Student Name: Course Name: Assignment Due Date: Week 3 SOAP Note Subjective Data: Chief Complaint: coughing, follow-up lab results. History of Present Illness: 37 year-old- Hispanic male, , who presents to the clinic for a follow up visit on abnormal triglyceride levels that were done 2 weeks ago, and a complaint of intermittent non-productive coughing x 2 weeks with mild clear nasal drainage and watery eyes. Cough worsens at night in supine position interfering with his sleep and is decreased during the day. Denies any. Constitutional symptoms or associated symptoms such as nasal congestion, headache, dyspnea or chest pain. Does anything make it better? Any OTC remedies? That all goes below. Medications: Lisinopril 20 mg once a day Simvastatin 20 mg once a day Metformin 1000 mg twice a day Glimepiride 4 mg once a day OTC- Loratadine 10mg once a day Allergies: No known drug allergies or food allergies. Has seasonal allergies during spring and summer.Possibly environmental as well. Past Medical History: hypertension, hyperlipidemia, diabetes, and seasonal allergies. Past Surgical History: No past surgical history. Personal/Social History: smokes one pack of cigarettes per day for 7 years. Still currently smoking. Drinks alcohol on occasion. Denies any drug use. States he does not exercise regularly and is not on any special diet, but is trying to start a diet and exercise program. Immunizations: Up-to-date. Last DTAP was 2 years ago, flu shot was in November 2012. Family History:. His father has diabetes and hypertension. His mother has hypertension and arthritis. He has one brother, still living with no medical problems. He is single, and has no children. Review of Systems: General: admits he is mildly obese, no recent weight change or loss, no fever, fatigue, or weakness. Skin: reports no rashes, mumps, sores, itching, dryness. Eyes: No changes in vision. No vertigo. No eye pain. Has watery eyes. Need to explain positive finding using the 7 variables Ears: No recent hearing loss. No tinnitus. No ear discharge or ear pressure. Nose: Seasonal allergies for which he takes Claritin but has been out for two months. Now symptoms are worsening. No nasal congestion. Has mild watery clear nasal discharge intermittently for three months with occasional cough at night. No epistaxis. Throat: Denies sore throat. No hoarseness. No bleeding gums or dry mouth. Neck: Denies neck pain or stiffness. Respiratory: See HPI. Non-productive cough. No hemoptysis. No wheeze. Cardiovascular: No palpitations, chest pain, edema, shortness of breath. States having history of diet controlled hypertension. Takes periodic readings at local pharmacy and ranges 130-140 systolic and 70 to 80 systolic. Has had difficulty controlling hyperlipedimia due to diet- likes eating fried food. Gastrointestinal: No nausea, vomiting, diarrhea, constipation. Endocrine: History DM type 2 which is control via diet and medication. Does not recall l.

1. Student Name:
Course Name:
Assignment Due Date:
Week 3 SOAP Note
Subjective Data:
Chief Complaint: coughing, follow-up lab results.
History of Present Illness: 37 year-old- Hispanic male, , who
presents to the clinic for a follow up visit on abnormal
triglyceride levels that were done 2 weeks ago, and a complaint
of intermittent non-productive coughing x 2 weeks with mild
clear nasal drainage and watery eyes. Cough worsens at night in
supine position interfering with his sleep and is decreased
during the day. Denies any. Constitutional symptoms or
associated symptoms such as nasal congestion, headache,
dyspnea or chest pain. Does anything make it better? Any OTC
remedies? That all goes below.
Medications:
Lisinopril 20 mg once a day
Simvastatin 20 mg once a day
Metformin 1000 mg twice a day
Glimepiride 4 mg once a day
OTC- Loratadine 10mg once a day
Allergies: No known drug allergies or food allergies. Has
seasonal allergies during spring and summer.Possibly
environmental as well.
Past Medical History: hypertension, hyperlipidemia, diabetes,

2. and seasonal allergies.
Past Surgical History: No past surgical history.
Personal/Social History: smokes one pack of cigarettes per day
for 7 years. Still currently smoking. Drinks alcohol on occasion.
Denies any drug use. States he does not exercise regularly and
is not on any special diet, but is trying to start a diet and
exercise program.
Immunizations: Up-to-date. Last DTAP was 2 years ago, flu
shot was in November 2012.
Family History:. His father has diabetes and hypertension. His
mother has hypertension and arthritis. He has one brother, still
living with no medical problems. He is single, and has no
children.
Review of Systems:
General: admits he is mildly obese, no recent weight change or
loss, no fever, fatigue, or weakness.
Skin: reports no rashes, mumps, sores, itching, dryness.
Eyes: No changes in vision. No vertigo. No eye pain. Has
watery eyes. Need to explain positive finding using the 7
variables
Ears: No recent hearing loss. No tinnitus. No ear discharge or
ear pressure.
Nose: Seasonal allergies for which he takes Claritin but has
been out for two months. Now symptoms are worsening. No
nasal congestion. Has mild watery clear nasal discharge
intermittently for three months with occasional cough at night.
No epistaxis.
Throat: Denies sore throat. No hoarseness. No bleeding gums or

3. dry mouth.
Neck: Denies neck pain or stiffness.
Respiratory: See HPI. Non-productive cough. No hemoptysis.
No wheeze.
Cardiovascular: No palpitations, chest pain, edema, shortness of
breath. States having history of diet controlled hypertension.
Takes periodic readings at local pharmacy and ranges 130-140
systolic and 70 to 80 systolic. Has had difficulty controlling
hyperlipedimia due to diet- likes eating fried food.
Gastrointestinal: No nausea, vomiting, diarrhea, constipation.
Endocrine: History DM type 2 which is control via diet and
medication. Does not recall latest HgB A1C reading- last
reading six months ago
Objective Data:
T: 36.5 Celsius (oral), BP 111/75, P: 96, RR: 16, wt: 119 kg
Need BMI
Generalized appearance is well with moderate obesity.
Remember, you need BMI to determine overweight versus
obese.
Skin: No rashes noted. No lumps or nodules.
Head: Normocephalic, Atraumatic.
Ears: Tympanic membranes are gray, non-bulging and freely
mobile with no erythematous. Ear canal patent bilaterally with
minimal cerumen. No drainage noted.
Nose: Nares patent bilaterally. No discharge. Mucosa pink and
moist. Septum midline. No edema over frontal or maxillary
sinuses. No sinus tenderness to percussion. Moderate clear nasal
discharge noted.

4. Pharynx: Oral mucosa pink, moist. Posterior oropharynx has no
erythema, exudate, or lesions. Tonsillar pillars are 2+ without
exudate. Uvula rises evenly. Gag reflex intact. No hoarseness.
Neck: Neck supple, non-tender without lymphadenopathy,
masses or thyromegaly.
Cardiac: Rhythm regular, no murmurs. Normal S1 and S2. No
S3, S4 or murmurs. No peripheral edema, cyanosis or pallor.
Extremities are warm and well perfused. Capillary refill is less
than 2 seconds. No carotid bruits.
Respiratory: Unlabored respirations. Symmetrical chest
expansion. Clear to auscultation bilaterally. No rales, rhonchi,
wheezing or diminished breath sounds.
Abdominal: Positive bowel sounds throughout all 4 quadrants.
Soft, non-distended, non-tender throughout with palpation. No
guarding or rebound. No masses. No hepatomegaly, spleen is
nontender with palpation.
GU: Not assessed.
Neuro: Gait normal. Oriented to person, place and time.
Labs: glucose 305, Hemoglobin A1C 11.4, Triglycerides 409.
Assessment:
Diagnosis 1: Hypertriglyerceridemia (diabetes, liver disease,
medications)
Differential Diagnoses:
1. Hypertriglyerceridemia: This condition occurs in diabetic
patients due to the insulin resistance, which often results in
increased free fatty acid delivery to the liver, causing peripheral
lipolysis (Subramanian, & Chait, 2012). This is the primary
diagnosis because elevated triglyceride levels were confirmed

5. by blood work. Patient is obese, not on a diet plan, smokes, and
has all the risk factors such as hypertension and diabetes. This
is the primary diagnosis.
2. Diabetes type 2,Poorly controlled: This condition occurs
when the body has problems with insulin resistance, causing a
disorder of the metabolism that manages blood glucose in the
blood stream. Hypertriglyceridemia can occur secondary to
diabetes, which in most cases, this is the cause of the condition.
Further, diabetes causes high, very low-density lipoprotein
cholesterol (VLDL-C) which is a form of fatty acids that are
present in obese patients, along with more abnormal lipid
profile such as high triglyceride (TG), high total cholesterol
(TC), low high-density lipoprotein cholesterol (HDL-C) and
high total cholesterol/high-density lipoprotein cholesterol
(TC/HDL-C) ratio (Breuer, Medizin, Gorlitz, 2001).
3. Liver disease: Liver disease can occur from high levels of
triglycerides in the blood, diabetes, obesity, and certain
medications (Mayo Clinic, 2012). The most common cause of
dyslipidemia is from over-production of endogenous TGs, which
is a form of free fatty acids that is produced by the liver
(Breuer, Medizin, Gorlitz, 2001).
4. Medications: Some medications can contribute to
hypertriglyceridemia, such as second-generation antipsychotic
medications, corticosteroids, and non-cardioselective beta-
blocker antihypertensives (Subramanian, & Chait, 2012; Yuan,
Al-Shali, & Hegele, 2007). However, in this case the patient is
not taking any of the medications that may increase the risk for
hypertriglyceridemia.
Diagnosis 2: Seasonal Allergies
Differential Diagnoses:
1. Seasonal allergies: Seasonal allergies are seen more
frequently from early spring to late fall, and can sometimes vary

6. depending on the location of where an individual lives (Moyad,
2008). The symptoms can include rhinorrhea, itchiness of the
nose and eyes, lacrimation, sneezing, and even headaches are
common at times (LeBlond, Brown, & DeGowin, 2009).
Postnasal drainage with supine position triggers cough to occur.
Patient reports clear nasal drainage and lacrimation, and denies
fever and sore throat. Reports history of seasonal allergies
(Seller, & Symons, 2012). Anterior clear nasal discharge was
noted on assessment (Holmes, & Scullion, 2012). Patient also
reported coughing to be worsen at night when he laid in a
supine position, which usually occurs with postnasal drip when
the discharge drips to the back of the throat due to gravity,
triggering the reflex to cause coughing to occur (Porth, &
Matfin, 2009). This is likely to be the primary diagnosis due to
the symptoms presented and his history of seasonal allergies.
2. Allergic rhinitis: This condition is pretty similar to seasonal
allergies. It even has the same symptoms as seasonal allergies.
The only difference between allergic rhinitis and seasonal
allergies is the cause of the symptoms. Allergic rhinitis is
usually cause by a triggering factor such as pollens, animal hair,
medicines, chemical, whereas in seasonal allergies, it would
normally occur certain time of the year (LeBlond, Brown, &
DeGowin, 2009). However, depending on the location, some
individuals may get seasonal allergies all year long (Moyad,
2008).
3. Sinusitis: This condition is usually accompanied by
coughing, rhinorrhea, and watery eyes. Patient denies fevers,
chills, or other complaints. No tenderness to sinuses with
percussion noted on assessment. No deviation to nasal septum.
Nasal turbinate boggy, pink, and glistening. No epistaxis. Nasal
cavity has clear discharge noted. Sinusitis is unlikely to be the
diagnosis because there is no sinus tenderness (Seller, &
Symons, 2012).
4. Upper respiratory infection: The patient does have the cough,
the lacrimation and rhinorrhea, but this condition is usually
accompanied by a low grade fever and malaise, which he denies

7. of any during the assessment. Lung sounds clear bilaterally.
URI is unlikely to be the diagnosis because there is no fever
(Seller, & Symons, 2012).
Plan:
1. Pulmonary: Chest xray ordered for coughing x 2 weeks to
rule out pneumonia (Huether, & McCance, 2012).
2. Endocrine: Actos increased to 30 mg by mouth (PO) every
day (QD) from 15 mg. Lantus started at 15 units subcutaneous
(SubQ) every night before sleep (QHS) to maintain morning
fingerstick blood sugar between 130 to 150. Add 1 unit to 15
units of Lantus every night until morning fingerstick blood
sugar is between 130 to 150.
3. Cardio: Discontinue simvastatin and start gemfibrozil 600 mg
QD. The combination of both these medications increases the
adverse risk for rhabdomyolysis (Curtin, & Jones, 2007). The
first-line agent of drug treatment for hypertriglyceridemia is
fibrates (Subramanian, & Chait, 2012).
4. Respiratory: Cetirizine 10 mg orally once a day reduces the
symptoms of seasonal allergies. Regular daily dose treatment
has been shown to be more effective than as needed basis
(Holmes, & Scullion, 2012).
5. ENT: Diphenhydramine 25 mg PO QHS as needed (PRN) to
reduce symptoms such as rhinorrhea and to reduce the risk of
side effects of drowsiness during day time. Diphenhydramine is
usually not recommended due to its drowsiness side effect, but
it is effective in reducing rhinorrhea (Holmes, & Scullion).
6. Health Promotion: Decrease in salt and fatty food intake,
exercise 2 to 3 times per week lasting 30 minutes each time, and
be compliant with medications. Do not drive after taking
diphenhydramine due to the side effect of drowsiness. Drink
plenty of fluids to maintain hydration and increase expectorant.
Avoid allergen or trigger factors such as staying in doors on

8. high-polluted days, pets with furs, pollens, etc. (Holmes, &
Scullion, 2012).
7. Send to lab for allergy testing.
8. Disease Prevention: Repeat blood work for blood glucose,
hemoglobin A1C, and fasting lipid profile in 3.
9. Return in 2 weeks for a follow up appointment for re-
evaluation of cough and allergy test, and in 2 months to review
repeat lab results for blood glucose, hemoglobin A1C, and
triglyceride levels.
10. Smoking cessation encourage. Given information regarding
smoking cessation approaches. Will discuss further at next visit.
Reflection Notes
In this situation, I agree to the plan of care. The one thing I
would have done differently is refer the patient to see an
allergist instead of waiting to see him again during the follow-
up appointment then referring him at that time. Sometimes it
may take weeks for the patient to actually get into see an
allergist. The sooner the patient is able to make an appointment,
the better it will be for him because the symptoms can be
controlled sooner. I would also recommend him to start taking
fish oil. Fish oil has been shown to decrease triglyceride levels
and reduce cardiovascular diseases (Oelrich, Dewell, &
Gardner, 2013).
References
Breuer, H., Medizin, A. I., & Gorlitz, St. C. (2001).
Hypertriglyceridemia: A review of clinical
relevance and treatment options: Focus on Cervistatin. Current
Medical Research and Opinion, 17(1), 60-73. Retrieved from
http://www.medscape.com/viewarticle/407814_1
Curtin, P., & Jones, W. (2007). Therapeutic rationale of
combining therapy with gemfibrozil and
simvastatin. Journal of the American Pharmacists Association:
Japha, 47(2), 140-146. Retrieved from http://www.japha.org/
Holmes, S., & Scullion, J. (2012). Allergic rhinitis: Assessment

9. and treatment. Nurse
Prescribing, 10(5), 222. Retrieved from
http://www.nurseprescribing.com/
Huether, S. E. & McCance, K. L. (2012). Understanding
pathophysiology (5th ed.). St. Louis,
MO: Mosby.
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2009).
DeGowin’s diagnostic examination
(9th ed.). New York, NY: McGraw Hill Medical.
Moyad, M. (2008). Conventional, complementary, and
alternative options for seasonal allergies.
Urologic Nursing, 28(3), 227-228. Retrieved from
http://www.suna.org/unj
Oelrich, B., Dewell, A., Gardner, C. D. (2013). Effect of fish
oil supplementation on serum
triglycerides, LDL cholesterol and LDL subfractions in
hypertriglyceridemia adults. Nutrition Metabolism and
Cardiovascular Diseases, 23(4), 350-357. Retrieved from
http://www.sciencedirect.com/science/journal/09394753
Porth, C. M., & Matfin, G. (2009). Pathophysiology: Concepts
of altered health states (8th ed.). Philadelphia, PA: Lippinocott
Williams & Wilkins.
Seller, R. H., & Symons, A. B. (2012). Differential diagnosis of
common complaints (6th ed.).
Philadelphia, PA: W. B. Saunders Company.
Subramanian, S., & Chait, A. (2012). Hypertriglyceridemia
secondary to obesity and diabetes.
Biochimica Et Biophysica Acta, 1821(5), 819-825.
doi:10.1016/j.bbalip.2011.10.003
Yuan, G., Al-Shali, K. Z., & Hegele, R. A. (2007).
Hypertriglyceridemia: Its etiology, effects,
and treatment. Canada Medical Association Journal, 176(8),
1113-1120. doi: 10.1503/cmaj.060963