Lab #9 Take home SOAP Case

Chief Complaint
Im here to see my new doctor for a checkup
HPI
Patricia Smith is a 61-year-old African-American female who presents to her new family medicine physician
for evaluation and follow-up of her medical problems. She was put on the DASH diet by her last physician
because of some high blood pressure readings before.
PMH
Insulin lispro 14 units subcutaneously TID with
Type 2 diabetes mellitus 4 years
meals
Chronic obstructive pulmonary disease (COPD),
Albuterol HFA MDI, two inhalations Q 46 h PRN
GOLD 3/Group C X 5 years
SOB
FH
Fluticasone/salmeterol DPI 250/50, one
Father died of colon cancer at age 73. Mother
inhalation BID
died of lung cancer at age 65. Father had HTN
and dyslipidemia. Mother had HTN and diabetes
All: Losartan (angioedema)
mellitus.
SH
ROS
Former smoker (quit 6 years ago; 25 pack-year
She complains of occasional headaches, which
history); reports moderate amount of alcohol
she uses Tylenol for and she denies blurred
intake She does not exercise regularly and is
vision and chest pain. She states that shortness
limited somewhat functionally by her COPD. She
of breath is usual for her, and that her
is retired and lives alone.
albuterol helps. She denies experiencing any
hemoptysis or epistaxis; she also denies nausea,
vomiting, abdominal pain, cramping, diarrhea,
constipation, or blood in stool. She denies
urinary frequency. She has no prior history of
Meds
arthritis.
Insulin glargine 16 units subcutaneously daily
Physical
Examination_______________________________________________________________________________________
Gen
WDWN, African-American female; moderately
overweight; in no acute distress
Lungs
VS
Lung fields CTA bilaterally. Few basilar crackles,
BP 169/94 mm Hg (sitting; repeat 167/92 mm
mild expiratory wheezing.
Hg), HR 70 bpm (regular), RR 17/min, T 37C; Wt
Heart
91 kg, Ht 61
RRR; normal S1 and S2. No S3 or S4.
HEENT
Abd
TMs clear; AV nicking noted; no hemorrhages,
Soft, NTND; no masses, bruits, or organomegaly.
exudates, or papilledema
Normal BS.
Neck
Genit/Rect
Supple without masses or bruits, no thyroid
Deferred
enlargement or lymphadenopathy
Ext
ECG
No CCE; no apparent joint swelling
Normal sinus rhythm
Neuro
No gross motor-sensory deficits present. CN IIXII
intact. A & O 3.

Labs
Na 141 mEq/L
Ca 9.7 mg/dL
Fasting lipid panel Spirometry (6 months
K 3.7 mEq/L
Mg 1.8 mEq/L
Total Chol 197 mg/dL ago)
Cl 97 mEq/L
A1C 7.4%
LDL 112 mg/dL
FVC 2.38 L (54% pred)
CO2 28 mEq/L
Alb 3.9 g/dL
HDL 23 mg/dL
FEV1 1.21 (38% pred)
BUN 24 mg/dL
Hgb 15.8 g/dL
TG 200 mg/dL
FEV1/FVC 51%
SCr 1.5 mg/dL
Hct 46%
Glucose 110 mg/dL
WBC 8.0 103/mm3
Uric acid 3.7 mg/dL
Plts 214 103/mm3
UA
Yellow, clear, SG 1.014, pH 5.2, (-) protein, () glucose, () ketones, () bilirubin, () blood, () nitrite,
RBC 0/hpf, WBC 12/hpf, neg bacteria, 15 epithelial cells, (-) leukocyte esterase
A: Pt is hypertensive per JNC7 guidelines, since BP is 169/94 and goal for an adult with prior diagnosis of
diabetes and without chronic kidney disease is less than 140/90. Diagnosis of uncontrolled hypertension is
also supported by presence of AV nicking. Pt is also moderately overweight, has a moderate intake of
alcohol and does not exercise due to her COPD. JNC7 guidelines state patient is recommended to begin
drug therapy with a thiazide-type diuretic as well as a CCB, as her race and diabetic status place her under
Recommendation 7.
P:
Drug/Non-drug:
Discontinue losartan, as it is not first-line treatment according to these guidelines.
Begin therapy of HCTZ 12.5 mg orally once a day as well as amlodipine 2.5 mg orally once a day.
Increase dosage to 25 mg HCTZ and 5 mg amlodipine after 2 weeks if target BP goal of 140/90
has not been met.
Readjust dose as necessary every 1-2 weeks if goal is not met. Maximum dosage threshold for
HCTZ is 50 mg HCTZ once a day orally and 10 mg amlodipine once a day orally. If goal is still not
met after maximum threshold has been reached, consider adding lisinopril 10 mg orally once a
day to the regimen and increase to maximum of 40 mg orally once a day if target is still not met.
Continue DASH diet as directed by physician.
Limit alcohol consumption to no more than 12 oz beer a day or an equivalent amount. Eliminate
alcohol consumption altogether if possible.
Consider a diet with the goal of losing weight. Ideal weight range for female of this height is
around 170 pounds, necessitating a 15% loss in weight from current 200 pounds. Limiting caloric
consumption to around 1600 calories a day given current activity level is advised, along with a
healthy, balanced, low-sodium and low-sugar diet.
Monitoring:
Return in 1-2 weeks for reevaluation of BP reduction goals and to readjust dosage or addition of a
third medication as needed.
Monitor K+ levels and maintain within normal range to determine safety and efficacy of thiazide
diuretic.
Monitor blood glucose levels and watch for renal or cardiovascular abnormalities associated with
hypertension secondary to diabetes.
Pt Education:
Advise pt on how to monitor blood pressure at home and keeping a regular log of blood pressure
readings throughout the day.
Do not eat grapefruit while taking amlodipine.
Inform pt of side effects of medications and to watch for postural hypotension as she lives alone
and a fall or fainting could be dangerous.
Follow-up:
Return in 1-2 weeks to reassess efficacy of drug and non-drug therapy.

Reinforce non-drug therapy as necessary and increase dosage of medications to maximum

efficacious thresholds if goal of 140/90 or less is not met.