Question:

Case Information:
CC/HPI
KJ is a 60 yowf who presents to your clinic with complaints of a persistent headache. She had
been diagnosed with HTN 2 years ago and was prescribed azilsartan (Edarbi®) 40mg daily, but
admits that she never took the medication because she could not afford it. She never followed
back up for another prescription.
Medications: none
Allergies: NKDA
PMH: hypertension
SH: 2 packs per day smoker for 40 years
FH: father died of MI at age 45, mother alive with diabetes and hypertension
Physical Exam
GEN: well nourished, obese female
VS: HR 85, RR 12, BP 190/96, T 98.6, Wt 220lb, Ht 5’5”
HEENT: PERRLA
COR: RRR, NMRG
CHEST: CTA
EXT: normal
NEURO: normal
Laboratory: WNL except as noted below
Total Cholesterol 240 mg/dL
LDL 180 mg/dL
HDL 30 mg/dL
Triglycerides 150 mg/dL
Important considerations for creating a SOAP note:

  1. What problems can you identify with this patient?
  2. What subjective/objective information in the case supports each of those problems?
    Please list only information that pertains to each problem under each problem.
  3. What is your assessment and plan for each problem? Provide pharmacological and nonpharmacological care (don’t forget to be specific). Will you discontinue any medication
    that the patient is currently taking and/or add any new medications?
    a. Include your therapeutic goals for each problem (use the subjective and objective
    information listed above to help you as well as guidelines discussed in text or
    supplemental information).
    b. How will you monitor each problem and each medication included in your plan?
    c. When will you suggest following up with the patient?
    d. Is there any laboratory monitoring that will need to be conducted to assure the
    safety of the patient?

Answer: A SOAP note contains the concerns of the patient, the observations of the nurse in the patient…….

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