solved

Patient Clinical Case :
Jane is a 56-year-old caucasian woman who has not seen her primary care provider for the last 9 months. She stays with her daughter and one cat and works as a waitress in a local restaurant She does a 12-hour shift. She enjoys drinking soda and chocolate ice cream She is always nervous whenever goes to see a doctor because she does not want to be told scary news about her health ‘ She smokes profusely to get off stress from her daily job. She is considering getting hormonal therapy if she is eligible
Past medical History: Obesity, HTN, postmenopausal, anxiety
Alleergies : bananas, Tegretol
Home medications : Enalapril 5 mg BID, ASA 81 mg daily, Lorazepam 1 mg
Social History: Father age 74 with cardiovascular with first MI at age 40, mother died at age 57, media history unknown, one older brother over weight with HTN and boarder line diabetes
Vitals BP = 156/86, P =76, RR= 20, Height =5’8’, BMI 31 kg/m3, Temp=98.7F
Physical Exam: Skin warm and dry to touch, PERRLA, oral mucosa clear, lymphadenopathy, RRR
Reference :
Na 135-146 142
K+ 3.5 -5 mEq/L 4.9
Cl – 95 -106 mEq/L 103
HCO3 – 21 -29 mEq/L 23
BUN 7-20 mg/dL 16
Creatine 0.6 -1.3 mg/L 0.9
Glucose 65- 99 mg/dL 120
Ca2+ 8.5 -10.5 mg/dL 8.2
A1C less than equal 6.5 % 7.5
AST 10-40 units/L 28
ALT 10 -40 units/L 34
Albumin 3.5-5g/dL 4
Phosphorus 2.3 -4.7 mg/dL 4
Magnessium2+ 1.3-2.1 mEq/L/Laboratory : ACC/AHA CV Risk Calculator is 20.2 %
WBC 4-11×103 cells/mm3 6
Hgb 13-18 g/dL 11. 6
Hct 38-50% 36
Platelets 150-450 x103 cells/mm3 160
Bands 3-5 % 4
Lymphocytes 20 -40 % 30
Neutrophils 45-73 % 50
Monocytes 2-8% 3
Eosinophils 0-5% 2
Basophils 0-1 % 1
Total Cholesterol less than 200mg/dL 240
HDL greater than 50 mg/dL 47
LDL less than 100 mg/dL 198
TG less than 150 mg/dL
Question: Write a SOAP Note on the above which includes:
Chief Complaint:
Subjective :
Objective :
Current Medications :
Assessment of Patient :
In the order of urgency/importance, evaluate the disease state(s), considering patient-specific risk factors and etiology :
Evaluate the appropriateness of current medications and the need for additional treatment, considering patient-specific factors :
Plan
Recommendations
Goals
Monitoring & Follow up
-Efficacy
– Toxicity
Relevant Drug interactions with other drugs, food, labs for each recommended drug
Patient Education :

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