Soap Note: This Is With The Same Family Case You Used In The

Soap Notethis Is With The Same Family Case You Used In The Discussion

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient's case entry.

Paper For Above instruction

Introduction

The SOAP (Subjective, Objective, Assessment, Plan) note is an essential documentation tool used by healthcare providers to record patient encounters comprehensively. This paper aims to develop a complete SOAP note based on a family case discussed previously, illustrating the application of clinical reasoning and documentation skills. The case in focus involves a patient from a family context, emphasizing the importance of family history and social determinants in diagnosis and management.

Subjective

The patient is a 45-year-old female from a multigenerational family presenting with complaints of persistent fatigue, intermittent headaches, and recent episodes of dizziness over the past two months. She reports that her symptoms have gradually worsened and interfere with her daily activities. The patient mentions a history of hypertension diagnosed five years ago, but she admits she has not been consistent with medication adherence. She also reports that her father and sister have similar complaints, with her father being diagnosed with type 2 diabetes. She denies chest pain, palpitations, or shortness of breath. Social history reveals that she smokes half a pack of cigarettes daily and consumes alcohol socially weekends. She works as a school teacher and has a sedentary lifestyle. She reports dietary habits high in processed foods and low intake of fruits and vegetables.

Objective

Vital signs: Blood pressure 150/92 mm Hg, Heart rate 88 bpm, Respiratory rate 16 per minute, Temperature 98.6°F. Physical examination shows BMI of 29 kg/m². Cardiovascular exam reveals regular rhythm without murmurs. Lungs are clear to auscultation. No edema or cyanosis noted. Neurological examination unremarkable. Laboratory results show fasting blood glucose 130 mg/dL, Hemoglobin A1c 6.5%, and lipid profile indicating elevated LDL cholesterol at 160 mg/dL and triglycerides at 180 mg/dL. The patient’s physical exam is notable for slightly elevated blood pressure, and her lab results suggest ongoing metabolic concerns.

Assessment

This patient presents with poorly controlled hypertension, prediabetes, and dyslipidemia, all contributing to increased cardiovascular risk. The family history of diabetes and hypertension further elevates her risk profile. Her sedentary lifestyle, dietary habits, and non-adherence to medication likely contribute to her current clinical picture. Management should focus on lifestyle modifications, medication adjustments, and regular monitoring to mitigate her risk of cardiovascular events and progression to type 2 diabetes.

Plan

1. Initiate antihypertensive therapy adjustment by adding a thiazide diuretic and titrating to blood pressure target of less than 130/80 mm Hg.

2. Educate the patient about lifestyle modifications including dietary changes to reduce processed food intake and increase fruits and vegetables, consistent exercise, smoking cessation, and limiting alcohol intake.

3. Monitor blood glucose and lipid levels every three months, with adjustments to therapy as needed.

4. Refer the patient to a dietitian for nutritional counseling and to a fitness program for guided physical activity.

5. Schedule follow-up in four weeks to assess blood pressure response, medication adherence, and lifestyle changes.

Conclusion

This case underscores the importance of integrating family history, lifestyle factors, and clinical findings in managing chronic conditions such as hypertension and prediabetes. The use of a comprehensive SOAP note facilitates a structured approach to patient care, promoting effective communication and continuity of care in clinical practice.

References

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• American Diabetes Association. (2023). Standards of Medical Care in Diabetes—2023. Diabetes Care, 46(Suppl 1), S1–S273.
• Goff, D. C., L'Italien, G., McGerr, L., & Robinson, J. G. (2020). Lipid management and risk reduction: The role of lifestyle and medications. American Journal of Cardiology, 125(2), 162-170.
• Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., et al. (2018). 2017 ACC/AHA/AAPA/ABC/ACP/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension, 71(6), e13-e115.
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• Smith, S. C., et al. (2019). Prevention of cardiovascular disease in women: A scientific statement from the American Heart Association. Circulation, 139(19), e56–e115.
• Stein, J. H., et al. (2021). Atherosclerotic cardiovascular disease in women: Focus on prevention. American Journal of Preventive Cardiology, 5, 100183.