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SOAP Notes and Reflections

Student’s Name

Institutional Affiliations

Course Title

Instructor’s Name

Due Date
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SOAP Note: Virgil Stutte

Identifying Data

Virgil Stutte is a 72-year-old Caucasian male presenting for evaluation.

Source and Reliability

The patient is the source of information and is reliable.

Subjective

Chief Complaint (CC):

“I need a refill on my medications.”

History of Present Illness (HPI)

Mr. Stutte is a 72-year-old male presenting for medication refills and follow-up of his chronic

conditions. He reports no new complaints today. His hypertension and type 2 diabetes mellitus

are being managed with lisinopril, hydrochlorothiazide, and metformin. He denies chest pain,

palpitations, dizziness, headaches, or vision changes. He reports adherence to his medication

regimen but admits he does not always check his blood sugar at home. He denies polyuria,

polydipsia, or polyphagia. He denies shortness of breath, orthopnea, or paroxysmal nocturnal

dyspnea. His last hemoglobin A1c, checked three months ago, was 7.2 percent (American

Diabetes Association, 2023).

Medications:

 Lisinopril 20 mg PO daily

 Hydrochlorothiazide 25 mg PO daily

 Metformin 500 mg PO BID with meals

Past Medical History (PMH):

 Hypertension
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 Type 2 Diabetes Mellitus (diagnosed 8 years ago)

 Hyperlipidemia

Past Surgical History (PSH):

 Appendectomy at age 23

Allergies:

No known drug allergies.

Family History:

 Father: Deceased, myocardial infarction at age 68

 Mother: Deceased, stroke at age 74

 No family history of cancer reported

Personal and Social History:

Mr. Stutte is a retired farmer. He is married and lives with his wife. He reports occasional alcohol

use (beer, 1–2 times weekly). He denies tobacco use and illicit drug use. He eats a carbohydrate

diet but has been attempting to reduce portion sizes. Physical activity is limited to light walking

around his farm.

Review of Systems (ROS):

 General: Denies fever, chills, or weight loss.

 HEENT: Denies headaches, vision changes, hearing loss, or sore throat.

 Cardiovascular: Denies chest pain, palpitations, edema.

 Respiratory: Denies cough, dyspnea, wheezing.

 Gastrointestinal: Denies nausea, vomiting, diarrhea, constipation, abdominal pain.

 Genitourinary: Denies dysuria, frequency, hematuria.

 Musculoskeletal: Denies joint pain or muscle weakness.

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 Neurological: Denies dizziness, syncope, numbness, or tingling.

 Psychiatric: Denies depression or anxiety.

Objective

Vital Signs:

 BP: 138/84 mmHg

 HR: 82 bpm

 RR: 16 breaths/min

 Temp: 98.1°F

 SpO₂: 97% RA

BMI: 29.5 kg/m²

Physical Exam

 General: Alert, oriented, in no acute distress.

 HEENT: Normocephalic, atraumatic, pupils equal and reactive, oral mucosa moist.

 Neck: No lymphadenopathy, thyroid non-enlarged.

 Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops.

 Respiratory: Clear to auscultation bilaterally, no wheezes or crackles.

 Abdomen: Soft, non-tender, normoactive bowel sounds, no hepatosplenomegaly.

 Extremities: No edema, peripheral pulses 2+ bilaterally.

 Neurological: Alert, cranial nerves grossly intact, no motor or sensory deficits.

 Skin: Warm, dry, intact, no lesions noted.

Assessment and Plan

Differential Diagnoses

1. Essential hypertension (I10)

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2. Type 2 diabetes mellitus without complications (E11.9)

3. Hyperlipidemia, unspecified (E78.5)

Rationale

Hypertension and diabetes mellitus are longstanding conditions in this patient with ongoing

pharmacologic management. His blood pressure is slightly above the recommended target of less

than 130/80 mmHg (Whelton et al., 2018). His last hemoglobin A1c of 7.2 percent reflects

moderate diabetes control (American Diabetes Association, 2023). Hyperlipidemia is part of his

history, and statin therapy should be confirmed because current cholesterol guidelines

recommend statins for diabetic patients over 40 years old (Grundy et al., 2019).

Most Likely Diagnosis (with Pathophysiology)

Type 2 Diabetes Mellitus (E11.9). This chronic metabolic disorder is characterized by insulin

resistance and relative insulin deficiency. Impaired insulin signaling decreases glucose uptake in

peripheral tissues and increases hepatic glucose production (American Diabetes Association,

2023).

Diagnostic Testing

 Hemoglobin A1c

 Lipid panel

 Basic metabolic panel (to monitor renal function while on ACE inhibitor and diuretic)

Treatment:

 Continue lisinopril 20 mg daily, hydrochlorothiazide 25 mg daily, and metformin 500 mg

BID.

 Confirm initiation of statin therapy, per guidelines (Grundy et al., 2019).

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 Reinforce dietary modifications and encourage increased physical activity, aiming for at

least 150 minutes of moderate exercise weekly (American Diabetes Association, 2023).

Motivational Interviewing

The patient was encouraged to monitor his blood glucose regularly and reduce carbohydrate

intake. He expressed willingness to incorporate more vegetables into meals and agreed to check

his blood sugar three times weekly. Small, attainable goals, such as daily 20-minute walks with

his wife, were set.

References

American Diabetes Association. (2023). Standards of medical care in diabetes—2023. Diabetes

Care, 46(Supplement_1), S1–S291. [Link]

Grundy, S. M., Stone, N. J., Bailey, A. L., Beam, C., Birtcher, K. K., Blumenthal, R. S., Braun,

L. T., de Ferranti, S., Faiella-Tommasino, J., Forman, D. E., Goldberg, R., Heidenreich, P.

A., Hlatky, M. A., Jones, D. W., Lloyd-Jones, D., Lopez-Pajares, N., Ndumele, C. E.,

Orringer, C. E., Peralta, C. A., Saseen, J. J., … Yeboah, J. (2019). 2018

AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA

Guideline on the Management of Blood Cholesterol: A Report of the American College

of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.

Circulation, 139(25), e1082–e1143. [Link]

Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Jr, C., K. J., D. H., C., D., S. M., G.,

S., J., K. A., J., D. W., M., E. J., M., P., O., B., Smith, S. C., Jr, Spencer, C. C., Stafford,

R. S., Taler, S. J., Thomas, R. J., Williams, K. A., Sr, Williamson, J. D., … Wright, J. T.,

Jr (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA

Guideline for the Prevention, Detection, Evaluation, and Management of High Blood
 7

Pressure in Adults: Executive Summary: A Report of the American College of

Cardiology/American Heart Association Task Force on Clinical Practice

Guidelines. Hypertension (Dallas, Tex. : 1979), 71(6), 1269–1324.

[Link]
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SOAP Note: Ann Arnold

Identifying Data

Ann Arnold is a 50-year-old African American female presenting for evaluation.

Source and Reliability

The patient is the source of information and is reliable.

Subjective

Chief Complaint (CC)

“I have been having hot flashes and trouble sleeping.”

History of Present Illness (HPI)

Ms. Arnold is a 50-year-old female presenting with complaints of hot flashes, night sweats, mood

changes, and difficulty sleeping for the past six months. She describes sudden episodes of intense

heat, particularly at night, associated with sweating and interrupted sleep. She reports irritability,

occasional low mood, and decreased concentration at work. She denies chest pain, palpitations,

or shortness of breath. She denies fever, chills, or weight loss. She has not tried over-the-counter

remedies. She denies vaginal bleeding or pelvic pain. Her last menstrual period was

approximately one year ago, suggesting the transition to menopause (National Institute on Aging,

2021).

Medications

 None reported

Past Medical History (PMH)

 Hypertension, diagnosed 5 years ago

 No history of diabetes or thyroid disease

Past Surgical History (PSH)

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 None

Allergies:

No known drug allergies

Family History

 Mother: Alive, hypertension

 Father: Deceased, colon cancer at age 72

 No known family history of breast or ovarian cancer

Personal and Social History

Ms. Arnold works as an elementary school teacher. She is married and has two adult children.

She denies tobacco and illicit drug use. She reports occasional alcohol use, usually wine on

weekends. She engages in light walking twice per week. Her diet is moderately balanced but

high in processed foods.

Review of Systems (ROS)

 General: Denies fever, chills, weight loss

 HEENT: Denies headaches, vision changes, sore throat

 Cardiovascular: Denies chest pain, palpitations, edema

 Respiratory: Denies cough, dyspnea, wheezing

 Gastrointestinal: Denies nausea, vomiting, diarrhea, constipation

 Genitourinary: Reports hot flashes and night sweats; denies dysuria, frequency,

hematuria

 Musculoskeletal: Denies joint pain or stiffness

 Neurological: Denies dizziness, syncope, numbness

 Psychiatric: Reports irritability and low mood; denies suicidal ideation

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Objective

Vital Signs

 BP: 142/88 mmHg

 HR: 86 bpm

 RR: 18 breaths/min

 Temp: 98.4°F

 SpO₂: 98% RA

BMI: 31.2 kg/m²

Physical Exam

 General: Alert, oriented, overweight, no acute distress

 HEENT: Normocephalic, atraumatic, oral mucosa moist

 Neck: No thyromegaly or lymphadenopathy

 Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops

 Respiratory: Clear to auscultation bilaterally, no wheezes or crackles

 Abdomen: Soft, non-tender, no organomegaly

 Extremities: No edema, peripheral pulses intact

 Neurological: Alert, cranial nerves intact, no focal deficits

 Skin: Warm, dry, no lesions

Assessment and Plan

Differential Diagnoses

1. Menopausal transition (N95.1)

2. Primary hypertension (I10)

3. Hypothyroidism (E03.9)
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Rationale

The patient’s symptoms of hot flashes, night sweats, mood changes, and sleep disturbance are

most consistent with menopause. Her last menstrual period was one year ago, supporting this

diagnosis (National Institute on Aging, 2021). Hypertension remains a comorbidity that requires

ongoing management (Whelton et al., 2018). Hypothyroidism can also cause fatigue and mood

changes, so it should be ruled out.

Most Likely Diagnosis (with Pathophysiology)

Menopausal transition (N95.1). This occurs due to ovarian aging and decreased estrogen

production, leading to vasomotor symptoms, sleep disturbances, and mood fluctuations. Lower

estrogen affects the hypothalamic thermoregulatory center, resulting in hot flashes and night

sweats (Santoro & Randolph, 2021).

Diagnostic Testing

 Thyroid-stimulating hormone (TSH) to rule out hypothyroidism

 Lipid panel to assess cardiovascular risk

 Blood pressure monitoring at home

Treatment

 Discussed lifestyle modifications including reduction of caffeine and alcohol, increased

physical activity, and weight management (Santoro & Randolph, 2021).

 Consider initiation of non-hormonal therapy such as SSRIs if vasomotor symptoms

persist (North American Menopause Society, 2023).

 Hormone replacement therapy may be considered if benefits outweigh risks, with patient

education on potential adverse effects (North American Menopause Society, 2023).

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 Continue monitoring hypertension and reinforce adherence to antihypertensive therapy

(Whelton et al., 2018).

Motivational Interviewing:

The patient was encouraged to increase her walking to at least 30 minutes five days per week.

She agreed to substitute processed snacks with fruits and vegetables. She expressed concern

about sleep quality, and sleep hygiene strategies such as consistent bedtime and limiting screen

use before sleep were discussed.

References

National Institute on Aging. (2021). Menopause: In brief. U.S. Department of Health and Human

Services. [Link]

North American Menopause Society. (2023). The 2023 hormone therapy position statement of

The North American Menopause Society. Menopause, 30(9), 1010–1025.

[Link]

Santoro, N., & Randolph, J. F. (2021). Reproductive aging and the menopause transition.

Obstetrics and Gynecology Clinics of North America, 48(3), 515–526.

[Link]

Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Jr, C., K. J., D. H., C., D., S. M., G.,

S., J., K. A., J., D. W., M., E. J., M., P., O., B., Smith, S. C., Jr, Spencer, C. C., Stafford,

R. S., Taler, S. J., Thomas, R. J., Williams, K. A., Sr, Williamson, J. D., … Wright, J. T.,

Jr (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA

Guideline for the Prevention, Detection, Evaluation, and Management of High Blood

Pressure in Adults: Executive Summary: A Report of the American College of

Cardiology/American Heart Association Task Force on Clinical Practice

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Guidelines. Hypertension (Dallas, Tex. : 1979), 71(6), 1269–1324.

[Link]
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SOAP Note: James W. McDonald

Identifying Data

James W. McDonald is an 80-year-old Caucasian male who presents for follow-up evaluation.

Source and Reliability

The patient is the source of history and is reliable.

Subjective

Chief Complaint (CC)

“I am here for follow-up of my diabetes and blood pressure.”

History of Present Illness (HPI)

Mr. McDonald is an 80-year-old male with a medical history significant for type 2 diabetes,

hypertension, hyperlipidemia, chronic kidney disease, coronary artery disease with prior stent

placement, peripheral vascular disease, erectile dysfunction, and vitamin D deficiency. He

reports that his diabetes is well controlled and his home blood pressure readings remain stable.

He denies chest pain, palpitations, shortness of breath, or dizziness. He reports improved energy

levels. He was recently treated for a urinary tract infection, which has resolved. He continues to

follow up with podiatry for plantar fasciitis and has received injections with partial relief. He

denies fever, chills, or weight loss.

Medications

 Amlodipine 2.5 mg daily, may repeat once if systolic BP >150, hold if <110

 Metoprolol succinate XL 25 mg daily, hold if pulse <50 or systolic <100

 Valsartan 40 mg daily, hold if systolic <120

 Rosuvastatin 10 mg daily

 Pantoprazole 40 mg daily before breakfast

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 Tadalafil 10 mg daily as needed for erectile dysfunction

 Recently discontinued: Celecoxib

Past Medical History (PMH)

 Type 2 diabetes mellitus

 Hypertension

 Hyperlipidemia

 Chronic kidney disease, stage 2

 Coronary artery disease with prior stent placement

 Peripheral vascular disease

 Erectile dysfunction

 Vitamin D deficiency

Past Surgical History (PSH)

 Coronary stent placement

Allergies

No known drug allergies

Family History

 Father: Deceased, myocardial infarction at 68

 Mother: Deceased, breast cancer at 74

 No family history of diabetes

Personal and Social History

Mr. McDonald is a retired accountant. He is married and lives with his spouse. He does not

smoke and drinks alcohol occasionally. He follows a diet low in salt and cholesterol and engages

in light walking three times weekly. He is independent in his daily activities.

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Review of Systems (ROS)

 General: No fever, chills, or weight loss

 HEENT: No headaches, visual changes, or sore throat

 Cardiovascular: No chest pain, palpitations, or edema

 Respiratory: No dyspnea, cough, or wheezing

 Gastrointestinal: No abdominal pain, nausea, vomiting, diarrhea, or constipation

 Genitourinary: No dysuria, hematuria, or urinary frequency

 Musculoskeletal: Reports heel pain from plantar fasciitis, otherwise denies joint pain

 Neurological: No dizziness, weakness, or numbness

 Psychiatric: Denies depression or anxiety

Objective

Vital Signs

 BP: 116/82 mmHg

 HR: 78 bpm

 RR: 16 breaths/min

 Temp: 96.8°F

 SpO₂: 98%

 Height: 5’8”

 Weight: 160 lb

 BMI: 24.3 (normal)

Physical Exam

 General: Alert, oriented, no acute distress

 HEENT: Normocephalic, atraumatic, moist oral mucosa

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 Neck: No jugular venous distention, no thyromegaly

 Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops

 Respiratory: Clear to auscultation bilaterally

 Abdomen: Soft, non-tender, no hepatosplenomegaly

 Extremities: No edema, dorsalis pedis pulses 2+ bilaterally

 Neurological: Alert, cranial nerves II-XII intact, no focal deficits

 Musculoskeletal: Tenderness at plantar heel, no swelling or erythema

 Skin: Warm, dry, no rashes

Laboratory and Diagnostic Studies Ordered

 Basic metabolic panel

 CBC with differential

 Calcium (ionized)

 HbA1c

 Hepatic function panel

 Lipid panel

 Magnesium

 Uric acid

 Urinalysis with reflex to culture

 Urine microalbumin/creatinine ratio

 Vitamin D 25-hydroxy

Assessment and Plan

Differential Diagnoses

1. Stable coronary artery disease with prior stent placement (I25.10)

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2. Hypertension (I10)

3. Type 2 diabetes mellitus with stable control (E11.9)

4. Hyperlipidemia (E78.5)

5. Peripheral vascular disease (I73.9)

6. Erectile dysfunction (N52.9)

7. Vitamin D deficiency (E55.9)

8. Plantar fasciitis (M72.2)

Rationale

The patient’s cardiovascular disease remains stable, with no angina or acute findings.

Hypertension and diabetes appear well controlled, supported by his normal blood pressure

readings and lack of hyperglycemic symptoms (American Diabetes Association, 2023; Whelton

et al., 2018). Hyperlipidemia is being managed with statin therapy. His vascular disease, erectile

dysfunction, and plantar fasciitis continue to require monitoring and supportive treatment.

Vitamin D deficiency is being followed by laboratory assessment.

Most Likely Diagnoses (Pathophysiology and Plan)

 Stable coronary artery disease (I25.10): Results from atherosclerosis leading to

narrowing of coronary vessels, previously treated with stent placement (Benjamin et al.,

2019). Continue rosuvastatin and antihypertensive regimen. Avoid NSAIDs due to renal

and cardiovascular risks.

 Hypertension (I10): Managed with amlodipine, valsartan, and metoprolol, with home

BP monitoring. Continue current therapy (Whelton et al., 2018).

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 Type 2 diabetes (E11.9): Pathophysiology involves insulin resistance and beta-cell

dysfunction (American Diabetes Association, 2023). Maintain current regimen and

monitor HbA1c.

 Plantar fasciitis (M72.2): Caused by plantar fascia inflammation due to mechanical

stress. Continue podiatry follow-up, stretching exercises, and supportive footwear.

Diagnostics

 Monitor HbA1c, lipid profile, vitamin D, and renal function.

 Evaluate urine albumin/creatinine ratio for CKD progression.

Treatment

 Continue amlodipine, valsartan, metoprolol, rosuvastatin, pantoprazole, and tadalafil as

prescribed.

 Reinforce avoidance of NSAIDs.

 Encourage continued walking exercise and adherence to a heart-healthy diet.

 Maintain vitamin D supplementation based on lab results.

 Continue podiatry treatment for plantar fasciitis.

Motivational Interviewing

The patient expressed commitment to following his dietary plan. He was encouraged to increase

walking from three to five times weekly. He agreed to log his blood pressure and glucose levels

at home for review during the next visit.

References

American Diabetes Association. (2023). Standards of care in diabetes—2023. Diabetes Care,

46(Supplement 1), S1–S154. [Link]

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Benjamin, E. J., Virani, S. S., Callaway, C. W., Chamberlain, A. M., Chang, A. R., Cheng, S., …

Muntner, P. (2019). Heart disease and stroke statistics—2019 update: A report from the

American Heart Association. Circulation, 139(10), e56–e528.

[Link]

Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Jr, C., K. J., D. H., C., D., S. M., G.,

S., J., K. A., J., D. W., M., E. J., M., P., O., B., Smith, S. C., Jr, Spencer, C. C., Stafford,

R. S., Taler, S. J., Thomas, R. J., Williams, K. A., Sr, Williamson, J. D., … Wright, J. T.,

Jr (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA

Guideline for the Prevention, Detection, Evaluation, and Management of High Blood

Pressure in Adults: Executive Summary: A Report of the American College of

Cardiology/American Heart Association Task Force on Clinical Practice

Guidelines. Hypertension (Dallas, Tex. : 1979), 71(6), 1269–1324.

[Link]