Case study:
Mrs. L., a 68-year-old woman, presents to your office today with a complaint of feeling tired all the time and now, more recently, feeling weak and like “I can’t catch my breath sometimes.”
HPI: She has been healthy except for high cholesterol, managed by Lipitor. Her husband died 9 months ago, and she has attributed her fatigue to dealing with his death but realizes that she is feeling worse and not better as time passes.
Medications: Takes only Lipitor.
Past surgical history: Appendectomy in childhood; hysterectomy for uterine myoma 10 years ago.
No significant medical history. Has two daughters living nearby.
Blood pressure (BP) 106/70 mm Hg, heart rate (HR) 98 beats/min and regular, respiratory rate 18 breaths/min and afebrile, body mass index (BMI) 22 (10-pound weight loss since death of husband).
Slender, quiet-spoken older woman appearing tired.
PE: Conjunctiva pale, mucous membranes moist. No lymphadenopathy of neck or femoral area.
Heart tachyarrhythmia with regular rate, soft midsystolic murmur. Chest (CTA), good air movement.
Abdomen soft, bowel sounds × 4.
Diagnostics:
Urine dipstick negative.
The results of a colonoscopy show a neoplasm in the colon.
Address the following in your SOAP note:
- What additional subjective data are you seeking?
- What additional objective data will you be assessing for?
- What medical history would you obtain from the patient? List at least three.
- What tests will you order? Describe at least four lab tests.
- What are the differential diagnoses that you are considering? Describe two.
- What is your plan of care? List at least two diagnostic tests you will order to evaluate the cause of her condition.
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