SOAP Note Exercise                                       

Case 1

CC: Sudden onset substernal chest pain that “woke me up “and lasted until now (about 45 mins) 

HPI: 70 y/o man with h/o hypertension, hyperlipidemia, 40 pack-years smoking history, and brother who died of MI at 60y/o brought in by ambulance to the ED with c/o substernal chest pain.  The pain is described as pressure-like and radiating to the left arm and jaw, accompanied by nausea, diaphoresis, and shortness of breath.  Nitroglycerin was administered sublingually, but only provided temporary relief.  Aspirin was given to the patient to chew in the ambulance.

PE:

VS: BP 150/70, HR 110, Temp 37.1 ͦC, R 30  Pulse oximetry: 96% on room air

Gen: obese, pale, diaphoretic patient

Lungs: clear to Auscultation and Percussion

Heart: RRR, S4 gallop noted

Ext: No cyanosis or edema

Labs:

CBC: Hemoglobin & hematocrit normal, WBC 11,000 (slightly high)

Electrolytes: Normal

Troponins: Troponin T and I are elevated

CK-MB: normal

EKG: sinus tachycardia, elevated ST segments in leads II, III, and AVF

Assessment: Acute Inferior wall MI

Plan:  Start Morphine drip IV, O₂ via nasal cannula, Metoprolol, urgent transfer to interventional cardiology lab

The patient has a balloon angioplasty and stent placement and is transferred to the telemetry unit for monitoring.  You see the patient the next day and need to document your visit in a progress note in the SOAP format. [See next page for information you need to write it]

The next day you visit the patient and must write a progress note to include the following:

A very brief synopsis of what occurred the day previously

His current medications:

Aspirin 81 mg orally, once a day

Plavix 75 mg orally, once a day

Lopressor 25 mg orally every 12 hours

His report of his condition today:  much more comfortable.  No pain, no shortness of breath.  Some mild fatigue when walking from room to nursing station

The EKG this morning shows normal sinus rhythm with no ST elevations and no Qwaves

The physical exam which includes: HR 72, BP 130/70, R 24, Temp 37.4   ͦC

General: appears comfortable. 

Extremities: peripheral pulses are slightly diminished and 1+

Heart: Regular rate and rhythm, no gallops or murmurs

Lungs: clear

Groin: femoral pulses intact and 2+ .  No hematoma

You believe he is doing well and that the same plan should be continued for now.  You would like the nurse to check his vital signs every 4 hours for one more day and then every 8 hours. 

If all goes well, patient is without chest pain and VS are stable, he can be discharged to home in 3 days.

SOAP note for the visit:

Subjective:

70 y/o man with h/o hypertension, hyperlipidemia, 40 pack-years smoking history, and brother who died MI at 60 y/o brought in by ambulance yesterday c/o pressure-like substernal chest pain that radiated to the left arm, along with nausea, diaphoresis, and SOB. Lab showed elevated troponin level, elevated ST segments in leads II, III, and AVF, and slightly elevated WBC. Temporary relief with sublingual nitroglycerin.  Was diagnosed with acute inferior wall MI and sent to interventional cardiology lab for balloon angioplasty and stent placement. Today, patient reports feeling much more comfortable, mild fatigue when walking from room to nursing station. Denies pain, SOB.

Meds: oral aspirin 81mg QD, oral Plavix 75mg QD, oral Lopressor 25 mg Q12H.

Objective:

HR 72, BP 130/70, R 24, Temp 37. 4   ͦC

General: appears comfortable

Extremities: peripheral pulses are slightly diminished and 1+

Heart: RRR, no gallops or murmurs.

EKG: normal sinus rhythm with no ST elevation and no Q waves (done this morning)

Lungs: clear

Groin: femoral pulses intact and 2+. No hematoma

Assessment:

Pt with acute inferior wall MI, post-operative day 1 for balloon angioplasty and sent placement.

Recovering well

Plan

1) Continue morphine drip IV, O2 via nasal cannula, Metoprolol

2) Check vital signs every 4 hours for one more day, then every 8 hours

3) If chest pain didn’t come back and VS are stable, discharge to home in 3 days

Patient Background:

Damien, age 33, was adopted by a NYC couple after birth to a single mother in Tennessee. He has been a long-haul truck driver and sometimes bus driver for private companies.  These jobs have not typically provided health coverage so even though he suffers from hypertension and gout, he has not been consistent about taking his medications for these conditions because he can’t always afford them.  He had regular health care through his teens when he was still on his parents’ insurance, but he hasn’t had a regular health care provider since turning 18 and has mostly managed by going to urgent care centers when he needs new prescriptions or has an acute problem.  He has just obtained a job in a UPS processing center which will mean that he’ll be on his feet all day rather than sitting and driving.  It also means he now has regular health insurance so he has come to see you today for a “once over” and to get prescriptions for his blood pressure and gout.

Damien rarely drinks alcohol, except on special occasions. He smokes cigars “when I want to relax” with friends at a cigar bar.  He estimates that he has about 4 cigars a week.  He drinks up to a gallon of (full fat) milk a day which he sees as a healthy behavior, but he otherwise has a basically poor diet. He eats a good deal of meat, is trying to cut back on sugary drinks, has developed a “beer belly” in spite of the fact that he rarely drinks beer. He loves snack food and pastries and cakes of all kinds.  He says he also loves edamame (fresh soy beans) and will enjoy salad but rarely chooses this in a restaurant, or buys it when shopping for food to bring home. 

Damien loves to be active, but also seems to express fatigue when he has done relatively little. He says he’d like to get more exercise and have a healthier life style but does not seem to be able to really put together a plan for this. He doesn’t get any regular exercise now.  He has been noted to enjoy the outdoors, his church community and basketball.   

Damien lives with his girlfriend and their 4 year old son in a 3^rd floor walk –up apartment in Bay Ridge Brooklyn.  He says he can walk up the stairs without being uncomfortable except when his feet are bothering him when he has a gout flare up.  He notes that he does get winded sometimes if he has to carry heavy groceries or his son’s tricycle up the stairs.

Other Information:

BP 140/88        P 72     R 18     T 98.6

Hgt 5 ft 10 in                Wgt 200 lbs                 Waist circumference: 43 in: inc

Gout: last episode of Right 1^st toe pain was 6 months ago after having a lobster dinner with red wine and a cheese appetizer.  He was given corticosteroids at an urgent care center and returned to baseline. 

Regular meds (when he takes them): hydrochlorthiazide 25 mg daily, diltiazem 120mg daily, allopurinol 100 mg daily

Case Study: Damien Jackson                                                           

Immunizations

• Influenza
• Tdap
• MMR
• Varicella 2 doses

Screening

Based on USPSTF recommendations:

• Alcohol misuse
• Depression
• Hypertension
• Obesity/weight loss
• HIV infection
• Hepatitis C virus infection

Because patient has hypertension, need to screen for:

• Diabetes mellitus
• Lipid disorders

Health Promotion/Disease Prevention Concerns

Injury Prevention:

Traffic safety

Falls prevention

Safe sleep environment

Poisoning prevention

Sports safety

Diet:

Damien is diagnosed with hypertension and gout, and has not been taking his medication regularly until now. His waist circumference is 43 inches. Given all these information, he is at increased risk of developing type 2 diabetes and coronary artery disease. He has a few dietary issues, such as drinking a lot of full fact milk, eating a large amount of meat, drinking sugary drinks, having sugary snack food.

One of the goal is to lower his risk of developing type 2 diabetes and coronary artery disease, one of the important dietary modifications is to cut down on sugar intake.

• Replace unhealthy snack food with small serving of nuts and seeds
• Begin with splitting the cake into two portions, and only eat half of the original serving size each time. Later on, slowly replace sweet treats with fresh fruits.
• Get a blender and make smoothies with fruits and vegetables to slowly replace sugary drink.
• Encourage patient to prepare these healthy food for his girlfriend and son might help him stick to the plan because he is also making healthy choice for his family at the same time

Hypertension is a risk factor for lipid disorder, so another thing is to cut down on fat. Also avoid food that would cause gout attack.

• Drink fat-free milk instead of whole fat milk. Other alternatives are plant-based milk such as soymilk, oatmilk or almond milk.
• Add more of vegetables in daily meal (salad and edmame).
• Bring homemade lunch to work as much as he can.
• Replace red meat with lean meat and fish for at least 2 meals every week
• Avoid lobster/shellfish and organ meats to prevent gout attack
• Besides these, Damien should watch his salt intake since he has hypertension.

Exercise:

Stick to a healthy diet is hopefully going to reduce the gout flare up, so Damien will have less limitation on doing exercise. Goal of exercise is to help him loss and maintain a healthier weight, also to lower his risk of developing cardiovascular disease. He is off to a good start by having the motivation to be active and do exercise. He would be standing and walking more during his new job, but its not adequate. CDC guidelines for adults are to have aerobic activity for 150min/week that’s moderate to intense or 75min/week that’s vigorous to intense. And muscle strengthening more than 2 times a week involving all major muscle groups.

He can start by doing light exercises and slowly increases intensity once he develops better tolerance and experience less fatigue. My suggestions are:

• Riding bicycles (can be with his son) for 30 minutes 3 x per week to start with, can increase duration or frequency later on
• Take 20-30 minutes walk after dinner on the days that he is tired or doesn’t feel like riding bicycles
• Incorporate strength training in small intervals (10-15 minuets) throughout week. At least 2 intervals to start with. Damien can utility light weights or resistant bands, or download an “exercise app” and follow their videos and suggestions
• Since he enjoys outdoor, hiking at least once every month with his family would be a great plan for weekends
• Play basketball at least once a month to start with

Harm Reduction:

• Quit cigar or replace cigar with smokeless nicotine alternatives
• Encourage regular follow up since he has health insurance now

Brief Intervention:

Smoking cessation

Damien reports that he smokes about 4 cigars a week with his friend at a cigar bar. Based on the information, he didn’t express any motivation to make change on this habit.

1) I would start by accessing his readiness to change and ask for permission:           

• I think quitting smoking is very important for you because it would further decrease your risk of having heart disease. Can we talk about this some more?
  • Have you ever tried to cut back on or quit smoking?

2) If he would like, I will continue to give information on the harm and benefit about smoking and quitting. Also give advise on medications and other tools that can help he quit cigar

• Ex) smoking cigar takes much longer time and can get more nicotine than cigarette
• Ex) quitting can improve exercise tolerance and save money

3) Assess addition to nicotine and if there is any other motivating factors that would help him stop smoking

4) Discuss and design a plan for he to start quitting

5) Schedule follow up appointments