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soapnote2

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Select a patient that you examined during the last 3 weeks. With this patient in mind, address the following in a SOAP Note: Subjective: What details did the patient provide regarding his or her personal and medical history? Objective: What observations did you make during the physical assessment? Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why? Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management including alternative therapies? Reflection notes: What would you do differently in a similar patient evaluation?
SOAP Notes

Purpose: The purpose of this SOAP note is to document about the patient information in an organized sequence. A SOAP note includes subjective, objective, assessment and plan of care.

SUBJECTIVE DATA:

Chief Complaint (CC): “I was feeling dizzy when I stood up when I was drinking alcohol. I am here to find out about my lab result.”
History of Present Illness (HPI): J.G. is a 42-year-old Mexican American male with type 2 diabetes for greater than 5 years and hypertension. He was first diagnosed in 2007 after he had an acute MI status post stents. He gained weight significantly afterward. He came into the office for a routine follow-up visit. He recently gained back 3 lbs despite being on Farxiga. He currently has returned to full strength ACEi. He has a pending sleep study. He complains of dizziness when standing up while he was drinking alcohol on the weekend with friends. However, he didn’t experience dizziness while he was sitting. He states that dizziness only lasted for a few seconds and disappeared. He states that he has not experienced dizziness in the past. He denies dim or blurred vision. He denies any other symptoms associated with dizziness.

Medications:
Aspirin tablet, delayed release (DR/EC) 81 mg, 1 tablet a day: inhibit clot formation to prevent MI.
Carvedilol tablet 12.5 mg, 1 tablet twice a day: Beta blocker for HTN and HF.
Digoxin tablet 125 mcg, 1 tablet once a day: antiarrhythmic agents to treat HF and arrhythmia.
Fenofibrate tablet 160 mg, 1 tablet once a day: to decrease cholesterol and triglycerides.
Humulin R U-500 “concentrated” (insulin regular hum u-500 conc) solution, 500 unit/ml 35u QAM, 35u QPM, 30 QHS: used to control BS; used for patients requiring high doses of insulin.
Invokana (canagliflozin) tablet 100 mg, 1 tablet once a day: used for controlling BS.
Lisinopril tablet 40 mg, 1 tablet once a day: HTN, cardiomyopathy, HF, and MI.
Pantoprazole tablet, delayed release 40 mg, 1 tablet once a day: PPI to treat GERD.
Plavix (clopidogrel) tablet 75 mg, 1 tablet once a day: to prevent MI.
Simvastatin tablet 10 mg, 1 tablet at bedtime: to decrease cholesterol and triglycerides to prevent MI.
Toujeo SoloStar (insulin glargine) insulin pen 300 unit/mL (1.5 mL): long-acting insulin to control BS.
Vitamin D2 (ergocalciferol) capsule 50,000 unit, 1 capsule once a week: to treat hypocalcemia in CKD.

Allergies: Penicillin: urticarial (hives)
Past Medical History (PMH):
1. Chronic kidney disease
2. Proteinuria
3. Hypertension – year diagnosed: 08/07/2007
4. Type 2 Diabetes – year diagnosed: 08/07/2007
5. Cardiomyopathy: ischemic
6. Congestive heart failure: EF 45%
7. Myocardial infarction: 2007 with stent x 2
8. Carpal tunnel syndrome
9. Dyslipidemia
Past Surgical History (PSH):
1. Tonsillectomy (1985)
2. AICD implant (2007)
3. Appendectomy (1986)
Personal/Social History:
1. Currently unemployed – previous occupation: bartender @ nightclub in Scottsdale
2. Single, never married
3. Place of birth: Phoenix, AZ
4. Former smoker: stopped smoking in 1989. Smoked 1 ppd for 17 years
5. Occasional drinker – one or 2 times a month on the weekends: 5 to 6 beers max
6. History of cocaine and amphetamine use – currently clean
7. Does not exercise regularly
Immunizations: Up to date. TDP (2014); flu vaccine (11/2015)
Family History:
1. Father deceases: unknown per patient
2. Mother living: HTN, multiple myeloma
3. Siblings living (4): DM2, obesity
4. Grandmother: HTN, DM2, heart disease
5. Grandfather: Cancer of lungs
Review of Systems:

General: Denies fevers, chills, night sweats, or unintentional weight loss.
Skin: Denies lumps, sores, rashes, itching, or changes.
HEENT: Denies headache or syncope. C/o dizziness when standing up. Denies ringing of the ears. Denies new visual changes, blurred vision, periorbital edema, or tinnitus.
Neck: Denies neck pain or stiffness.
Breasts: N/A
Respiratory: Denies dyspnea. Denies hemoptysis. Denies coughs or wheezes. Denies history of asthma or chronic bronchitis.
Cardiovascular: Denies chest pain or chest discomfort. Denies palpitations, PND related symptoms, orthopnea, edema in extremities.
Gastrointestinal: Denies nausea, vomiting, or diarrhea. Denies any changes in appetite, difficulty chewing, or swallowing. Denies abdominal pain after meals. Reports no changes in bowel habits and denies blood in stools.
Peripheral vascular: Denies easy bruising or swelling. Denies sores or lesions that do not heal.
Urinary: Denies changes in the urine stream, gross blood in urine, pain burning, and hesitancy with urination.
Genital: N/A
Musculoskeletal: Denies myalgia or new joint effusions, muscle weakness or pain.
Psychiatric: Reports alcohol use. Denies depression or anxiety. Denies mood changes or hallucinations.
Neurological: Denies recurrent headaches, syncope, or seizures. Denies tremors. Denies numbness in extremities.
Hematologic: N/A
Endocrine: Denies polydipsia.

OBJECTIVE DATA:

T: 97.6 F (oral), BP: R 100/56, P: 68, RR: 24, Ht: 5 ft 9 in, Wt: 365 lbs, BMI: 52.5
Manual BP standing: R 94/60, L 90/60, BP sitting: R 100/56, L 98/60
General: J.G is morbidly obese, well-mannered, and well-groomed Mexican American male who is alert and cooperative. Affect and response to questions are appropriate. Appears as stated age.
SKIN: No rashes, lesions, or petechiae. Skin dry and intact.
HEENT: Head normocephalic. PERRLA. Bilateral nares patent without polyps. Oropharynx without erythema or exudate.
Neck: Supple. No masses. Trachea midline.
Chest/Lungs: Chest wall expansion symmetrical bilaterally; BS clear to auscultation in all lung fields; No SOB.
Heart/Peripheral Vascular: HR regular with S1, S2. No gallops, murmurs, or rubs. No peripheral edema. L sided AICD.
Abdomen: Bowl sounds normoactive in all 4 quadrants. Soft, non-tender, no distention, and no masses.
Genital: N/A
Musculoskeletal: Full ROM. No joint effusion.
Neurological: Alert & oriented X3. Normal speech. No asterixis. DTR’s +2 bilaterally. CNII – XII intact.
Labs: BUN 22 mg/dL (03/11/2016), Protein/Creat Ratio 116 mg/g creat (03/11/2016), Serum creatinine 2.03 (03/11/2016), Serum creatinine 1.19 (09/03/2015), Serum creatinine 1.27 mg/dL (12/28/2015).

ASSESSMENT:

1. Orthostatic hypotension (likely ACEi induced)
Orthostatic hypotension (OH) occurs when systolic blood pressure (SBP) drops at least 20 mm Hg or diastolic blood pressure of 10 mm Hg within a few minutes of standing; however, a reduction in SBP of 30 mm Hg is indicative of OH in patients with hypertension due to the differences in the baseline BP (Shibao, Lipsitz, & Biaggioni, 2013). Clinical presentations of OH include an occurrence of dizziness after standing within a few seconds, blurred vision, fatigue, and a dull pain in the shoulder or back of the neck (Shibao et al., 2013). J.G. did not report any other symptoms other than dizziness when standing. Although physical examination did not show OH, syncope and falls are risk factors if dizziness occurs again. Another concern is that J.G. has a history of heart failure and MI. Reports from multiple studies indicated that heart failure and coronary artery disease are associated with OH (Shibao et al., 2013). J.G. is currently on multiple hypertension medications. Hypertension medications such as ACE inhibitors and ARBs can cause postural hypotension (Westaway et al., 2015). BP is controlled too well in the case and may need to re-evaluate his medications.

Differential DX:
Atrial fibrillation (AF): AF can be asymptomatic, but a large percentage of patients have symptoms such as dyspnea, dizziness, and fatigue (Lowres, Neubeck, Redfern, & Freedman, 2013). AF is considered as differential diagnosis due to the patient’s history of cardiovascular disease and MI. Individuals who are diagnosed with AF are at higher risk of stroke and MI due to asymptomatic periods; therefore, early diagnosis is essential and recommended by ESC guidelines (Lowres et al., 2013).
Dehydration: Dehydration can cause dizziness as well as reduced blood flow to the kidneys and liver which can be induced by hypertension medications (Lowres et al., 2013). Also, the patient reported dizziness while he was drinking alcohol and excess consumption of alcohol can cause dehydration.
Hypoglycemia: The patient has type 2 diabetes and currently on multiple antihyperglycemic agents. Hypoglycemia is often caused by insulin or other agents used to treat diabetes mellitus; the condition is confirmed by symptoms of hypoglycemia, a plasma glucose level is less than 55 mg/dl and symptom resolution post raising plasma glucose level (Martens, 2014). The patient complained of dizziness, and dizziness or lightheadedness can be one of the symptoms of hypoglycemia.

2. Acute kidney injury (AKI) on Chronic kidney disease (CKD)
Although AKI and CKD were considered separate issues with different approaches to clinical studies in the past decade, recent studies revealed close interconnection between AKI and CKD where AKI is a risk factor for the CKD development and CKD is a risk factor for AKI (Chawla, Eggers, Star, & Kimmel, 2014). The patient has CKD, and the recent lab showed decreased kidney function with increased protein and creatinine ratio. Side effects and susceptibility to antihypertensive medications including ACE inhibitors are the mechanisms by which the decreases follow (Chawla et al., 2014). Renal hypoperfusion can be suspected due to hypotension and CHF. According to Harty (2014), the causes of hypoperfusion include CHF, antihypertensives, and renal artery stenosis.

Differential DX:
Acute tubular necrosis (ATN): ATN is considered the most common cause of AKI, which is a result from pathophysiological alteration including renal ischemia, shock, dehydration, polypharmacy, toxicity from drugs, and pigment injury due to myoglobin (Lameire et al., 2013). Sudden increase in BUN and creatinine and decreased glomerular filtration rate (GFR) are features of ATN.
Diabetic nephropathy: Clinical features of diabetic nephropathy (DN) include proteinuria with a slow and progressive decline in GFR, and the diagnosis of DN will depend on microalbuminuria detection of albumin excretion of greater than 30 mg/g within six months (Gonzalez-Suarez, Thomas, Barisoni, & Fornoni, 2013). The patient has diabetes and CKD, and routine screening for DN is essential.
Multiple myeloma: Clinical hallmark of multiple myelomas include elevation of calcium, kidney insufficiency, anemia, and bone disease; multiple genes are involved in the malignant plasma cell development (Mikhael et al., 2013). Multiple myeloma is added to differential diagnosis due to the family history of the disease although the patient did not have elevated calcium or known bone disorder.
PLAN:

1. Renal ultrasound: Renal ultrasound is a useful diagnostic tool that helps detect renal perfusion; structural damage can also be detected (Lameire et al., 2013).
2. Serum protein electrophoresis (SPEP): SPEP is used to measure specific proteins in the blood; elevation of a specific protein can indicate different conditions such as multiple myeloma, a certain type of malignancies, and autoimmune diseases (Lameire et al., 2013).
3. Consider holding Lisinopril if orthostasis continues.
4. 24 hour BP monitoring.
5. Alcohol usage: information is provided regarding alcohol usage concerning to his disease process. Will be reinforced at next appointment.
6. Discussed bariatric surgery option.
Health Promotion:
1. Encourage exercise times a week.
2. Decrease carbohydrate intake to prevent postprandial hypotension.
3. Keep a log of BP and BS readings.
4. Discontinue alcohol intake.
5. Increase hydration.
6. Encourage weight loss.
Disease Prevention:
1. Return to clinic in one week to discuss diagnostic testing result and possible changes in current drug regimen.
2. Return to clinic in 3 months for follow-up appointment or as needed.
REFLECTION:
References

Chawla, L. S., Eggers, P. W., Star, R. A., & Kimmel, P. L. (2014). Acute kidney injury and chronic kidney disease as interconnected syndromes. The New England Journal of Medicine, 371(1), 58-66.

Gonzalez-Suarez, M. L., Thomas, D. B., Barisoni, L., & Fornoni, A. (2013). Diabetic nephropathy: is it time yet for routine kidney biopsy? World Journal of Diabetes, 4(6), 245-255. doi:10.4239/wjd.v4.i6.245

Harty, J. (2014). Prevention and Management of Acute Kidney Injury. The Ulster Medical Journal, 83(3), 149–157.

Lameire, N. H., Bagga, A., Cruz, D., De Maeseneer, J., Endre, Z., Kellum, J. A., … Vanholder, R. (2013). Acute kidney injury: an increasing global concern. The Lancet, 382(9887), 13-19. doi:10.1016/S0140-6736(13)60647-9

Martens, P. (2014). Approach to the patient with spontaneous hypoglycemia. European Journal of Internal Medicine, 25(5), 415-421. doi:10.1016/j.ejim.2014.02.011

Mikhael, J. R., Dingli, D., Roy, V., Reeder, C. B., Buadi, F. K. Hayman, S. R.,… Lacy, M. Q. (2013). Management of newly diagnosed symptomatic multiple myeloma: updated Mayo Stratification of Myeloma and Risk-adapted Therapy (mSMART) consensus guidelines 2013. Mayo Clinic Proceedings, 88(4), 360-376. doi: http://dx.doi.org/10.1016/j.mayocp.2013.01.019

Lowres, N., Neubeck, L., Redfern, J., & Freedman, S. B. (2013). Screening to identify unknown atrial fibrillation; a systematic review. Thrombosis and Haemostasis, 110, 213-222. doi:10.1160/TH13-02-0165

Shibao, C., Lipsitz, L. A., & Biaggioni, I. (2013). Evaluation and treatment of orthostatic hypotension. Journal of the American Society of Hypertension, 7(4), 317-324. doi:10.1016/j.jash.2013.04.006

Westaway, K., Frank, O., Husband, A., McClure, A., Shute, R., Edwards, S., Curtis, J. & Rowett, D. (2015). Medicines can affect thermoregulation and accentuate the risk of dehydration and heat-related illness during hot weather. Journal of Clinical Pharmacy and Therapeutics, 40: 363–367. doi: 10.1111/jcpt.12294

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