Running head: SOAP NOTE 2 1

Name: Erika Payne

SOAP NOTE 2

Subjective Information

Identification (ID): P.R.

Date of visit: 2/6/2020

Age: 56 y/o

DOB: 8/3/1963

Gender: Male

Advanced directives: No

Insurance: Aetna

Ethnicity: Caucasian

Source: Self, reliable historian

Chief Complaint:

“Follow up and lab review.”

History of Present Illness (HPI):

P.R. is a 56-year-old male that presents for a follow up visit and lab review. He had lab work

completed on 1/28/20 in order to review at this visit. He was last evaluated at this office in 2017,

but then resumed care through the Veterans Affairs (VA). He wants to reestablish primary care

with Tennova. He explained that he stopped taking his Atorvastatin about 1 month ago in order

to reassess his cholesterol levels and possibly stop the medication completely. He reports he is

currently stressed with work and purchasing a new house, so he has not been eating healthy. He

denies any changes in his health except in May 2019 he had a work-related injury. He was struck
SOAP NOTE 2 2

with an osteotome in the right side of his face which required surgical repair. Denies any deficits.

He denies any pain at this time.

Past Medical History (PMH):

General health: Fair

Surgeries: Perirectal abscess x3, facial impalement (May 2019)

Hospitalizations: May 2019 for facial injury.

Past Medical Problems:

Neurologic: Denies history of seizures or tremors.

HEENT: Denies allergic rhinitis and recurrent sinusitis.

Respiratory: Denies history of asthma, pneumonia, COPD, sleep apnea, or bronchitis.

Cardiovascular: Reports history of hyperlipidemia. Denies hypertension. Denies history of

cardiac events.

Musculoskeletal: Denies history of arthritis or fibromyalgia.

Endocrine: Reports history of prediabetes. Denies history of thyroid disorders.

Dermatologic: Denies history of psoriasis, atopic dermatitis, rosacea, skin cancer, and urticaria.

Gastrointestinal: Reports history of GERD. Denies IBS.

Genitourinary: History of BPH. Denies history of kidney stones, bladder infections, or kidney

disease.

Psychiatric: History of depression. Denies history of attention deficit disorder, insomnia, or

mood disorders.

Health Maintenance:

Last PE: October 2017 (Tennova)

Diagnostic tests:
- Last colonoscopy in 2019. Recall 3 years.
SOAP NOTE 2 3

Specialists: None

Immunizations: Up to date
- Influenza: 10/19

Social History:

Personal History:
Marital status: Married

Sexual orientation: Heterosexual

Religious preferences: Deferred

Occupation: Medical Supply

Safety or abuse issues: None

Health Habits:

Tobacco use: Former smoker x30 years.

Alcohol use: Denies

Drinks per day: Denies

Illicit drugs: Denies

Diet: Fair. 1 cup of coffee per day.

Exercise: Occasional. Walks frequently at work.

Exposure to toxins: Deferred

Family History:

Mother, living, breast cancer x2, arthritis, MI

Father, living, MI, malignant tumor of pharynx

Medications:

Atorvastatin 20mg tablet. Take 1 tablet by mouth daily.

SOAP NOTE 2 4

Class: Antilipidemic Agent, HMG-CoA Reductase Inhibitor

Adverse Effects: Diarrhea, arthralgia, nasopharyngitis, nausea, dyspepsia, urinary tract infection

Contraindications: Active liver disease, persistent elevated serum transaminases, pregnancy,

breastfeeding (Lexicomp, 2020a)

Buspirone 15mg tablet. Take 1 tablet by mouth twice a day.

Class: Antianxiety Agent, Miscellaneous

Adverse Effects: Dizziness, drowsiness, headache, nausea

Contraindications: Concomitant use of MAOIs (Lexicomp, 2020b)

Cyclobenzaprine 10mg tablet. Take 1 tablet by mouth TID as needed for muscle spasms.

Class: Skeletal Muscle Relaxant

Adverse Effects: Drowsiness, dizziness, xerostomia, headache

Contraindications: Heart failure, arrhythmias, hyperthyroidism, within14 days of MAOIs

(Lexicomp, 2020c)

Escitalopram 20mg tablet. Take 1 tablet by mouth daily.

Class: Antidepressant, Selective Serotonin Reuptake Inhibitor

Adverse Effects: Headache, insomnia, drowsiness, nausea, diarrhea, erectile dysfunction

Contraindications: Use of MAOIs (Lexicomp, 2020d)

Meloxicam 15mg tablet. Take 1 tablet by mouth daily as needed.

Class: Analgesic, Nonsteroidal Anti-Inflammatory Drug (NSAID)

SOAP NOTE 2 5

Adverse Effects: Dyspepsia, diarrhea, nausea, abdominal pain

Contraindications: History of asthma or urticaria with aspirin or NSAID use, bypass graft

surgery (Lexicomp, 2020e)

Tamsulosin 0.4mg capsule. Take 1 capsule by mouth daily.

Class: Alpha 1 Blocker

Adverse Effects: Hypotension, headache, dizziness, rhinitis

Contraindications: Hypersensitivity to tamsulosin or any component of the formulation

(Lexicomp, 2020f)

Taking OTC omeprazole 20mg by mouth once a day.

Allergies:

Allergic to Penicillin – Reaction: rash

Denies allergy to food, latex, or stinging insects.

Review of Systems (ROS):

General:

Denies sleep disturbance, fatigue, fever, weight loss/gain, or chills.

Diet:

Reports eating a moderate amount of fried or fatty foods.

Skin, Hair, & Nails :

SOAP NOTE 2 6

Denies any bruising, redness, abrasions, lesions, or discoloration to skin. Denies changes in nails

or hair. Scar to right cheek.

Eyes:

Denies vision disturbances, dry eye, watery eyes, discharge, and trauma. Wears glasses.

Ears:

Denies hearing loss, otalgia, discharge, or tinnitus.

Nose:

Denies nasal congestion, epistaxis, postnasal drip, or sneezing.

Throat and Mouth:

Denies sores in mouth, sore throat, or dry mouth.

Head and Neck:

Denies headaches or neck pain.

Chest and Lungs:

Denies cough, shortness of breath, dyspnea on exertion, wheezing, or night sweats.

Cardiovascular:

Denies chest pain, palpitations, edema, claudication, exercise intolerance, varicosities, or

syncope.

Gastrointestinal:

Reports intermittent “heart burn” after meals. Denies abdominal pain, nausea, vomiting, or

diarrhea.

Genitourinary:

Denies urinary frequency, urgency, hematuria, or dysuria.

Musculoskeletal:
SOAP NOTE 2 7

Reports intermittent low back pain without radiation to legs. Denies change in range of motion,

weakness, heat, or swelling.

Neurologic:

Denies loss of coordination, weakness, numbness, or tingling.

Objective Information:

Physical Exam:

Vital Signs:

Temperature: 98F

Heart Rate: 75

Respirations: 16

BP: 121/80

Height: 5’7”

Weight: 205lbs

BMI: 32.1% (Obese)

Pain Scale: 0/10

Focused exam:

General Appearance

Patient is a 56-year-old male who is well groomed, wearing appropriate dress for season, and

cooperative. He is alert. No distress noted. Sitting in chair when I enter the room.

Mental Status and Neurological

Oriented to person, place, and time. Speech is clear and understandable. Sensory and motor

function intact. Deep tendon reflexes of patella 2+ bilaterally.

Skin/hair/nails
SOAP NOTE 2 8

Skin is fair, warm, dry. Hair is brown and clean. Scar to right cheek (2cm). No bruising,

abrasions, redness, lesions, or swelling noted. Nails are trimmed with no cracking or

discoloration. Nail beds are pink, capillary refill is < 3 seconds, and no evidence of clubbing of

the fingers is noted.

Head

Head is normocephalic, atraumatic.

Neck

No jugular vein distention noted. No bruits noted on auscultation of the carotid arteries. Trachea

is midline and freely mobile. Neck is supple with full range of motion. No nodules or masses

palpated on thyroid gland.

Eyes

Pupils are equal, round, and reactive to light. Conjunctiva is pink and sclera is white. Extraocular

movements intact. Orbits and eyelids are atraumatic.

Ears

Symmetrical. Bilateral ear canals are patent. Tympanic membranes are pearly, gray with cone of

light present bilaterally.

Nose

Mucosa is pink without discharge. Nasal septum appears midline. No tenderness noted upon

palpation of frontal and maxillary sinuses. Nares are patent, no erythema, or drainage noted.

Mouth and Throat

Lips are moist. Dentition is intact with no obvious caries. Buccal membranes are pink and moist.

Tongue is pink, midline, and moist. No erythema or exudate present on posterior pharynx.

Tonsils are 1+.

SOAP NOTE 2 9

Chest and Lungs

Chest is symmetrical in shape. Symmetrical, bilateral movement of chest expansion. 16

respirations per minute. No visible use of accessory muscles. No crepitus, masses, lesions, noted

to anterior or posterior chest. Clear auscultated lung sounds throughout anterior and posterior

lung fields bilaterally. No wheezes, crackles, rubs or rhonchi.

Heart/Peripheral Vascular

No signs of acute distress. PMI is palpable at the left midclavicular line at the 5th intercostal

space. No heaves, lifts, thrills or thrusts at PMI. S1 and S2 are audible with regular rhythm. No

splitting, gallops, rubs, murmurs or snaps at the five cardiac points of auscultation. Dorsalis pedis

pulses are 2+, regular. No cyanosis or edema throughout body.

Gastrointestinal

Abdomen is rounded, symmetrical. Skin color is fair. Active bowel sounds in all four quadrants.

No aortic bruits. Tympany percussed in all four quadrants. Liver not palpable. Abdomen is soft

to light and deep palpation. No masses, tenderness, or presence of organomegaly with palpation.

Genitourinary

Examination deferred.

Musculoskeletal

Patient is able to walk around room and change positions independently. Joints are appropriate

size, symmetrical, and contour. No ecchymosis, erythema, or changes in the skin integrity. No

guarding, discoloration, pallor, or cyanosis of joints throughout. No warmth or crepitus of joints.

No edema, masses, atrophy, hypertrophy, increased tone irregularities noted in any muscle

groups bilaterally. No scoliosis or deformities palpated of spine. No pain with palpation of spine.
SOAP NOTE 2 10

Diagnostic Tests or Labs:

Labs on 1/28/20

CBC – WDL

CMP – WDL except glucose was 112

Hemoglobin A1C – 6.1%

Lipid Panel – Total Cholesterol: 211, LDL: 141, HDL: 50, Triglycerides: 95

PSA, total with reflex to PSA, free – 1.5

Labs on 10/12/17

CBC – WDL

CMP – WDL except glucose was 114

Hemoglobin A1C – 5.9%

Lipid Panel – Total Cholesterol: 164, LDL: 105, HDL: 36, Triglycerides: 35

Assessment Information:

Diagnostic Criteria

Patients with hyperlipidemia are often asymptomatic and diagnosed on routine screening

examinations (Santos, 2019). Diagnostic criteria for hyperlipidemia is based on the following lab

values (Santos, 2019):

LDL:

* Optimal: <70mg/dL

* Desirable - Above Desirable: 70 - 129mg/dL

* Borderline high: 130-159mg/dL

* High: 160-189mg/dL

* Very high: >190mg/dL

SOAP NOTE 2 11

Total Cholesterol:

* Optimal: <170mg/dL

* Desirable: <200mg/d

* Borderline high: 200 - 239mg/dL

* High: >240mg/dL

HDL:

* Low: <40mg/dL

Triglycerides:

* Ideal: <100mg/dL

* Desirable: 100-<150mg/dL

* Borderline high: >150mg/dL

* High: 200 - 499mg/dL

* Very high: > 500mg/dL

This patient was previously diagnosed with hyperlipidemia. Recommendations for drug

therapy is based on age, comorbidities, and cardiovascular risk (Santos, 2019). The patient’s total

cholesterol and LDL have increased and his triglyceride level has decreased since his last visit in

2017. He explained that he stopped taking Atorvastatin about 4 weeks ago in order to get an

accurate reading on his current cholesterol level. The patient’s atherosclerotic cardiovascular

disease (ASCVD) risk score was calculated in the office and resulted as 6.1%. We discussed

these results with the patient. According to the recommendations he does not have to be on a

statin medication at this time because his risk is <7.5%. He is requesting to trial modifying his

diet and starting exercising in order to remain off statin medication.

SOAP NOTE 2 12

Diabetes mellitus type 2 affects nearly 8 percent of the United States population

(McCullouch & Hayward, 2019). Risk factors include age greater than 45 years, obesity, family

history, sedentary lifestyle, hyperlipidemia, hypertension, polycystic ovary syndrome, and

history of vascular disease (McCullouch & Hayward, 2019). Screening tests for type 2 diabetes

include a fasting plasma glucose, hemoglobin A1C, and an oral glucose tolerance test

(McCullouch & Hayward, 2019). According to McCullouch & Hayward (2019), diagnosis of

diabetes mellitus is based on the following test findings and must be confirmed on a subsequent

day by repeating the same test:

* Fasting plasma glucose >126 mg/dL

* Hemoglobin A1C > 6.5%

* Two-hour plasma glucose > 200mg/dL during oral glucose tolerance test

* Random plasma glucose > 200mg/dL with symptoms

This patient has a hemoglobin A1C of 6.1%, therefore, he is classified as prediabetic. We

discussed what diabetes is and the potential long-term effects of the disease. He is motivated to

modify his diet and start exercising to prevent developing diabetes.

According to Zuckerman and Carrion (2019), gastroesophageal reflux disease (GERD) is

diagnosed clinically. A trial of proton-pump inhibitors can provide both diagnosis and initial

treatment of this condition (Zuckerman & Carrion, 2019). “Heartburn" and regurgitation are the

most common symptoms, which usually occur after meals (Zuckerman & Carrion, 2019).

Symptoms are typically worse if the patient is lying down or bending over (Zuckerman &

Carrion, 2019). Treatment goals aim to control symptoms and prevent complications

(Zuckerman & Carrion, 2019). This patient has an established diagnosis of GERD and has been

on proton-pump inhibitors, which are the mainstay therapy for this condition (Zuckerman &
SOAP NOTE 2 13

Carrion, 2019). He is current taking over the counter omeprazole and is experiencing

breakthrough symptoms.

According to MacKinnon (2019), depressive disorders affect approximately 5% to 10%

of patients in primary care. Symptoms of depression include low mood, loss of interest, reduced

energy, appetite changes, sleeping change, and poor concentration (MacKinnon, 2019). The

Depression Scale of the Patient Health Questionnaire (PHQ-9) is a quick, helpful tool to perform

depression screening in the primary care setting (MacKinnon, 2019). The main antidepressant

treatment options include selective serotonin-reuptake inhibitors (SSRI), serotonin-

norepinephrine reuptake inhibitors (SNRI), bupropion (dopamine-reuptake inhibitor), and several

more which are best selected based on individual factors (MacKinnon, 2019). This patient has an

established diagnosis of depression and has been taking combination therapy of escitalopram and

buproprion which is effectively controlling his symptoms.

Approximately 84% of adults will experience low back pain at some point in their lives

(Knight et al., 2020). The majority of patients in primary care have nonspecific back pain that is

self-limiting. This patient has an established diagnosis and has had intermittent low back pain for

several years. He explained that he will occasionally “tweak” his back and will require a couple

of days of pharmacologic therapy to improve. Nonpharmacologic treatment for low back pain

includes heat, massage, exercises, acupuncture, and more (Knight et al., 2020). Recommended

pharmacotherapy includes nonsteroidal anti-inflammatory drugs which may be in combination

with muscle relaxants if necessary (Knight et al., 2020). This patient was previously prescribed

meloxicam and cyclobenazaprine for low back pain and reports taking them about once a month

as needed.
SOAP NOTE 2 14

Benign Prostatic Hyperplasia (BPH) can lead to increased urinary frequency, hesitancy,

urgency, weak urinary stream, or nocturia (Cunningham & Kadmon, 2020). This is a common

condition that increases in prevalence as men age (Cunningham & Kadmon, 2020). Initial

treatment recommendations include Alpha-1-adrenergic antagonists to help relieve symptoms

(Cunningham & Kadmon, 2020). This patient has an established diagnosis of BPH and has been

taking tamsulosin with improvement in his symptoms of weak urinary stream and hesitancy.

DIAGNOSES:

ICD 10 codes:

E78.5 – Hyperlipidemia

K21.9 – Gastroesophageal reflux disease (GERD)

F32.89 – Depressive disorder

M54.5 – Low back pain

R73.03 – Prediabetes

N40.0 – Benign prostatic hyperplasia without lower urinary tract symptoms

CPT codes:

99204 – Office Visit, New Patient, 2 Key Components: Detailed History; Detailed Examination;

Medium Decision, Moderate Complexity

(Coded as new patient due to >2 years since last visit).

PLAN:

- Labs reviewed with patient. Discussed increased cholesterol levels and increased

hemoglobin A1C since last visit in 2017.

SOAP NOTE 2 15

- Pt was previously on Atorvastatin 20mg daily but stopped taking it about 4 weeks ago in

anticipation of his lab draw. Patient notified that his ASCVD risk score is 6.1%.

Discussed ASCVD risk score criteria for statin therapy. Discussed lifestyle changes

including diet modifications and exercise. Pt appears to be very motivated and wants to

trial lifestyle modifications at this time. Discussed limiting fried and fatty foods and

increasing vegetable and protein intake. Will reassess a fasting lipid panel in 3 months to

determine if statin therapy should be restarted. Pt agreeable to plan.

- Patient currently taking Omeprazole 20mg tablet daily over the counter. Pt reports he is

occasionally having breakthrough symptoms of GERD. He has tried Protonix in the past

without improvement in symptoms. Discussed trying Dexilant 60mg capsule, delayed

release tablet by mouth once a day. Dispense: 30 capsules. Refill:2. Pt notified of online

copay card. If this medication is too expensive, discussed taking two tablets of

Omeprazole 20mg daily. Discuss avoiding large meals and avoiding laying down after

eating. Pt agreeable to plan.

- Discussed continuing Buspar and Escitalopram for depression as he is doing well. Will

refill.

o Buspar 15mg tablets. Take 1 tablet by mouth twice a day. Dispense: 60 tablets.

Refill: 5

o Escitalopram 20mg tablet. Take 1 tablet by mouth daily. Dispense: 30 tablets.

Refill: 5

o Discussed importance of taking regularly for efficacy. Discussed adverse effect of

drowsiness with both medications. Will reevaluate and complete PHQ-9 in 6

months.
SOAP NOTE 2 16

- Discussed continuing taking Meloxicam and Cyclobenazaprine as needed for low back

pain. Recommended home stretches or yoga for low back pain. Discussed not using

Meloxicam daily due to risk of ulcers and impact on kidney function. Take Meloxicam

with food. Pt notified that he should not drive while taking Cyclobenazaprine. He states

that he infrequently takes this medication, only about once or twice a month, and does not

need a refill at this time. He can call the office if he needs a refill before next visit.

- Continue Tamulosin daily. Requesting refill.

o Tamulosin 0.4mg capsule. Take 1 capsule by mouth daily. Dispense: 30 capsules.

Refill: 5

o Discussed monitoring for signs of urinary infection including dysuria or blood in

urine.

- Lifestyle modifications including diet and exercise discussed with patient. The

importance of controlling is blood sugar was emphasized as his is at risk of developing

diabetes in the next couple of years. Discussed eliminating carbohydrates as he is

classified as prediabetic. We discussed eliminating his soda intake and replacing it with

water.

- Wash hands frequently to avoid illness.

- Release of information sign to obtain records from the VA and Parkridge hospital.

- Routine eye exam scheduled for this summer. Next colonoscopy will be in 2021.

- He was instructed to follow up in 3 months, or sooner if necessary, to reassess his

cholesterol level with fasting labs. Wellness examination will be in 6 months. Advance

directives not discussed at this visit but will be reviewed at his next wellness

examination. All questions were answered.

SOAP NOTE 2 17

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SOAP NOTE 2 18

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SOAP NOTE 2 19

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