Encounter date: ___4/15/2020_____________________
Patient Initials: _TT_____ Gender: M/F/Transgender ____ Age: _62____ Race: _Hispanic____ Ethnicity _Argentinian___
Reason for Seeking Health Care: _The patient came to the clinical facility with a history of lower limb edema and difficulty in breathing for a period of five months.____________________________________________
HPI: The patient came in with a history of hypertension on Carditan-H tab BD. Patient explains that he has not been adherent to the medication. An analysis elicits that the patient had had a progressive history of non-tender, bilateral lower limb edema. The history of difficulty in breathing could be classified as NYHA Class III. Further analysis elicits that the patient has not had any prior history of fever. Other systems are non-remarkable.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Allergies(Drug/Food/Latex/Environmental/Herbal): _Patient has an allergy to drugs contain Sulphur.__________________________________
Current perception of Health: Excellent Good Fair Poor
Past Medical History
Major/Chronic Illnesses-Patient is a known hypertensive not adherent to Carditan H medication.___________________________________________________
Trauma/Injury- There was a prior history of a right femur fracture. ___________________________________________________________
Hospitalizations _The patient got admitted for a period of three weeks after an ORIF procedure for the management of the femur fracture._________________________________________________________
Past Surgical History_- Patient has had an open reduction and internal fixation (ORIF) procedure which was done four years ago.__________________________________________________________
Medications: _Patient is on Carditan H BD. She also takes Cetrizine once in a while for the management of rhinitis._________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Family History: _There is a maternal history of breast cancer. There is also a paternal history of hypertension.___________________________________________________________
Social history:
Lives: Single family House/Condo/ with stairs: ___________ Marital Status: The patient is a divorcee.______ Employment Status: _Self-Employed._____ Current/Previous occupation type: _The patient works as a shop manager.________________
Exposure to: ___Smoke_Doesn’t smoke.___ ETOH _Takes 4 glasses of white wine per week.___Recreational Drug Use: __Not available.________________
Sexual orientation: _Straight______ Sexual Activity: N/A____ Contraception Use: __Patient is post-menopausal.__________
Family Composition: Family/Mother/Father/Alone: _Lives with her daughter, who helps her in the house.____________________________
Health Maintenance
Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _Patient has had a mammogram done which was non-remarkable.____
Exposures: There was a history of a right leg X-ray which was done 3 years before due to the history of a fracture.
Immunization HX: Immunization history is non-remarkable.
Review of Systems:
General: Patient is in slight respiratory distress when conversing. There is no pain distress. Patient seems to be overweight.
HEENT: This system is non-remarkable with no symptoms.
Neck: There are no presence of elevated jugular vein pressures.
Lungs: Patient does not have dyspnea, although, mentions that the difficulty in breathing is more prevalent when the patient is lying down.
Cardiovascular: There is a history of palpitations, according to the patient, which occurred during exertion. She has a history of syncope which occurred 2 months ago.
Breast: This system is non-remarkable with no symptoms.
GI: This system is non-remarkable with no symptoms.
Male/female genital: This system is non-remarkable with no symptoms.
GU: This system is non-remarkable with no symptoms.
Neuro: This system is non-remarkable with no symptoms.
Musculoskeletal: This system is non-remarkable with no symptoms.
Activity & Exercise: The patient lives a sedentary lifestyle with no apparent active exercise regimens.
Psychosocial: This system is non-remarkable with no symptoms.
Derm: This system is non-remarkable with no symptoms.
Nutrition: Patient has an adequate nutritional status but rarely takes fruits and vegetables.
Sleep/Rest: There is a history of insomnia associated with the episodes of difficulty in breathing.
LMP: The patient is post-menopausal.
STI Hx: This system is non-remarkable with no symptoms.
Physical Exam
BP_150/84_______TPR_37.1____ HR: _75____ RR: _21___Ht. _5’6”____ Wt. __72____ BMI (percentile) _25____
General: Patient is in apparent respiratory distress with no elicitation of pain.
HEENT: This system is non-remarkable with no symptoms.
Neck: There is no distention of the Jugular Veins.
Pulmonary: Auscultation elicits the presence of crepitations.
Cardiovascular: There is a displacement of apex heart beat.
Breast: This system is non-remarkable with no abnormalities.
GI: This system is non-remarkable with no abnormalities.
Male/female genital: This system is non-remarkable with no abnormalities.
GU: This system is non-remarkable with no abnormalities.
Neuro: This system is non-remarkable with no abnormalities.
Musculoskeletal: This system is non-remarkable with no abnormalities.
Derm: This system is non-remarkable with no abnormalities.
Psychosocial: This system is non-remarkable with no abnormalities.
Misc. This system is non-remarkable with no abnormalities.
Plan:
Differential Diagnoses
1. Hypertensive Heart Disease
2. Congestive Cardiac Failure (CCF).
3. Renal Failure
Principal Diagnoses
1. Hypertensive Heart Disease
2. Congestive Cardiac Failure (CCF).
Plan
Diagnosis Congestive Cardiac Failure (CCF).
Diagnostic Testing: Chest X ray, Echo, ECG
Pharmacological Treatment: The utilization of diuretics such as aldactone plus Carditan-H.
Education: Patient needs to be adherent to medications.
Referrals: Referral to a cardiologist may be important.
Follow-up: Follow-up at a hypertension clinic would be prudent for monitoring her condition.
Anticipatory Guidance: There would be need to regularly assess the BPs and also the baseline tests.
Diagnosis Hypertensive Heart Disease.
Diagnostic Testing: Chest X ray, Echo, ECG
Pharmacological Treatment: The utilization of beta-blockers plus Valsartan may be effective.
Education: Patient needs to be adherent to medications.
Referrals: Patient needs to be adherent to medications.
Follow-up: Follow-up at a hypertension clinic would be prudent for monitoring her condition.
Anticipatory Guidance: There would be need to regularly assess the BPs and also the baseline tests.
Signature (with appropriate credentials): __________________________________________
Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________
Cabrera-Sole et al, (2018) elicit that the utilization of Valsartan is effective in the management of hypertensive heart disease (HHD). James et al, (2018) depict the efficacy of aldactone in the management of cardiomyopathy secondary to congestive cardiac failure (CCF).
DEA#: 101010101 STU Clinic LIC# 10000000
Tel: (000) 555-1234 FAX: (000) 555-12222
Patient Name: (Initials)______________________________ Age ___________
Date: _______________
RX ______________________________________
SIG:
Dispense: ___________ Refill: _________________
No Substitution
Signature: ____________________________________________________________
Cabrera-Sole, R., Turpin Lucas, C., Urrego Rivera, L., Nuñez Galdamez, A., Garcia Ruiz, S., Stephan Luekpe, E., & Aguilera Saldaña, M. (2018). Abstract P319: Effects on Cardiac Output, Arterial Stiffness and Blood Pressure of Sacubyrtil+ Valsartan in Hypertensive Patients With Heart Failure Whose Previously Received Ace Inhibitors or Arb+ Diuretics. Prospective Study and Follow-up to 24 Weeks. Hypertension, 72(Suppl_1), AP319-AP319.
James, R., Guillot, E., Garelli-Paar, C., Huxley, J., Grassi, V., & Cobb, M. (2018). The SEISICAT study: a pilot study assessing efficacy and safety of spironolactone in cats with congestive heart failure secondary to cardiomyopathy. Journal of Veterinary Cardiology, 20(1), 1-12.