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View Full Version : A Case to Practice SOAP



Janis.Y.Chen
Sun 10th April '16, 8:05pm
The steps involved in therapeutics planning (problem identi cation, problem prioritization, and selection of patient-speci c drug and nondrug interventions) are illustrated in the following patient case example.

Patient Case
Date: Late August
Location: Outpatient clinic
CC: “There has to be something you can do for my allergies”
HPI: Louisa Sorensen is a 31 y/o F with a 20+ yr history of seasonal allergic rhinitis (SAR) and type 2 diabetes mellitus (DM). She is allergic to ragweed and has symptoms every fall but claims that this fall is much worse than usual. She complains of multiple bouts of sneezing, runny nose, fatigue, irritability, and itchy eyes, nose, and throat. Her symptoms are worse when she is outside and better when she is inside air-conditioned buildings. She’s had to trade out of recess duty at work and has not been able to attend her children’s soccer games. She has taken every available prescription antihistamine but feels they are not as effective as the nonprescription antihistamines. However, nonprescription antihistamines make her too drowsy to work or drive, so she doesn’t take many doses. She started taking nasal cromolyn sodium four times a day a couple of weeks ago. She has taken several short courses of oral steroids in the past but hasn’t taken any for several years. She tries to avoid steroids because they make her diabetes hard to control. She denies fever, sore throat, cough, vomiting, or diarrhea.
PMH: Type 2 DM × 10 yr controlled with oral medications and diet; S/P appendectomy age 16 yr
SH: Married, four children (sons 8 and 10 and daughters 4 and 5). Lives in a two-story house in the suburbs. No tobacco, no alcohol, no illicit drugs. Elementary school teacher (teaches rst grade).
FH: M↑ (50, + SAR, + asthma), F↑ (51, + SAR); two siblings + SAR; all four of her children + SAR
ROS: As per history of present illness

Medication History
Current prescription medications:
metformin (Glucophage) 1000 mg twice daily × 5 yr
Past prescription medications:
Has tried “every prescription antihistamine available.” She says that they “sort of work” but are not as effec- tive as the nonprescription antihistamines. Has taken several different medications for the type 2 DM but cannot remember their names. Has had to use insulin a couple of times while taking prednisone.
Takes prednisone for a few days “when my allergies are really bad”; cannot remember exact dosages or dates
Current nonprescription medications:
diphenhydramine (Benadryl Allergy) 25 mg once or twice a day, mostly in the evenings or at night; started about 2 wk ago
cromolyn sodium (NasalCrom) one spray each nostril four times daily during fall allergy season × 2 yr; started about 2 wk ago
Current complementary and alternative medicines:
No current alternative medicines
Past complementary and alternative medicines: Has tried
devil’s claw, pollen extracts, and echinacea for her aller- gies without noticeable bene t (unknown dates, dosages, durations)
Immunizations: Had all the usual childhood vaccines; last tetanus/diphtheria booster was 5 yr ago; gets the in uenza vaccine every fall
Drug allergies: NKDA
Adverse drug reactions: None
Adherence: Takes her medications as prescribed or recommended
Diet: Low fat (<200 mg cholesterol/day), high ber (30 g/day), low sodium (<2.4 g/day) with moderate carbohy- drates (about 50% of total daily caloric intake)

Physical Examination Findings
General: LS is a pleasant but uncomfortable-appearing
woman. She is 5′1′′ tall and weighs 180 lb (BMI 34). Vital signs: Afebrile; BP 114/74 mm Hg; HR 72 beats/min,
RR 10 breaths/min
HEENT: PERRLA, EOMI, TM intact; + conjunctival injection; + chemosis; + rhinorrhea (clear watery secretions); pale, swollen nasal mucosa; oropharynx clear except for some postnasal drip; + periorbital edema; + allergic shiners; + allergic crease
Chest and lungs: CTAP
CV: RRR; + S1, + S2; PMI 5ICS MCL; no m/r/g
Abdomen: NABS; NTND; appendectomy scar RUQ
Extremities: Strength 5/5 UE and LE; re exes 2+ UE and LE Neuro: A×3; cranial nerves II-XII intact

Laboratory Tests and Diagnostic Procedures
Today’s labs: Random ngerstick blood glucose 110 mg/dL Labs from last visit 5 mo ago: Hb A1C 6.5%