SOAP Note Template

Team Student Date

Name(s)
Ginny Joshi January 18, 2023

COLLECT

Subjective and Objective

Patient Initials: Age: Gender Preferred Height/ Allergies/Sensitivities

MR 51 ID: Pronoun(s Weight: (include reaction type): NKDA
Female ): 5’7 /135 lbs
She/her
CC (if applicable): Follow up after recent hospitalization for an acute ischemic stroke

HPI: MR is a 51 year old African American patient who presented to the hospital to follow up after her
recent hospitalization due to an acute ischemic stroke. The patient was not given tPA as her symptoms had
been ongoing and the patient went to bed the previous evening. MR left the hospital without appropriate
discharge because she needed to go back to work as she is the sole provider for her family. MR is supposed
to take aspirin every day due to the stroke and does not recall the other medications she was supposed to
initiate.

Past Medical History:

Mild intermittent asthma, essential hypertension, dyslipidemia, ischemic stroke, allergies

Active/Current Medication List (check home, inpatient, or both depending on situation)

Hom Inpatient Medication (Name, Dose, Sig, etc) Indication

e
☒ ☐ Aspirin enteric coated, 81 mg, 1 po qd w Ischemic stroke
food
☒ ☐ Vitamin D3, 25 mcg, 1 po qd Dietary supplement
☒ ☐ Cetirizine, 10 mg, 1 po qd prn Allergies
☒ ☐ Albuterol HFA, 90 mcg, 2 puffs q4h prn Asthma
☐ ☐
☐ ☐
☐ ☐
☐ ☐
☐ ☐
☐ ☐
☐ ☐
☐ ☐
Past Surgical History:
N/A

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Family/Social History:
- Father deceased at 62 year old due to stroke
- Mother alive with diabetes
- 7 children alive and healthy
- Brother with heart disease
- MR drinks alcohol most weekends and 3 drinks most nights
- MR smokes 1 PPD 15 minutes after waking.
Immunization History:
up to date

Objective Parameter Value(s)

Vital Signs 1/18/23
BP: 146/92 mm Hg
Pulse: 66 bpm

1/1/23
BP: 156/94 mmHg
Pulse: 78 bpm
Physical Examination Neurologic – drowsiness
(pertinent findings
only)
Laboratory Results 1/1/23
(pertinent findings LDL: 156 mg/ dL
only) TC: 224 mg/dL
Triglycerides: 160 mg/dL
HDL: 36 mg/ dL

12/30/21
LDL: 150 mg/ dL
TC: 220 mg/dL
Triglycerides: 159 mg/dL
HDL: 36 mg/ dL

Other Pertinent Diagnostic Tests & Results

Date Diagnostic Summary of Results
1/1/23 Stroke Evidence of acute ischemic stroke
Workup
1/18/2 Pulmonary FEV1: 70%
3 Function FVC: 75%
Test
1/18/2 Asthma Daytime exacerbations: 1-3/month
3 Severity Nocturnal awakening: 1-2/year
Use of albuterol 1-3/month
No interference with normal activities

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 Results consistent with mild intermittent asthma

ASSESSMENT & PLAN

Assessment & Plan

(Prioritized drug-related problem list with an assessment and plan for each problem. Be sure to include an
evaluation of the subjective/objective information and your recommendations including initiation, discontinuation,
dose changes, and monitoring parameters.)

Drug-Related Problems: Assessment and Plan:

1. DRP: Secondary stroke prevention, dyslipidemia and uncontrolled stage 2 hypertension

requiring pharmacotherapy

a. Assessment: Patient MR was recently hospitalized for an acute ischemic

stroke however she was discharged against medical advice due to her urgency
to go back to work. MR was instructed to take baby aspirin after
hospitalization and does not recall the other new medications that were
required to be initiated after the stroke. MR did not take any medications for
blood pressure or dyslipidemia prior to the stroke. The patients lipid panel
indicates she is a good candidate for treatment with a high intensity statin as
she has elevated LDL levels of 156 mg/dL, total cholesterol 224 mg/dL,
triglycerides 160/mg/dL, and low levels of HDL 36 mg/dL from January 1,
2023 and LDL of 150 mg/dL, TC of 220 mg/dL, TG of 159 mg/dL, and HDL
of 36 mg/dL from December 30, 2021. According to the AHA/ASA guideline
for the early management of patients with acute ischemic stroke, an
antiplatelet agent such as aspirin 81 mg once daily and high intensity statin
such as rosuvastatin 20 mg once daily are recommended to prevent a future
stroke events. The AHA/ACC guidelines state the goal is to reduce LDL-C by
50% or more for high risk patients. MR is considered a high risk patient as she
has experienced one ASCVD event, has elevated blood pressure and is a
smoker. In addition, MR requires pharmacotherapy for uncontrolled stage 2
hypertension as hypertension is a modifiable risk factor for stroke. The
patient’s blood pressure on January 18, 2023 was 146/92 mm Hg with a
second reading indicating 148/94 mm Hg and on January 1, 2023 her blood
pressure was 156/94 mm Hg. The patient is a good candidate for
antihypertensive therapy with a thiazide such as chlorthalidone 12.5 mg daily.
According to the ACC/AHA guidelines, the goal for MR is to achieve a blood
pressure reading of < 130/80 mm Hg.

b. Plan:

i. Continue medication: aspirin enteric coated, 81 mg, 1 po qd w food

ii. Discontinue medication: N/A

iii. Adjust medication: N/A

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 iv. Start Medication: rosuvastatin 20 mg po qd for dyslipidemia and
chlorthalidone 12.5 mg po qd for hypertension

v. Non-Pharm:

- Increase intake of vegetables, fruits, whole grains, legumes,

healthy protein sources, nontropical vegetable oils, low fat dairy
products with reduced content of saturated and total fat
- Limit intake of sweets, sugar sweetened beverages and red meat
- Manage weight within healthy range, BMI 18.5-24.9 kg/m2
- Engage in aerobic physical activity 3-4 times/week lasting 40
minutes per session
- Consume dietary fiber at 2g/day, < 200mg/day dietary cholesterol,
total fat range of 24-35% and <7% total calories with reduced
intake of trans fatty acids activity
- Suggest smoking cessation
- Reduce dietary sodium intake to no more than 2.4 g sodium or 6 g
sodium chloride/day or absolute reduction in 1 g sodium/day
- Limit alcohol consumption to no more than one standard drink per
day for women

vi. Monitoring:

Patient: Monitor for rosuvastatin side effects such as muscle soreness,

tiredness or weakness. Monitor for chlorthalidone side effects such
photosensitivity, impotence, dizziness and rash. Monitor blood
pressure for goal blood pressure of <130/80 mm Hg and heart rate of
60 – 100 bpm.

Prescriber: Baseline lipid panel repeated 4-12 weeks after initiating

therapy and every 3 to 12 months thereafter. Monitor LFTs at baseline.
For chlorthalidone therapy monitor electrolytes, renal function, blood
pressure and fluid status. Monitor patient adherence to medication
regimen.

vii. Follow-up: in 1 month with primary care physician or urgent care if

patient does not find a PCP

2. DRP: Adverse reaction of drowsiness to cetirizine

a. Assessment: Patient MR has been experiencing an increase in drowsiness

which is a side effect associated with the antihistamine medication cetirizine.
MR stated that she drinks alcohol most weekends and 3 drinks most nights
thus the use of alcohol can increase the effects of cetirizine such as the
drowsiness. She currently takes cetirizine once daily however she can take the
medication in the evening or at bedtime to avoid feeling drowsy during the
day while she is working. The goal is to limit the drowsiness MR experiences

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 throughout the day so that she can continue to be productive with work and
other daily activities.

b. Plan:

i. Continue medication: N/A

ii. Discontinue medication: N/A

iii. Adjust medication: cetirizine 10 mg po at bedtime

iv. Start Medication: N/A

v. Non-Pharm:

- Limit exposure to allergy triggers

- Avoid opening windows
- Remain indoors when pollen counts are high
- Clean and change sheets and blankets weekly
- Avoid consumption of alcohol while taking allergy medication
vi. Monitoring: Note whether there is a change in the level of drowsiness
experienced during the day after taking the medication at bedtime
instead of taking the medication in the morning.

vii. Follow-up: with PCP or urgent care after 2 weeks if drowsiness

persists

References:

1. 2019 014 ACC/AHA/AATS/PCNA/SCAI/STS Guideline for the Early Management of

Patients with Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early
Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From
the American Heart Association/American Stroke Association. Stroke, 50 (12): e344-418.
2. 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: A Report of the American College of Cardiology/American Heart Association
Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018;71:e127-e248
3. 2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the
Diagnosis and Management of Patients with Stable Ischemic Heart Disease.Retrieved
January 5, 2023.
4. Lexicomp Online. Hudson, Ohio: Lexi-Comp, Inc; January 18, 2022.

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