Select a geriatric patient that you examined during the last 3 weeks. The patient you select should be currently taking at least five prescription and/or over-the-counter drugs. With this patient in mind, address the following in a SOAP Note:
Subjective: What was the patients subjective complaint? What details did the patient provide regarding his or her personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the Beers Criteria and consider alternative drugs if appropriate.
Objective: What observations did you make during the physical assessment? What functional assessments were used?
Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from top priority to least priority.
Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management including alternative therapies? What is your care plan for patient? How would you offer caregiver support?
Reflection notes: What would you do differently in a similar patient evaluation? How might you improve your assessment, diagnosis, and/or plan through interprofessional collaboration?
I HAVE MY FORMAT AND AN ASSESSMENT ON ACTUAL SOAP NOTE PLEASE REWRITE FOR NO CRAMMER ERROR
Age: 76 years Sex: Male DOB:
Associated Diagnoses: None
Supervising Physician Comments
By: Attending Physician.
History of Present Illness
76 year old male Patient with h/o DM, recurrent pleural effusion, non ischemic CM EF 35%, NSVT recently started on amiodarone, Chronic Kidney Desease stage 3, dementia who was admitted from 10/14/16-10/20/16 with sob and pleural effusion. Patient was diuresis and underwent right thoracentesis with 1.8 liters removed on 10/14/16. Also treated for Citrobacter UTI. Patient had NSVT and was seen by cardiology and started on amiodarone. Patient\’s wife says he\’s compliant with all meds. When pt 1st got home he was coughing a lot. few days he was doing okay, then his wife noted he was lethargic and then around noon was sob so she brought him to office. Patient says he\’s fine but his wife thinks he\’s still slightly sob. At the OSH patient was found to have pleural effusion and CHF on CXR. BP was low and he was give 250 mL of NS. Patient then transferred to nearest hospital for further management.
Past Medical History
CHF, nonischemic cardiomyopathy
echo Nov 2015
1. Moderate concentric LVH with normal chamber size and moderately severe
reduction in systolic function, LVEF 35% range.
2. Mild RV systolic dysfunction.
3. Moderate bi-atrial enlargement.
4. Moderate MR/TR/AR.
5. The pulmonary artery pressure is moderately elevated at 60 mm Hg
(RAP/CVP elevated as well).
6. The aortic root is moderately dilated.
recurrent right pleural effusion s/p thoracentesis in April, May and 9/7/16
ckd stage 3
atherosclerosis of aorta
Allergic Reactions (Selected)
cephalexin 500 mg q8hrs x 7 days
amiodarone 200 mg 2 tabs bid x 7 days then 2 tabs qd
lasix 40 mg bid
glipizide 10 mg qd
atorvastatin 80 mg qhs
latanoprost 0.005% 1 drop both eyes qhs
asa 325 mg qd
Review of Systems
Review of Systems
Constitutional: denies fever, denies chills.
Head/Neck: denies lightheadedness, denies headache.
Eye: denies impaired vision.
Ear/Nose/Mouth/Throat: denies sore throat.
Neurologic: denies weakness, denies syncope.
Cardiovascular: dyspnea, denies chest pain, denies peripheral edema.
Respiratory: cough, dyspnea, denies wheezing, denies pleuritic pain.
Gastrointestinal: denies abdominal pain, denies abdominal distension, denies nausea, denies vomiting, denies diarrhea, denies constipation, denies melena, denies hematochezia.
Genitourinary: denies dysuria.
Musculoskeletal: denies back pain.
Skin: denies rash.
Psychiatric: denies anxiety, denies depression.
brother – prostate ca
mother – dm
denies Tobacco Exposure
denies Alcohol Use
Vital Signs/Measurements 48 hour : Vital Signs/Measurements
9/10/2016 02:00 EDT Temperature 97.9 Degrees F NML
Pulse Rate 78 BPM NML
Respiratory Rate 18 Br PM NML
Pulse Oximetry 100 % NML
Systolic BP 94 mmHg NML
Diastolic BP 58 mmHg LOW
Eye: no redness, conjunctiva clear.
Head: normocephalic, atraumatic.
Exam: supple, no lymphadenopathy, full range of motion.
on 2lnc. no respiratory distress. right side decreased breath sounds at bases and crackles about mid-way. left side decreased breath sound at bases, no rales.
Exam: Regular rate and rhythm, no murmur, no lower extremity edema.
soft, some mild distension, slightly enlarged liver, nontender to palpation.
Exam: no rashes.
Exam: alert, confused, follows commands, moving all extremities.
pro-bnp: 24487, wbc 4.5, hgb 10.8, plts 188, na 131, k 4.6, co2 29, gluc 187, bun 50, cr 2.3, ca 8.7, tnI 0.176
cxr: RLL effusion, chf
Impression and Plan
Impression and Plan
Shortness of breath (ICD10-CM R06.02, Working, Medical).
1. shortness of breath with recurrent right pleural effusion
cytology was negative for malignancy
will get CT chest wo contrast
pulmonary and cardiology consults
due to worsening renal function, will hold on lasix though diuresis may improve renal function if pt in a low output state.
clinically doubt pneumonia or PE
2. acute on chronic renal failure: Cr was 1.7 on d/c. hold lasix, repeat Cr level
diuresis may improve renal function
3. chronic low bp: no ivf\’s unless symptomatic
4. anemia of chronic disease: stable
5. nonischemic cardiomyopathy: due to low blood pressure does not tolerate ACEI/ARB
6. nsvt: amiodarone 400 mg bid x 7 days (started 9/7) then 400 mg qd
7. dm2: hold glipizide. accuchecks, ssi
8. recent Citrobacter UTI: complete course of keflex. repeat UA/UC
9. DVT prophylaxis: sq heparin
10. Full Code
PLEASE ADD ALL OTHER ASSESSMENT MISSING
SOAP NOTE FORMAT