Instructions: Please create a case study based on the template attached and as good as the paper attached for the following patient. Please, please reword and use plenty of in text citations. Thank you.A 53 year old African American man is in for follow up of his elevated blood pressure. He was seen last week in your office for a Department of Transportation commercial driver’s examination where his blood pressure was 176/92. Subjective questioning is negative. BP today is 174/94.His physical exam is remarkable for a loud S2, sustained PMI at 5icslmcl, an S4 gallop is present. The remainder of his physical exam is unremarkable.Family history is remarkable for high blood pressure.Self describes his lifestyle as pretty sedentary due to driving long hours every day. Diet is often fast food with many cups of coffee.EKG – NSR with LVH by voltageCBC – normalCBP – normal except for glucose 154 (fasting). Fingerstick last week was 152A1C – 7.81.List 5 subjective questions it would be very important to know about this patient.2.Explain the significance of the loud S2 finding.3.What does the finding of his PMI indicate?4.Explain the significance of the PMI in the normal location.5.Explain the significance of the S4 finding.6.Explain the finding of LVH given his current circumstances.7.What additional diagnostics or testing (if any) you would like to order?8.What are the top two diagnoses you are going to address at this time?9.What is your pharmacologic plan for this man? Why did you choose the agent you did? Be sure to state your rationale and references.10.Identify 5 lifestyle modifications to improve his health that he could implement in his current situation.
Running head: RUNNING HEAD HERE
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DIRECTIONS: Use this template to write your SOAP notes. Edit the running head and note
instructions and insert the information for your project.
Typing Template for SOAP notes: A Sample for NU664B and NU665B
Student A. Sample
Regis College: NU664 / NU665
Date
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General
Chief Complaint:
Source & Reliability of History:
HPI:
O
L
D
C
A
A
R
T
PMH: remember LMP for women of childbearing age
PSH:
Social:
Family History:
Medications:
Allergies:
Subjective
2
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Go system by system head to toe. What do you need to know about this person to try to figure
out what’s going on with them and how to treat them? Remember to include general info such as
sick contacts and fevers.
Recall what patient statements go with subjective data- Can you insert, “Patient states or patient
denies” in front of the statement? Remember to FOCUS your assessment for the chief complaint
if you are doing a focused visit.
General
HEENT
Resp
Card
Etc.
Objective
Recall what is included in objective information. Keep your physical exam organized system by
system in a head to toe fashion. Focus your physical assessment for the chief complaint if you
are doing a focused visit.
Assessment
This is the differential diagnosis section. List FOUR differential / working diagnoses. One of this
will be your final diagnosis. For EACH of your diagnoses list a brief rationale indicating why
this diagnosis should be considered or not considered as the final diagnosis. Include references
used to guide your thinking.
1.
2.
3.
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4.
Plan
All plans until you graduate contain the following elements. If an item does not apply to the
particular situation, please indicate- not applicable or not needed at this time. If it’s not indicated
it is assumed to not have been addressed.
Pharmacology Medications both prescription and OTC go here. Write out your prescription
meds just like a prescription.
Non-Pharmacology What non-pharmacologic interventions do you recommend for your
patient?
Diagnostics Are there any lab tests, radiology or other diagnostics you would like to order?
Remember to think primary care. No troponins or bedside stat echos in the office.
Consults / Referrals Would you like to phone a friend? Should they follow up with a specialist
for additional or further care?
Patient Education What important information do you need to make certain they know? Don’t
forget about serious medication interactions or OCP.
Follow Up Think about how much leeway you want to give this patient before someone lays
eyes on them again? One week? Two? What should they do if they experience new or worsening
symptoms?
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References
American Psychological Association. (2010). Publication manual of the American Psychological
Association (6th ed.). Washington, DC: Author.
Daresh, J. C. (2004). Beginning the assistant principalship: A practical guide for new school
administrators. Thousand Oaks, CA: Corwin.
Herbst-Damm, K. L., & Kulik, J. A. (2005). Volunteer support, marital status, and the survival
times of terminally ill patients. Health Psychology, 24, 225-229. doi:10.1037/02786133.24.2.225
U.S. Department of Health and Human Services, National Institutes of Health, National Heart,
Lung, and Blood Institute. (2003). Managing asthma: A guide for schools (NIH
Publication No. 02-2650). Retrieved from http://www.nhlbi.nih.gov/
health/prof/asthma/asth_sch.pdf

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