Soap_Note

Patient: Zelda N. Milkyway MRN: 56781234 DOB: 2/12/45 Date: September 3, 2010 PCP: Dr. Casey Starburst, Family Medicine Group ZM is a 65 year old CF who presents to the Family Medicine office with c/c of always having a headache after taking HCTZ. Last visit was 3 months ago for elevated BP in which she started HCTZ 25 mg daily. She states she is compliant with all of her medications (except for 1-2x per week she skips HCTZ). HPI: Her headaches are happening daily and she rates her pain 5-6 out of 10; which she describes as dull, constant pain. ZM never had headaches until starting HCTZ therapy, on days where she does not take HCTZ she experiences no headaches. PMHx: Depression x 30 yrs, HTN x 3 months SHx: Diet: she states she has been trying to avoid salt most days of the week Exercise: she states she walks 2-3 times/week on a treadmill EtOH- neg, Tob- pos 1ppd, no illicit drug use FHx: Mother: ↓colon cancer, DM 2, HTN Father: ↓ HTN, hypothyroid 2 sons: ↑↑ healthy ROS: HTN: headache with HCTZ use, some dizziness in the afternoon in which she need to lay down when this happens. She has not D/C’d HCTZ use Depression: states she feels depressed moods about 3-4x/week and improves when she gets to play with her grandchildren. She regularly takes lexapro daily, currently following with a psychiatrist. Vitals: BP 138/86 (last visit 156/92), P 86, RR 18, temp 98.6 Height: 5’5”; weight: 160 lbs (last visit 166 lbs); BMI 26.6 Labs: FLP: TC 207 TG 187 HDL 50 LDL 120 (7/10) BMP: Na 136 Cl 99 BUN 15 Gluc 92 K 5 CO2 25 SrCr 0.8 Microalbumin: not collected , Hgb 10.1 Hct 31 WBC 5.4 Plt 206 PE: Gen: no acute distress, well nourished, well developed. Neuro: She is alert and oriented to person, place and thing; and cranial and nerve function are intact. HEENT: Clear to auscultation and percussion Heart: no murmurs, rubs or gallops Lungs: clear to auscultation, equally bilateral, no CVA tenderness GI: bowel sounds present, no RUQ tenderness Extremities: no edema, clubbing, or cyanosis, Skin is smooth and dry with no visible lesions. Pelvic and rectal: deferred Allergies: NKDA Immunizations: Flu: NO Pneumo: Refused Tetanus: 2006 Zostavax: NO Medications: MVI daily lexapro 20 mg daily claritin 10 mg daily PRN HCTZ 25 mg qam ASA 81 mg qhs OTC and herbals: none SOAP note for ZM S: ZM is a 65 year old Caucasian Female with Depression and hypertension, who presents today with a complaint always having a headache after taking HCTZ. Her headaches are happening daily and she rates her pain 5-6 out of 10; which she describes as dull, constant pain. Her headaches started after starting the HCTZ therapy. The headaches are not noticeable on days she misses the HCTZ. Her last physician visit was 3 months ago for elevated BP and HCTZ 25 mg daily was started. She is adherent with all of her medications, but occasionally misses HCTZ 1-2x/week. Her diet consists of a low salt diet most days of the week and she exercises 2-3 times/week on a treadmill. She denies alcohol and illicit drug use, but smokes one PPD of tobacco. Her family history includes the passing of her mother (colon cancer, DM, HTN) and father (HTN and hypothyroid). Her two sons are will. She states adherence with her lexapro and claritin as directed. O: Upon focused review of systems she notes occasional dizziness in the afternoon that causes her to lay down. She notes depressed moods 3-4x/week, but not over the last 3 weeks when her grandkids were around. Vitals: BP 138/86 (last visit 156/92), P 86, RR 18, temp 98.6 Height: 5’5”; weight: 160 lbs (last visit 166 lbs); BMI 26.6 Labs: FLP: TC 207 TG 187 HDL 50 LDL 120 (7/10) BMP: Na 136 Cl 99 BUN 15 Gluc 92 K 5 CO2 25 SrCr 0.8 Microalbumin: not collected , Hgb 10.1 Hct 31 WBC 5.4 Plt 206 Allergies: NKDA, Immunizations: Flu: NO Pneumo: Refused Tetanus: 2006 Zostavax: NO Medications: MVI daily lexapro 20 mg daily claritin 10 mg daily PRN HCTZ 25 mg qam ASA 81 mg qhs PE: Gen: no acute distress, well nourished, well developed. Neuro: She is alert and oriented to person, place and thing; and cranial and nerve function are intact. HEENT: Clear to auscultation and percussion Heart: no murmurs, rubs or gallops Lungs: clear to auscultation, equally bilateral, no CVA tenderness GI: bowel sounds present, some RUQ tenderness Extremities: no edema, clubbing, or cyanosis, Skin is smooth and dry with no visible lesions. Pelvic and rectal: deferred A/P: Problem #1:Headache Goal: resolution of daily headache Uncontrolled, moderately painful headache likely due to HCTZ therapy. No headaches on HCTZ drug-free days. Stop the HCTZ today. Educated patient on how soon the headaches should resolve. Monitor for worse headache ever felt or other changes in quality or severity of her headache. Follow up with PCP in 3 weeks. Problem #2: HTN Goal: < 140/90 HTN is controlled today. Non-adherence appears to be an issue with HCTZ therapy due to ADR. Last BP was elevated and she will need another BP agent. D/C HCTZ. There is no compelling indication in this patient (JNCVII Guidelines) so we will start Lisinopril 10mg Daily. Educated patient on new medication and to watch for dry cough. Monitor K/Sc in 3-4 weeks along with BP. Follow up in 4 weeks. Problem #3: Depression Goal: decrease frequency of down days Depression is well controlled today. This has been an issue in the past. Likely improvement is due to increased socialization. No change in her meds. Educated patient to continue to plan family activities. Referred patient back to her psychiatrist with any changes in her control. Problem #4: Tobacco Goal: Cessation Patient not willing to quit at this time. Follow up in future visits.