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The Goal of This Lab

This lab is aimed to build upon the concept of writing a SOAP note that was introduced in the Introductory SOAP Note. In the Introductory SOAP Note activity, you reviewed a note for structure and graded it with a rubric. In this upcoming lab, you and your partner will team up to write a full note, which will be graded by an instructor.

This Prelab Work

This assignment will help you prepare to write an Assessment and Plan as discussed in class before lab. You will see that the S and O part are already done. Watch the online video (about 5 minutes) on Blackboard as well. You are to write an A/P component and bring it to lab, where you and your partner will grade each other with the rubric.

Tips

  • This case is overall not too complicated. You will see that the patient is doing some inappropriate things at this time, however.

  • How should the patient change her/his current therapy?

  • What nonpharmacological interventions would help with this patient?

  • When do you think this patient should be seen again?

Bring this to the lab. Your participation sheet is the last page.

  • Patient: John Doe

  • MRN: 98874839

  • Date: 11/5/2019 [adjust dates for the activity as needed]

HPI

Mr. Doe is a 62-year-old man who returns to the HF clinic for his 3-month follow-up with the medical team for review of his current status. Mr. Doe was diagnosed in 2016 with HFrEF that seems to be due to his past history, including an MI back in 2014 in which he had two stents placed. He states today he is feeling well, with no significant issues to report. He has been walking more due to the weather he claims, though his knees have been bothering him with the cold. He has been taking Aleve over-the-counter to help with the pain. He was previously on APAP but likes the idea of taking medications less often. Lastly, his diet appears to be noncompliant with his HF restrictions, eating primarily take-out food high in salt.

PMH

  • DM2

  • HTN

  • CAD

  • S/P MI (2014) × 2 stents

  • High cholesterol

  • OA

  • HFrEF (30%)

SH

Lives alone, wife deceased. Works at Walmart. Past smoker, quit. Drinks 1–2 beers a week.

FH

Mother deceased (stroke). Father deceased (MI). Brother with DM2.

Medications (from patient)

  • Aspirin 81 mg by mouth in the morning

  • Lisinopril 20 mg by mouth daily

  • Metoprolol succinate 100 mg by mouth daily

  • Crestor 20 mg by mouth daily

  • Lasix 40 mg by mouth twice a day

  • Potassium 20 meq by ...

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