CREATE A SOAP NOTES OUT OF THIS CASE Chief Complaint “I just moved to town, and I’m here to see my new doctor for a check up. I’m just getting over a cold. Overall, I’m feeling fine, except for occasional headaches and some dizziness in the morning. My other doctor prescribed a low-salt diet for me, but I don’t like it!” HPI Sam Street is a 62-year-old African-American male who presents to his new family medicine physician for evaluation and follow-up of his medical problems. He generally has no complaints, except for occasional mild headaches and some dizziness after he takes his morning medications. He states that he is dissatisfied with being placed on a low sodium diet by his former primary care physician. He reports a “usual” chronic cough and shortness of breath, particularly when walking moderate distances (states, “I’m just out of shape”). PMH Hypertension × 15 years Type 1 diabetes mellitus Chronic obstructive pulmonary disease, Stage 2 (Moderate) Benign prostatic hyperplasia Chronic kidney disease FH Father died of acute MI at age 71. Mother died of lung cancer at age 64. Mother had both HTN and DM. SH Former smoker (quit 3 years ago; smoked 1 ppd × 28 years); reports moderate amount of alcohol intake. He admits he has been nonadherent to his low sodium diet (states, “I eat whatever I want.”) He does not exercise regularly and is limited somewhat functionally by his COPD. He is retired and lives alone. Meds Triamterene/hydrochlorothiazide 37.5 mg/25 mg po Q AM Insulin 70/30, 24 units Q AM, 12 units Q PM Doxazosin 2 mg po Q AM Albuterol INH 2 puffs Q 4–6 h PRN shortness of breath Tiotropium DPI 18 mcg 1 capsule INH daily Salmeterol DPI 1 INH BID Entex PSE 1 capsule Q 12 h PRN cough and cold symptoms Acetaminophen 325 mg po Q 6 h PRN headache All PCN—Rash ROS Patient states that overall he is doing well and just getting over a cold. He has noticed no major weight changes over the past few years. He complains of occasional headaches, which are usually relieved by acetaminophen, and he denies blurred vision and chest pain. He states that his shortness of breath is “usual” for him, and that his albuterol helps. He denies experiencing any hemoptysis or epistaxis; he also denies nausea, vomiting, abdominal pain, cramping, diarrhea, constipation, or blood in stool. He denies urinary frequency, but states that he used to have difficulty urinating until his physician started him on doxazosin a few months ago. Physical Examination Gen WDWN, African-American male; moderately overweight; in no acute distress VS BP 168/92 mm Hg (sitting; repeat 170/90), HR 76 bpm (regular), RR 16 per min, T 37°C; Wt 95 kg, Ht 6'2'' HEENT TMs clear; mild sinus drainage; AV nicking noted; no hemorrhages, exudates, or papilledema Neck Supple without masses or bruits, no thyroid enlargement or lymphadenopathy Lungs Lung fields CTA bilaterally. Few basilar crackles, mild expiratory wheezing Heart RRR; normal S1 and S2. No S3 or S4 Abd Soft, NTND; no masses, bruits, or organomegaly. Normal BS. Genit/Rect Enlarged prostate; benign Ext No CCE Neuro No gross motor-sensory deficits present. CN II–XII intact. A & O × 3 Labs Na 142 mEq/L Ca 9.7 mg/dL Fasting Lipid Panel Spirometry (6 months ago) K 4.8 mEq/L Mg 2.3 mEq/L Cl 101 mEq/L HbA1C 6.2% Total Chol 169 mg/dL FVC 2.38 L (54% pred) CO2 27 mEq/L Alb 3.5 g/dL BUN 22 mg/dL Hgb 13 g/dL LDL 99 mg/dL FEV1 1.21 L (38% pred) SCr 1.6 mg/dL Hct 40% HDL 40 mg/dL Glucose 136 mg/dL WBC 9.0 × 103 /mm3 TG 151 mg/dL FEV1/FVC 51% Plts 189 × 103 /mm UA Yellow, clear, SG 1.007, pH 5.5, (+) protein, (–) glucose, (–) ketones, (–) bilirubin, (–) blood, (–) nitrite, RBC 0/hpf, WBC 1–2/ hpf, neg bacteria, 1–5 epithelial cells ECG Normal sinus rhythm ECHO (6 months ago) Mild LVH, estimated EF 45%
CREATE A SOAP NOTES OUT OF THIS CASE
Chief Complaint
“I just moved to town, and I’m here to see my new doctor for a check up. I’m just getting over a cold. Overall, I’m feeling fine, except for occasional headaches and some dizziness in the morning. My other doctor prescribed a low-salt diet for me, but I don’t like it!”
HPI
Sam Street is a 62-year-old African-American male who presents to his new family medicine physician for evaluation and follow-up of his medical problems. He generally has no complaints, except for occasional mild headaches and some dizziness after he takes his morning medications. He states that he is dissatisfied with being placed on a low sodium diet by his former primary care physician. He reports a “usual” chronic cough and shortness of breath, particularly when walking moderate distances (states, “I’m just out of shape”).
PMH
Hypertension × 15 years
Type 1 diabetes mellitus
Chronic obstructive pulmonary disease, Stage 2 (Moderate) Benign prostatic hyperplasia
Chronic kidney disease
FH
Father died of acute MI at age 71. Mother died of lung cancer at age 64. Mother had both HTN and DM.
SH
Former smoker (quit 3 years ago; smoked 1 ppd × 28 years); reports moderate amount of alcohol intake. He admits he has been nonadherent to his low sodium diet (states, “I eat whatever I want.”) He does not exercise regularly and is limited somewhat functionally by his COPD. He is retired and lives alone.
Meds
Triamterene/hydrochlorothiazide 37.5 mg/25 mg po Q AM Insulin 70/30, 24 units Q AM, 12 units Q PM
Doxazosin 2 mg po Q AM
Albuterol INH 2 puffs Q 4–6 h PRN shortness of breath Tiotropium DPI 18 mcg 1 capsule INH daily
Salmeterol DPI 1 INH BID
Entex PSE 1 capsule Q 12 h PRN cough and cold symptoms Acetaminophen 325 mg po Q 6 h PRN headache
All
PCN—Rash
ROS
Patient states that overall he is doing well and just getting over a cold. He has noticed no major weight changes over the past few years. He complains of occasional headaches, which are usually relieved by acetaminophen, and he denies blurred vision and chest pain. He states that his shortness of breath is “usual” for him, and that his albuterol helps. He denies experiencing any hemoptysis or epistaxis; he also denies nausea, vomiting, abdominal pain, cramping, diarrhea, constipation, or blood in stool. He denies urinary frequency, but states that he used to have difficulty urinating until
his physician started him on doxazosin a few months ago.
Physical Examination
Gen
WDWN, African-American male; moderately overweight; in no acute distress
VS
BP 168/92 mm Hg (sitting; repeat 170/90), HR 76 bpm (regular), RR 16 per min, T 37°C; Wt 95 kg, Ht 6'2''
HEENT
TMs clear; mild sinus drainage; AV nicking noted; no hemorrhages, exudates, or papilledema
Neck
Supple without masses or bruits, no thyroid enlargement or lymphadenopathy
Lungs
Lung fields CTA bilaterally. Few basilar crackles, mild expiratory wheezing
Heart
RRR; normal S1 and S2. No S3 or S4
Abd
Soft, NTND; no masses, bruits, or organomegaly. Normal BS.
Genit/Rect
Enlarged prostate; benign
Ext
No CCE
Neuro
No gross motor-sensory deficits present. CN II–XII intact. A & O × 3
Labs
Na 142 mEq/L Ca 9.7 mg/dL Fasting Lipid Panel Spirometry
(6 months ago) K 4.8 mEq/L Mg 2.3 mEq/L Cl 101 mEq/L HbA1C 6.2% Total Chol 169 mg/dL
FVC 2.38 L (54% pred) CO2 27 mEq/L Alb 3.5 g/dL BUN 22 mg/dL
Hgb 13 g/dL LDL 99 mg/dL FEV1 1.21 L (38% pred) SCr 1.6 mg/dL Hct 40%
HDL 40 mg/dL Glucose 136
mg/dL
WBC 9.0 × 103 /mm3 TG 151 mg/dL FEV1/FVC 51%
Plts 189 × 103 /mm
UA
Yellow, clear, SG 1.007, pH 5.5, (+) protein, (–) glucose, (–)
ECG
Normal sinus rhythm
ECHO (6 months ago) Mild LVH, estimated EF 45%
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