Sample Soap Note

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SAMPLE SOAP NOTE

S: Denies SOB/CP overnight. Now with 3 pillow orthopnea (improved from 4 on admission). Pt feels swelling in feet has improved, but still must elevate legs frequently. Walking in hall without difficulty, but did not tolerate stairs yesterday.

O: Tm 99.3, Tc 98.6, HR 87, RR 14, BP 114/69-129/78; I/O 1800cc/4500cc

Physical Exam GEN: A&O x3, NAD HEENT: PERRL, oral mucous membranes moist CV: RRR, S3 present, no m/r RESP: few crackles bilateral bases, o/w CTA ABD: S/NT/ND, (+) BS, no HSM GU: Foley draining clear yellow urine EXT: no cyanosis or clubbing, 2+ pitting edema to mid calf bilaterally

Labs

WBC: 8.6, Hgb 10.1, plt 243

140/96/18
- - - - - - - < 153
3.1/26/1.4


Blood sugars: 141/153/127/159


Imaging CXR: infiltrates in bilateral bases, improved in comparison to admission film

A/P: 68 y/o WM with a hx of CHF, HTN, & Type 2 DM who was admitted for DOE and edema  found to have decompensated CHF.

1. CHF: Symptoms improved from admission with aggressive diuresis, but still with mild dyspnea on exertion. Echo scheduled today to evaluate EF and overall cardiac function. Will continue ACE-I and low Na diet along with aggressive diuresis with furosemide. Could consider addition of digoxin if symptoms persist in spite of adequate diuresis.

2. HTN: Well controlled on ACE-I and furosemide. Continue current treatment.

3. Diabetes: Blood sugars higher than our target of <180. Will increase glargine to 46 units qHS.

4. Hypokalemia: Likely secondary to diuresis with furosemide. Replace K+. Continue to monitor BMP.

5. Prophylaxis: Receiving nexium for GI ppx and enoxaparin for DVT ppx.

Dispo: Anticipate discharge in next 3-4 days if symptoms continue to improve.

Code Status: Full Code