SOAP Notes 2

Sample Answer

Reason for Seeking Health Care

• Sudden onset of weakness in the right arm and slurred speech, which lasted more than half an hour.

HPI

T.R is a sixty-five-year-old Caucasian male patient who came to the facility with reports of a sudden onset of weakness in his right arm and slurred speech. The patient indicates that the reported symptoms lasted for approximately more than half an hour. His partner, who accompanied him, reported that the symptoms commenced suddenly when they were resting on their balcony at home. Both the weakness in the right arm and the speech resolved within an hour. They also reported that the patient did not report any walking difficulty, visual changes, headache, or loss of consciousness.

Allergies(Drug/Food/Latex/Environmental/Herbal)

• The patient reports no known allergies

Current perception of Health

• Good

Past Medical History

Major/Chronic Illnesses

• The patient has a history of hyperlipidemia and hypertension

Trauma/Injury

• No past trauma or injuries

Hospitalizations

• The patient has been admitted three times in the past to help stabilize his BP due to hypertension. He was also admitted in his teenage for a few days after food poisoning.

Past Surgical History

• The patient underwent appendectomy at the age of 27

Medications

• Aspirin, 81 mg daily for cardiovascular prophylaxis
• Lipitor, 40 mg daily for hyperlipidemia
• Lisinopril, 20 mg daily for hypertension

Family History

The patient’s father is still alive at 91 and lives with diabetes and hypertension. The mother died at the age of 75 years of myocardial infarction, and she also had a history of hyperthyroidism. He has three siblings alive one sister, 76 old, living with diabetes, and two younger brothers, 60 and 55 years old, respectively.

Social history

• Lives: Single-family House/Condo/ with stairs single-family house with stairs.
• Marital Status: Married
• Employment Status: Retired
• Current/Previous occupation type: Engineer
• Exposure to ___Smoke (No)
• ETOH (drinks two to three times weekly)

Recreational Drug

• Use reports no recreational drug use

Sexual orientation

• Heterosexual, Sexual Activity Active, Contraception Use None

Family Composition

• Family/Mother/Father/Alone
• The patient currently lives with his wife, while two of their children are married and living in a different town

Health Maintenance

Screening Tests

• PSA (six months ago, normal), Colonoscopy (normal, eight months ago)

Exposures

• No exposures

Immunization HX

• The patient’s immunization is up to date.

Review of Systems

General

• The patient reports no fatigue, fever, or intentional weight loss

HEENT

• No headaches, vision changes, eye discharge, eye pain or hearing loss

Neck

• No neck stiffness or neck pain

Lungs

• No cough, sputum, or breath shortness

Cardiovascular

• No edema, palpitations or chest pain

Breast

• No breast discharge or breast lumps

GI

• No changes in bowel behaviors, nausea, or abdominal pain.

Male/female genital

• No discharge, swelling or pain

GU

• No hematuria, frequency, or dysuria

Neuro

• The patient reports a recent episode of transient right arm weakness as well as slurred speech

Musculoskeletal

• No joint swelling or joint pain

Activity & Exercise

• The patient takes a 40-minute walk every two days

Psychosocial

• No mental health concerns, no depression or anxiety

Derm

• No lesions or rashes

Nutrition

• Reports a balanced diet with no recent changes in his diet

Sleep/Rest

• Sufficient sleep, six to eight hours every night

LMP

• N/A

STI Hx

• None

Physical Exam

• BP 154/85
• TPR 98.3
• HR 76
• RR 18
• Ht. 203 cm
• Wt. 185
• BMI (percentile) 26.5

General

The patient is well-dressed and groomed. He is also alert and oriented with no immediate concern or distress.

• HEENT Normocephalic, atraumatic, PERRLA, no visual deficits. The TMS is intact, no pharyngeal erythema
• Neck No carotid bruits. Supple
• Pulmonary Clear to auscultation bilaterally. No wheezes observed
• Cardiovascular No gallops or murmurs. Regular rhythm and rate
• Breast No discharge. No breast tenderness. No masses observed
• GI Normal bowel sounds were heard, but no hepatosplenomegaly. Soft and non-tender
• Male/female genital No swelling or masses. The external genitalia is normal
• GU Normal. No tenderness was noted.
• Neuro Normal gait, intact sensation, strength 5/5 bilaterally. Cranial nerves are intact.
• Musculoskeletal Full range of motion. No joint pain or tenderness
• Derm No itches, lesions, or rashes.
• Psychosocial The patient is in a good mood
• Misc. None

Plan

Differential Diagnoses

1. Transient Ischemic Attack
2.  Hypoglycemia
3. Stroke

Principal Diagnoses

1. Transient Ischemic attack

The patient experienced a sudden onset of slurred speech and right arm weakness, which lasted for around thirty minutes. Transient ischemic attack is known to present with these symptoms, and it is also known to resolve within a period of twenty-four hours (Amarenco, 2020). The absence of other symptoms, such as loss of consciousness, visual change, or headache, supports this diagnosis over others like seizures or migraine (Pohl et al.,2021).

Plan

Diagnosis

• Transient Ischemic Attack

Diagnostic Testing

• Blood tests (HbA1c, lipid panel, BMP, and CBC), EKG, echocardiogram, and brain MRI (Mendelson & Prabhakaran, 2021)

Pharmacological Treatment

The patient is to continue with a low dose of aspirin (81 mg daily) for cardiovascular prophylaxis, introduce Plavix (75 mg) daily to help lower the risk of stroke, and Lisinopril to be adjusted as needed to control blood pressure. The current dosage of Lipitor to be maintained

Education

It is vital to educate the patient on different health and care points. The patient and the partner should be educated on the symptoms and signs of stroke and when to seek for immediate medical intervention. There is also a need to adjust and modify the patient’s lifestyle. For example, the diet used should help reduce the risk factors. In addition, the patient needs to engage in more exercise as the current plan is insufficient.

Referrals

The patient has been referred to a cardiologist and neurologist for further cardiovascular risk assessment and urology assessment, respectively.

Follow-up

A follow-up visit has been scheduled in seven days’ time to review the test results and adjust the treatment plan as appropriate

Anticipatory Guidance

The patient has been guided to reduce alcohol consumption and eliminate it with time. The importance of adhering to the medication plan and the mentioned lifestyle changes was restated and emphasized.

2. Hypertension

The patient also presented with a blood pressure reading of 154/85, which is a sign of hypertension (Mills et al.,2020). He also has a history of hypertension, which requires ongoing treatment and management

Diagnosis

• Hypertension

Diagnostic Testing

• Appropriate and regular blood pressure monitoring

Pharmacological Treatment

The patient is to continue with the current medications. However, appropriate adjustments will be made depending on the monitoring results and the blood pressure readings

Education

The patient should restrict intake of sodium and engage in increased activity and physical exercise. The DASH diet was discussed, and the patient was educated as appropriate to consider the diet

Referrals

• No referral has been made at this point

Follow-up

A follow-up visit has been scheduled in a month’s time to discuss the progress in hypertension management and check the program of BP monitoring

Anticipatory Guidance

The patient has been educated on the symptoms of uncontrolled hypertension. The patient and partner are to monitor symptoms of uncontrolled hypertension and immediately report to the facility.

References

• Amarenco, P. (2020). Transient ischemic attack. New England Journal of Medicine, 382(20), 1933-1941. Doi 10.1056/NEJMcp1908837
• Mendelson, S. J., & Prabhakaran, S. (2021). Diagnosis and management of transient ischemic attack and acute ischemic stroke a review. Jama, 325(11), 1088-1098. Doi 10.1001/jama.2020.26867
• Mills, K. T., Stefanescu, A., & He, J. (2020). The global epidemiology of hypertension. Nature Reviews Nephrology, 16(4), 223-237. https //doi.org/10.1038/s41581-019-0244-2
• Pohl, M., Hesszenberger, D., Kapus, K., Meszaros, J., Feher, A., Varadi, I., … & Feher, G. (2021). Ischemic stroke mimics a comprehensive review. Journal of Clinical Neuroscience, 93, 174-182. https //doi.org/10.1016/j.jocn.2021.09.025