Week 3: Focused SOAP Note Essay  

Week 3: Focused SOAP Note Essay

Week 3: Focused SOAP Note Essay

Assessment Description
Using the condition you posted about in DQ 1 this week, provide a SOAP note using the format outlined below. Support your summary and recommendations plan with a minimum of two APRN-approved scholarly resources. You may not select a condition or disorder that has already been profiled by another learner; you must select a different one.

Subjective

CC (Chief complaint)
HPT (History of present illness)
History (Pertinent medical, surgical, social, medications, exposure, family history, allergies, vaccines)
ROS (Review of systems)
Objective

Vital signs/BMI
Physical exam findings
Diagnostic results (include actual “results” or “findings” that you would expect for a certain scenario)
Assessment/Plan

Differential list and rationale for final/working diagnosis
Problem list
Plan for Each Problem

Based on evidence with proper references
Further diagnostic testing you would order
Nonpharmacologic therapy
Pharmacologic therapy, including specific medication dose
Frequency and duration of therapy
Patient education
Follow-up

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Subjective

Patient:  Initials: P.M  

Age: 78 years

Sex- Male

Chief Complaint: “Calf pain.”

History of Present Illness:  P.M is a 78-year-old white male who presents with a chief complaint of calf pain in both lower legs. He says that the calf pain began about four months ago. It started as a mild discomfort but has progressed over time. The patient states that he initially thought the calf discomfort was due to aging, but he is now bothered that it could be worse, like DVT. He describes the calf pain as cramping, non-radiating pain. Associated symptoms include leg weakness, fatigue, and some degree of pressure. The calf pain is aggravated by walking and alleviated by rest. The patient reports taking OTC Tylenol and using warm compressions to relieve the pain, but they were ineffective. He rates the pain at 4/10.

Past Medical History: Medical history of Type 2 Diabetes- diagnosed at 44 years.

                                    History for hypertension (controlled for 4 years) diagnosed at 46 years.

                                    Hyperlipidemia- diagnosed at 40 years.

                                    Obesity from the mid-30s.

Past Surgical History:  Cataract surgery at 65 years.

Medications:  Enalapril 20 mg OD; Verapamil 80 mg PO twice daily; Metformin 850 mg OD; Atorvastatin 40 mg OD.

Allergies: No drug, food, or environmental allergies.

Immunizations:  Fully vaccinated against COVID. Last TT shot-8 years ago. The last influenza shot was a year ago.

Family History:  The patient’s father had HTN and died at 83 years from stroke. The mother had Alzheimer’s and diabetes and died from renal failure at 84 years. The elder brother (80 years) has HTN. His younger brother (74 years) has COPD. Children are alive and well.

Social History/Risk Factors:  P.M is married and lives with his wife at his ranch in Sheridan County, NE. He has four children, 53, 50, 47, and 45 years. He is a retired banker and currently manages his ranch with his wife. He states that the ranch makes him enough income to sustain his family and pay his workers. He admits to alcohol consumption and tobacco smoking but says he has been trying to quit following medical advice. He takes 3-4 beers three days a week and smokes about four cigars per day. However, he denies using illicit substances. He denies experiencing elder abuse. His hobbies include reading magazines and playing chess.

Review of Systems:

General: Negative for weight changes, appetite changes, fever, chills, or generalized fatigue/body weakness.

 

Head: Negative for headache, dizziness, or sinus pain/pressure.

 

Eyes: Negative for visual changes, blurred/ double vision, floaters, eye redness, eye drainage, or teary eyes. Last eye exam: 9 months ago.

 

Ears: Negative for changes or difficulty in hearing, ear pain, or drainage.

 

Nose: Negative for difficulty smelling, rhinorrhea, nasal congestion, or epistaxis.

 

Mouth/Throat: Negative for swallowing problems, difficulty eating/chewing foods, mouth sores or lesions, or sore throat. Last dental exam- 1 year ago.

 

Neck: Denies neck stiffness, pain, or reflux.

 

Respiratory: Negative for difficulty breathing, dyspnea, cough, sputum, or wheezing.

 

Cardiovascular: Negative for chest pain, palpitations, fluttering, or dyspnea with exertion.

 

GI: Negative for nausea/vomiting, heartburn, acid reflux, abdominal pain, pain with defecation, hemorrhoids, rectal bleeding, constipation, or diarrhea.

 

GU: Negative for urinary difficulties, painful urination, frequency, or urgency.

 

 

Musculoskeletal: Positive for painful bilateral legs at the calf muscles, limitations in movement, bilateral leg fatigue, weakness, and pressure. Negative for joint pain or stiffness, problems with a range of motion, or backache.

 

Neurological: Negative for muscle weakness, dizziness, unsteady gait, memory changes, or mood changes.

 

Psychiatric: Negative for depression, anxiety, sleep disturbances, suicidal ideations/ attempts.

 

Skin: Negative for skin color changes, rashes, or lesions.

 

Endocrine: Negative for weight loss/ weight gain, excessive lacrimation, hair thinning/loss, heat or cold intolerance, excessive thirst, or hunger.

 

Hem/Lymph: Negative for bruising, excessive healing time, or anemia.

Objective

Vital Signs: Temp-98.4; BP- 138/88; HR-84; RR-20; SPO2-98%

Height- 5’5 Weight- 198, BMI-32.9.

General: White male in his late 70s. He is neat and appropriately dressed for the weather and function. The patient is alert, in no distress, and maintains adequate eye contact. He is oriented to person, place, and time. His thought process is logical and goal-oriented, and his speech is clear.

HEENT:  Head is symmetrical and normocephalic. Eyes: Conjunctiva is pink; Sclera is white; PERRLA. Ears: TMs are shiny and intact bilaterally; Minimal pus was noted on both ears. Nose: Pink nasal mucosa; Nasal septum well-aligned. Throat: Pink and wet mucous membranes; Tonsillar is non-inflamed and non-erythematous.    

Neck: Symmetrical, trachea is midline, and the thyroid gland is normal on palpation.

Lymph Nodes: Non-palpable lymph nodes.

Respiratory:  Smooth respiratory movements with no use of accessory muscles. The chest is clear on auscultation.

Cardiovascular:  No edema or jugular vein distension. Regular heart rate and rhythm. S1 and S2 are present. No systolic murmurs.

GI: Normoactive BS in all quadrants. No organomegaly, abdominal masses, guarding, or tenderness on percussion and palpation.

Back: Spine is well-aligned.

Musculoskeletal: Pain on palpation of the calf muscle bilaterally. Diminished popliteal pulses bilaterally. ROM-5/5.

Neurological:  Muscle strength 5/5. CNs are intact.

Skin:  Fair skin with wrinkles on the hands, necks, and face. Slightly delayed skin turgor.

Psychiatric (affect, mood): The self-reported is happy, and affect is appropriate.

Diagnostic Results: Resting Ankle-brachial index (ABI) – 0.6.       

 

Assessment

Peripheral Arterial Disease (PAD) (I73. 9):  PAD is a progressive disorder that manifests with stenosis or occlusion of large and medium-sized arteries other than those supplying the heart or the brain. It occurs in the lower extremities more commonly than in the upper extremity (Lecouturier et al., 2019). It causes recurrent leg fatigue, cramping sensation, and leg pain triggered by walking and alleviated by rest. Individuals with diabetes have 2–4 times the risk of developing PAD, while smokers have 2.5 times (Shu & Santulli, 2018).  

Physical exam findings include loss or diminished lower extremity pulses, pain on palpation, pallor, cool and cyanotic skin, muscle atrophy, and presence of bruit. In addition, patients with claudication have an ABI of 0.5-0.9 (Shu & Santulli, 2018). PAD is the presumptive diagnosis based on pertinent positive symptoms of bilateral calf cramping pain aggravated by walking and alleviated by rest, leg weakness, fatigue, and pressure. In addition, physical findings of pain on palpation of the calf muscle diminished popliteal pulses and ABI of 0.6 points to PAD.

Deep vein thrombosis (DVT) (I82. 409): DVT is a sign of venous thromboembolism. It is characterized by unilateral edema, leg pain, tenderness, and warmth or erythema of the skin over the area of thrombosis. Physical exam findings often present in DVT include calf pain on dorsiflexion of the foot, different discoloration of the lower limb, and blanched leg appearance due to edema (Rodríguez, 2020). DVT is a differential diagnosis based on pertinent positive findings of calf pain and pain on palpation. However, it is an unlikely primary diagnosis due to the absence of leg edema, which is the most specific symptom of DVT. Besides, the patient’s symptoms are bilateral, while DVT symptoms are usually unilateral (Rodríguez, 2020).

Sciatica (M54.30): Sciatica is characterized by leg pain localized in the distribution of one or more lumbosacral nerve roots, mostly L4-S2. It may or may not have neurological deficits (Davis et al., 2022). Patients experience pain in the lumbar spine, which is almost always unilateral. Besides, they report pain or a burning sensation deep in the buttocks and often complain of paresthesia accompanying the pain. Sciatica is a differential diagnosis based on the patient’s symptom of leg pain. However, bilateral leg pain, lack of paresthesia, and abnormal ABI rule out Sciatica as a primary diagnosis (Davis et al., 2022).

Plan

Further Diagnostic Tests: Duplex ultrasound will be requested to diagnose the anatomic location and stenosis severity (Shu & Santulli, 2018). It is indicated in patients with symptomatic PAD in whom revascularization is considered.

Pharmacological Treatment:

Cilostazol 100 mg PO BD. Take 30 minutes before or 2 hours after meals.

Treatment for claudication entails using cilostazol, which promotes vasodilation and prevents the proliferation of vascular smooth muscle cells (Firnhaber & Powell, 2019).

Continue the following treatments:

1. Enalapril 20 mg OD
2. Verapamil 80 mg PO twice daily

• Metformin 850 mg OD

1. Atorvastatin 40 mg OD.

Non-pharmacological Therapy: Exercise therapy will be recommended to improve the patient’s walking ability. It will involve the patient walking until he reaches pain tolerance, stopping for a short rest, and walking again when the pain alleviates (Firnhaber & Powell, 2019). The walking sessions will last 30 to 45 minutes, 3 to 4 days per week for at least 12 weeks.

Patient Education:  Patient education will focus on measures that will help control diabetes, blood pressure, and cholesterol levels, promote weight loss and lower cardiovascular risk profile. The patient will be educated on smoking cessation to lower blood pressure and prevent diabetes macrovascular complications like neuropathy and diabetic foot ulcers (Firnhaber & Powell, 2019). He will also be educated on limiting alcohol consumption to lower BP and cholesterol levels.

Referrals/Consultations: Consultation with a vascular surgeon

Follow-Up: The patient will be followed up after four weeks to assess response to medication and exercise therapy.

References

Davis, D., Maini, K., & Vasudevan, A. (2022). Sciatica. In StatPearls. StatPearls Publishing.

Firnhaber, J. M., & Powell, C. S. (2019). Lower Extremity Peripheral Artery Disease: Diagnosis and Treatment. American family physician, 99(6), 362–369.

Lecouturier, J., Scott, J., Rousseau, N., Stansby, G., Sims, A., & Allen, J. (2019). Peripheral arterial disease diagnosis and management in primary care: a qualitative study. BJGP Open, 3(3), bjgpopen19X101659. https://doi.org/10.3399/bjgpopen19X101659

Rodríguez, F. M. (2020). Diagnosis of deep vein thrombosis. Diagnóstico de la trombosis venosa profunda. Revista clinica espanola, S0014-2565(20)30132-6. Advance online publication. https://doi.org/10.1016/j.rce.2020.03.009

Shu, J., & Santulli, G. (2018). Update on peripheral artery disease: Epidemiology and evidence-based facts. Atherosclerosis, 275, 379–381. https://doi.org/10.1016/j.atherosclerosis.2018.05.033