Please follow the soap note template provided:
Title page – including the identified case study name and number
1. Learning Issues – what do you need more information in order to develop a plan? If so, what information do you need or want? (Can be bullet points)
1. Example – Chest Pain
1. How do you evaluate a patient with a history of chest discomfort and risk factors for heart disease?
2. What are the laboratory findings that are important to look for with someone with chest discomfort?
* How do you manage abnormal lipids?
1. What lifestyle changes are important to recommend to reduce cardiac risk
2. Interpretation of Cues, Patterns, and Information – symptoms analysis and identification of any missing data that would helpful in making a plan for care (Can be bullet points)
1. Example – Chest pain
1. Chest discomfort – musculoskeletal vs gastrointestinal vs cardiac vs respiratory?
2. What labs are missing that would assist in the planning process for this patient?
* Family history that could increase risk of cardiovascular disease
1. Psychosocial issues – caffeine intake, smoking, ETOH use, or working history
2. Differential Diagnoses – include 3 differential diagnoses including ICD-10 codes (Can be bullet points)
1. Example – Chest pain
7. Precordial Pain – R07.2
8. Acute Myocardial Infarction – I21.9
* Gastroesophageal Reflux Disease without esophagitis– K21.9
4. Diagnostic Options – what additional laboratory work, diagnostic testing, or possible referrals may be required? (Can be bullet points)
5. Final Diagnosis – what is the most probable cause of the patient problem?
6. Therapeutic Options – this is related to your final diagnosis (Paragraph Form or Bullet Points)
1. Pharmacological
2. Nonpharmacological
3. Educational
4. Social Determinants of Health
7. Follow up – when should this patient return to the office? What conditions would need earlier follow up? (Paragraph Form)
8. References page (APA Format)
Case 16
1:30 PM
Jerome Wilson
Age 47 years
Opening Scenario
Jerome Wilson is a 47-year-old man on your schedule for a follow-up visit. He had an annual examination six months ago with elevated lipid levels. At that time, you recommended that he start lipid-lowering medication. Rather than using medication, Mr. Wilson preferred to try to improve his lipids by working on lifestyle changes for six months. He was started on a heart-healthy diet and an exercise and stress management plan. The results of his lipid profile drawn six months ago, as well as other tests ordered, are shown in Table 16-1 and Table 16-2.
Notes of Jerome Wilson’s Visit Six Months Ago
Reason for Visit
Jerome Wilson is a 47-year-old man scheduled for a complete physical examination. It has been three years since his last physical with you.
History of Present Illness
“I am planning to increase my exercise level by joining a local fitness club. I thought it would be a good idea to schedule a physical before doing this. I feel fine and have not had any change in my health.”
Medical History
No hospitalizations or surgery. Seen twice in the past for bursitis of the left shoulder, which required steroid injections. No hypertension, coronary artery disease (CAD), or diabetes mellitus.
Family Medical History
Mother: 71 years old (hypercholesterolemia, surgery at age 65 for vascular occlusion in the leg)
61
Father: 71 years old (Alzheimer’s disease for three years)
Sister: 47 years old (current diagnosis of breast cancer)
Grandparents: All died many years ago; he does not know causes of death
Social History
Lives with wife and three children, ages 3, 8, and 12. Works as a certified public accountant in a large accounting firm. Nonsmoker for 15 years. Four drinks of alcohol per week. Three cups of coffee per day. Golfs two to three times a week in good weather.
Medications
None
Allergies
NKDA
Review of Systems
General: States energy level is good; sleeps well; feels healthy but stressed keeping up with family and work responsibilities
Integumentary: Dry, itchy areas on scalp
HEENT: Denies problems with hearing; recently began to use reading glasses; sees dentist regularly
Respiratory: Denies any chest pain, shortness of breath, cough, or dyspnea on exertion
Gastrointestinal: No heartburn, nausea, abdominal pain; occasional constipation with occasional painful hemorrhoid; no rectal bleeding
Genitourinary: No dysuria, frequency, hesitancy, nocturia
Musculoskeletal: No current joint pain, but occasionally (every few months) notes transient joint pain in knees, wrists, and fingers; uses aspirin or acetaminophen when needed with good relief of symptoms
Neurological: No headaches; denies depression, memory changes
Physical Examination
Vital signs: Temperature 98.0° F; pulse 72 bpm; respirations 16/min; BP 136/74 mm Hg
Height: 5 ft 8 in; weight: 160 lb; BMI: 24
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Categories
Chest Pain 1. How do you evaluate a patient with a history of chest discomfort and risk factors for heart disease?
