SOAP NOTE Presentation Peer Responses

Responding to Miguel

Hello Miguel,

Great work on your insightful presentation on the patient case involving hypertension. This highly detailed evaluation and diagnostic approach demonstrates a thorough comprehension of primary hypertension and how it should be treated. As you bring in lifestyle alterations such as the DASH diet and regular physical activity to tally, it also contributes to blood pressure management. Studies point toward adherence to the DASH diet, containing fruits, vegetables, whole grains, and low-fat dairy products that reduce systolic blood pressure by up to 11 mmHg in subjects with hypertension (Challa & Uppaluri, 2023). Additionally, moderate aerobic activity can reduce systolic pressure by another 4–9 mm Hg.

Notably, although this patient would be best treated with an ACE inhibitor and a thiazide diuretic, the use of dual therapy is reasonable as initial treatment, considering his blood pressure and family history. However, regulators should be alert to the possibility of such adverse events, particularly with thiazide diuretics (which can cause electrolyte disturbances), which may necessitate significant monitoring and prompt intervention (Akbari & Khorasani-Zadeh, 2023). Now, these authors conclude that when someone’s blood pressure “is not controlled by initial therapy,” the add-on of a calcium channel blocker will likely provide some help. In the real world, clinical trials used the typical ACE and ARB drug combination.

Further, it is valuable to include patient educational points about decreasing sodium intake beyond the DASH diet because even small reductions in sodium can be markedly beneficial for blood pressure control. Home blood pressure monitoring and a home record of blood pressure can motivate the patient to participate actively in their care and enable them to understand how various factors influence their condition (Parati et al., 2021). Notably, the plan to conduct follow-up visits at two weeks and three months is advantageous as it helps identify whether a particular therapeutic approach might eventually benefit the patient or not.

References

Akbari, P., & Khorasani-Zadeh, A. (2023, January 23). Thiazide diuretics. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532918/

Challa, H. J., & Uppaluri, K. R. (2023). DASH diet (dietary approaches to stop hypertension). Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK482514/

Parati, G., Stergiou, G. S., Bilo, G., Kollias, A., Pengo, M., Ochoa, J. E., Agarwal, R., Asayama, K., Asmar, R., Burnier, M., De La Sierra, A., Giannattasio, C., Gosse, P., Head, G., Hoshide, S., Imai, Y., Kario, K., Li, Y., Manios, E., & Mant, J. (2021). Home blood pressure monitoring: Methodology, clinical relevance and practical application: A 2021 position paper by the Working Group on Blood Pressure Monitoring and Cardiovascular Variability of the European Society of Hypertension. Journal of Hypertension, 39(9), 1742–1767. https://doi.org/10.1097/hjh.0000000000002922

Responding to Nathalie

Hello Nathalie,

Thank you for this valuable, detailed SOAP note about a 75-year-old patient with symptoms related to peripheral vascular disease (PVD). The presentation is commendable as it showcases a comprehensive understanding of the condition and evaluation of risk factors. Still, PVD is a disease often underdiagnosed due to its insidious onset and symptoms that could be blamed on old age. Indeed, the symptoms of intermittent claudication improve through the enhanced muscle metabolism and collateral circulation promoted by the supervised exercise program. In addition, encouraging the patient to walk or cycle in low-impact activities for at least 30 minutes three times a week will bring significant benefits regarding symptom reduction and improved quality of life (Qiu et al., 2022).

Besides the pharmaceutical treatments you have prescribed, adding a statin might be useful, considering the added benefits even when the patient’s cholesterol levels are within target ranges. According to Almeida and Budoff (2019), the cholesterol-lowering properties of statins possess anti-inflammatory and plaque-stabilizing effects that might reduce the progression of atherosclerosis. Furthermore, optimization of blood pressure control to a target of less than 130/80 mm Hg may further reduce the risks of not only PVD but also other cardiovascular diseases.

According to Cáceres-Farfán et al. (2021), the ankle-brachial index (ABI) measurement can be a good and noninvasive means of confirming the diagnosis of PVD. It effectively identifies the severity of arterial obstruction and guides further treatment. Referral to a cardiologist, as you have suggested, would be quite prudent for general cardiovascular assessment, considering his age and risk profile.

References

Almeida, S. O., & Budoff, M. (2019). Effect of statins on atherosclerotic plaque. Trends in Cardiovascular Medicine, 29(8), 451–455. https://doi.org/10.1016/j.tcm.2019.01.001

Cáceres-Farfán, L., Moreno-Loaiza, M., & Cubas, W. S. (2021). Ankle-brachial index: More than a diagnostic test? Archivos Peruanos de Cardiología Y Cirugía Cardiovascular, 2(4). https://doi.org/10.47487/apcyccv.v2i4.168

Qiu, Y., Fernández-García, B., Lehmann, H. I., Li, G., Kroemer, G., López-Otín, C., & Xiao, J. (2022). Exercise sustains the hallmarks of health. Journal of Sport and Health Science, 12(1), 8–35. https://doi.org/10.1016/j.jshs.2022.10.003

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Peer Response 1:

By: Miguel

Video Link: https://www.youtube.com/watch?v=5BlE57rN5F0

Transcript:

0:00

hello good afternoon my name is Miguel

0:01

SRA Garcia I’m a practitioner student

0:03

United State University currently in the

0:05

FMP

0:06

597 uh I uh want to share a case with uh

0:10

that I attend this week with all of you

0:12

it was a patient with the initial ml 45

0:15

years old white male was born uh in

0:18

January 1st 1979 the patient came to the

0:21

clinic along with was impressed as a Rel

0:24

history he came complaining of a

0:26

moderate headache that had start weeks

0:28

ago the headache was described as a

0:31

Conant pressure in the occipital region

0:32

with an intensity of six of 10 on the

0:35

visual analog scale the patient the pain

0:38

radiated to the upper part of the neck

0:40

symptoms worsen it with a stress

0:42

specifically longward days of more than

0:45

10 hours additionally he had noticed the

0:49

lot of sleep made his symptoms s the

0:51

patient admitted that he had noticed

0:53

that his headache sometime uh improve

0:56

with at least 2 hour of rest he deny

0:59

fever next stiffness blue Vision disz or

1:02

hearing change the patient Deni

1:04

experience disz loss of conscious or

1:07

vomiting he had not taken any medication

1:09

to relieve his symptoms uh when

1:12

evaluating his past medical history the

1:14

the patient reported that he had no

1:16

previously known medical problem and

1:19

admitted uh that his last cholesterol

1:21

test and blood pressure measurement were

1:24

two years ago with normal results he

1:26

reported having undergone an

1:28

appendectomy on at the age of 16 without

1:31

complication the patient deny any

1:34

allergy or medication use the patient

1:36

has a positive family history of high

1:38

blood pressure his social uh history

1:41

reveal that the patient does not smoke

1:43

and admitt that he uh consumes alcohol

1:46

occasionally for five beer per week he

1:48

denied drug use he admitted to having a

1:51

moderately highly diet but report that

1:54

he did little physical activity during

1:57

the system review the patient did

2:00

experience General symptoms visual

2:02

disturbance or tigit addition

2:05

additionally uh the patient denied heavy

2:07

uh cardiovascular and respiratory

2:10

symptoms he admitted to having uh being

2:13

experienced moderate to severe heada in

2:15

the back of the uh scull uh which was

2:18

not accompanied by other symptoms he

2:21

deny neurological alteration or symptoms

2:23

accompaning the the current uh condition

2:26

objective examination reveal an elevated

2:29

blood pressure of 160 over 95 mm of

2:33

mercury heart rate is 80 respiratory

2:36

rate 16 uh temperature 36.8 oxygen

2:39

saturation 98% and a report pain level

2:43

of 6 out of 10 the patient is 180 cm

2:47

toll and weight is 85 resulting in a

2:50

body mass index of 26.2 which is why he

2:54

was classified as overweight at the time

2:56

of the consultation no emergency uh

2:58

suppl were performed their physical

3:00

examination reveal an alert an Orient

3:03

patient with no sign of respiratory

3:05

distress or cardiovascular distress the

3:08

cardiovascular respiratory neurological

3:10

and abdominal system were normal on

3:12

utation and palpation no significant

3:14

finding neurological examination show

3:16

normal strin tone and reflex with intact

3:20

coordination and sensation ningal sign

3:23

were observed the re relevant finding

3:26

were high blood pressure and overweight

3:29

essential primary hypertension ICD 10 uh

3:33

A10 was considered uh the most likely

3:36

diagnosis du it to the elevated blood

3:39

pressure and Heche pressure in the

3:40

patient supported by a family history of

3:43

hypertension and the as of other

3:45

symptoms suggesting a secondary CA

3:47

essential hypertension represent 90% of

3:50

cases in high blood pressure

3:52

characterized by a high systolic and

3:54

diastolic blood pressure level Tension

3:56

Headache was ruled out due to the

3:58

intensity and location of the pain which

4:01

differ from the typical presentation of

4:03

this condition alra secondary

4:05

hypertension was considered it is

4:07

probability it is low given the asent of

4:11

symptoms associated with underlying

4:14

causes such as kidnic problem or

4:16

hormonal disorder secondary hypertension

4:19

usually present with additional symptom

4:21

that indicated the cause of the

4:23

hypertension home blood pressure

4:25

monitoring was indicated as part of his

4:27

patient plant in addition blood test

4:30

such as sodium potassium serum creating

4:33

estim estimated glomular filtration rate

4:36

lipid profile fasting glucose di urine

4:38

State uh test and 12 L EK were indicated

4:43

uh which uh coincided with the

4:46

recommendation of hunger H in 2020 it’s

4:50

a reference that I use uh this uh same

4:53

outs pointed out the imagin stud studies

4:57

additional Laboratory test uh and

4:59

hormonal and hormonal study can be used

5:02

to diagnose hypertension and root out

5:04

secondary causes uh the patient was

5:07

intruded to start a dash diet reducing

5:09

sodium intake and fried and sugary uh

5:12

Foods as suggested by Sylvia at in 20122

5:16

is a reference in addition it was

5:18

recommended to increase physical

5:20

activity and lose weight until reaching

5:22

the ideal weight is recommended by kry

5:26

and collaborator in 2021 it’s a

5:28

reference that I use for this it was

5:31

also recommended to reduce alcohol

5:33

consumption Stress Management and

5:34

exposure to noise and air pollution

5:37

according to the suggestion of uh C and

5:40

collaborator in 2024 it was indicated to

5:43

start treatment with lyso 10 milligram

5:45

per day orally in the morning refill in

5:48

3 months and hydrochloride 25 milligram

5:51

in the morning CS are mentioned in 2024

5:54

the importance of starting the treatment

5:57

of hypertensive patient with dual

5:59

therapy and including a theide diuretic

6:02

and Angiotensin converting enzyme inator

6:06

the patient was educated about uh

6:09

hypertension the important of blood

6:11

pressure control to prevent complication

6:13

and a strategy to modify his lifestyle

6:16

he was thought blood pressure self-

6:18

monitoring and providing with

6:19

educational materials followups

6:22

appointment were scheduled at two weeks

6:24

and 3 months to evaluate his respon to

6:27

treatment and adjust his medication is

6:30

necessary thank you so much

PEER RESPONSE 2

BY: Nathalie

Video Link: https://www.youtube.com/watch?v=Y8dl7lAaHU0

Transcript:

0:00

hello I’m Natalie and this is my soap

0:03

note on a 75-year-old Asian male um he

0:08

does have insurance he presented to the

0:10

clinic uh Alone um he’s a good

0:14

historian um so and he does have

0:17

insurance I don’t know if I already

0:19

mentioned that so the patient is a

0:20

75-year-old male who presents to the

0:22

clinic alone with complaints of coldness

0:24

weakness and pain in his legs uh the

0:27

symptoms have been gradually worsening

0:29

over the past 4 months mons uh he

0:31

reports persistent coldness especially

0:33

in his uh lower legs and feet which does

0:36

not improve with warming measures he

0:38

described his leg pain as aching and

0:40

cramping predominately occurring when he

0:42

walks or engages in physical activities

0:45

but improving with rest the pain is more

0:48

severe in his calves although he can

0:50

occasionally experience discomfort in

0:51

his thighs um he gives a pain score of a

0:54

four on a scale of uh 1 to 10 uh he also

0:58

reports like weakness uh St that his

1:00

legs often feel tired and heavy making

1:02

difficult to walk long

1:04

distances he denied any recent trauma

1:07

fever swelling his legs he has a history

1:09

of hypertension hyper hyperlipidemia but

1:12

denies a history of diabetes or smoking

1:14

although he smoked for 30 years and quit

1:16

like 20 years ago he takes medication

1:18

for his blood pressure and cholesterol

1:20

which he reports taking as prescribed uh

1:23

there are no no recent uh change in his

1:25

medication he denies any recent changes

1:27

in his appetite or weight loss

1:30

um he also stated that he no longer

1:32

participates in his usual daily

1:34

activities such as walking around the

1:36

neighborhood or standing for extended

1:38

period uh without um discomfort he

1:41

denies any history of diabetes or

1:43

marinal disease but has a family history

1:45

of cardiovascular disease he denies

1:47

having a nocturnal cough uh dpia chest

1:50

tightness swelling of the lower limbs

1:52

palpitation orenia so for the past

1:55

medical history uh preventive care his

1:57

up to dat on his Dental visit and his

1:59

vision um medical problem is uh stated

2:03

hyperemia and hypertension surgery he

2:06

never had um any surgery hospitalization

2:09

he was Hospital hospitalized like 20

2:11

years ago due to a pulmonary TB but he

2:14

stayed in the facility for 3 days and

2:16

then discharge he recovered well without

2:18

complications he denies any allergies to

2:21

food medication or environment uh

2:23

medication he’s on test 20 Mig daily and

2:26

laran 20 um sorry laran 50 Mill GS twice

2:30

a day for family history his grand um

2:34

grandparents um he does not know um for

2:38

mother she passed away congestive

2:40

cardiac failure at the age of 89 the

2:43

father uh blad cancer at 68 his brother

2:47

is alive it’s 60 69 years old um and his

2:52

health and sister alive with 60 uh she’s

2:54

64 years old with type 2 diabetes for

2:57

social history died he does not consume

2:59

many drunk food uh exercise he’s not

3:02

engaged on exercise right now safety he

3:05

does have

3:07

um no history injuries he wears a seat

3:10

belt and he does have the smoke

3:11

detectors at home and no firearm at home

3:13

chemical history he denies vaping of

3:15

smoking Tob back for the last 20 years

3:18

um he does not do any illicit drug and

3:20

he does not drink and he’s a businessman

3:22

for living so R was basically um

3:26

negative all that than um you know hint

3:29

was negative cardiovas respiratory

3:30

gastrointestinal generator urinary um

3:34

muscul skeletal and

3:37

um and that’s it for objective his

3:41

vitals was within normal limits uh bp1

3:43

16 over 72 Tempa 98 respiration 18 uh

3:48

oxygen 96 pain uh EST state is 4 out of

3:51

10 his BMI is 23.1 he 56 143

3:56

lb so the physical exam uh he was

4:00

looking but well-nourished uh his hint U

4:02

was uh normal was negative um

4:06

cardiovacular cardiovascular was normal

4:09

um the Apex speed is not deviated the

4:11

capillary refill um I’m so sorry the

4:14

capillary refill was delayed in the

4:16

lower

4:17

extremities um the dorsalis pedis fer on

4:20

and popta pulsers are diminished their

4:22

brutes osculating the fal arteries there

4:25

are no murmurs or

4:26

gallops

4:28

um and there was p uh on the elevation

4:32

of the lower limbs uh respiratory was

4:35

normal um you know within normal limits

4:38

gastrointestinal within normal limits

4:41

and then we go to muscle skeletal so the

4:43

lower limbs were cold to touch uh but

4:46

the muscle power is a five out of five

4:48

the toen Nils were thicken and the skin

4:49

on the leg it was hairless thin and

4:52

shiny uh the motion range for the limbs

4:54

was normal and the dip tender reflex

4:55

were intact the peripheral pulses um

4:58

were weak and regular and the joints

5:01

were not swollen or Tender and

5:03

neurological he was within normal limits

5:06

so for differential diagnoses uh it was

5:09

a peripheral vascular disease um so PVD

5:14

is a considerable differential because

5:15

the patient presented with pain and

5:17

paralysis of the lower limbs PVD results

5:20

from artherosclerosis which involves the

5:23

deposition of proteins and cholesterol

5:24

to form core surrounded by fiber in the

5:27

artery walls um the other two was deep

5:32

um deep Vin

5:33

trombosis uh adopter was done and that

5:36

was negative and then the second diag um

5:39

differential diagnos was peripheral

5:42

neuropathy so the final diagnos once

5:44

again was peripheral vascular disease

5:46

when it comes to diagnostic examinations

5:49

um it’s interesting to do a complete

5:51

blood count so we order that um a doler

5:54

ultrasound and also a CT angram was um

5:58

ordered

5:59

uh for the plan uh starting on aspirin

6:02

80 Mig once daily this medication

6:05

prevents the formation of blood clots in

6:07

the leg oral cyto

6:11

costasol 100 Mill 100 milligrams daily

6:14

this medications is peripheral dilator

6:17

uh continue with his to a the medication

6:19

to vadin lartin patient education was

6:22

informed uh the patient about the risk

6:23

factors cause treatment and

6:25

complications emphasize the need to

6:27

adhere to prescrib medication uh explain

6:30

the patient importance of adopting a low

6:32

fat low cholesterol low sodium diet

6:35

encourage the patient to participate in

6:36

supervised exercise programs um stress

6:40

the patient the need of continuing

6:41

checkups to evaluate the status and

6:43

review any requirements uh discuss with

6:46

the patient the Cardinal symptoms of

6:49

PVD and then the followup will be

6:51

returning 14 days times to assess

6:54

treatment e efficacy and the refer

6:57

referral was sent to a Cardiologist

7:00

thank you