Alyssa Matulich

Geriatric Soap Note

SUBJECTIVE:

PATIENT IDENTIFIERS: T.S.., male, 61, African American, 7/26/18, not a reliable historian
here with fiancé who is primary care giver

CHIEF COMPLAINT (CC): follow up for stroke in March

HISTORY OF PRESENT ILLNESS (HPI): Patient had a stroke in March and is needing
refills on medications. Pt stroke due to uncontrolled high blood pressure and pt noncompliance
with blood pressure medication. Fiancé states pt was in the hospital for one week and then did a
week in rehab. Fiancé has noticed problems with memory and trouble walking with left leg.

PMH: Pt has a history of arthritis of knees, benign prostate hyperplasia, cardiomegaly, CVA,
genital warts, gout, HTN, and hyperlipidemia.

ALLERGIES & REACTIONS: No known allergies

PERSONAL HISTORY: Patient lives in a single-family home his fiancé in Alabama. He is

unemployed due to inability to work since his stroke.

SOCIAL HISTORY: Pt denies smoking currently but is a former. Pt states he drinks 2 beers per
day. Denies illicit drug use. Patient states he does not exercises due to trouble walking since the
stroke. Patient has access to food, running water, electricity, and shelter. Patient states he feels
safe in his neighborhood. He lives 30 minutes from the nearest hospital. He does not have health
insurance. All verified by fiancé.

HEALTH MAINTENANCE: Last PE Jan 2018; Labs WNL expect lipid profile was extremely
high. Pt needs a colonoscopy and has been referred through project access but was unable to go
to appointment due to stroke. PSA done in Jan 2018 WNL. Vaccines up to date at this time per
patient and fiancé no record available.

FAMILY HISTORY: Mother has a history of HTN. Father has a history of Alzheimer’s disease
and HTN.

CURRENT MEDICATIONS & TREATMENTS: pt does NOT take medications regularly

and does not know which medications he does take.

1) Allopurinol 100mg- 1 tablet twice daily

2) Amlodipine Besylate- 1 tablet daily
3) Baby Aspirin 81mg- 1 tablet daily
4) Cialis 10mg- one tablet daily one hour before needed
5) Lisinopril-Hydrochlorothiazide 40-25mg- 1 tablet daily
6) Metoprolol Tartate 50mg-1 tablet every 12 hours
Alyssa Matulich

7) Pravastatin sodium 80mg- 1 tablet at bedtime

8) Tamsulosin HCL 0.4mg- 1 tablet daily
9) Clopidogrel 75mg- 1 tablet daily
10) Colrite 100mg- 1 tablet twice daily
11) Ibuprofen 800mg- 1 tablet every 8 hours
12) Naproxen 500mg 1 tablet every 8 hours

REVIEW OF SYSTEMS:
GENERAL: denies fever, chills, fatigue, malaise, night sweats and weight change.

DIET: No change in appetite. Pt does not eat a low fat, low sodium diet. Pt cannot complete a
24-hour diet recall. Fiancé states he eats a lot of fried chicken and frozen hungry man dinners.
This morning he ate bacon, eggs, a biscuit and gravy. He does not take vitamins or supplements

SKIN, HAIR, NAILS: Denies Rash, lesions, eruptions, itching, and pigment changes.

HEAD AND NECK: Denies headaches, dizziness, head injuries, loss of consciousness.

EYES: Denies blurring, double vision, visual changes, glasses, trauma, and eye diseases.

EARS: Denies hearing loss, pain, discharge, vertigo, tinnitus.

NOSE: Denies congestion, nosebleeds, postnasal drip, allergies

THROAT AND MOUTH: Denies hoarseness, sore throat, bleeding gums, ulcers, tooth

problems

GASTROINTESTINAL: Denies indigestion, heartburn, vomiting, bowel regularity/changes

LYMPH: denies tenderness, enlargement

ENDOCRINE: denies Heat/cold intolerance, weight change, polydipsia, polyuria, hair changes,
increased hat, glove, or shoe size

CHEST AND LUNGS: denies Cough, sputum, shortness of breath, dyspnea on exertion, night
sweats, exposure to TB.

CARDIOVASCULAR: Denies chest pain, palpitations, edema, claudication, exercise

intolerance. Sleeps with 2 pillows
Alyssa Matulich

HEMATOLOGY: denies anemia, easy bruising

GENITOURINARY: denies dysuria, urgency, frequency, nocturia, hematuria, and dribbling.
Denies flank pain.

MUSCULOSKELETAL: denies joint pain, heat or swelling.

NEUROLOGIC: denies fainting, weakness, loss of coordination

MENTAL STATUS: denies trouble with concentration, sleeping, eating, socialization, mood
changes, suicidal thoughts ( Fiancé states that he has trouble concentrating and with memory.)

OBJECTIVE:
Physical Examination: Pt had taken no medication prior to appointment
VS: TPR: 98.5, BP: 190/121 recheck 213/110 after medication taken 172/101, Ht: 5ft 5 in, Wt:
205 lb 6oz, HR: 74, Resp: 20, O2: 99

GENERAL APPEARANCE: 61, AA male, posture and gait adequate, wearing sunglasses in
office.

MENTAL STATUS: pt is awake and oriented to place, speech quality clear. Slums completed
and pt scored a 9. Pt unable to correctly state the year, month, and president. Pt cannot recall
what he had for breakfast this morning.

SKIN: skin uniformly warm and dry, resilient, turgor < 2, no edema. Skin color dark brown.
Hair black and has male distribution pattern. Nails are nontender, medium length, clean, without
deformities. Nail bed pink, nail base 160 degrees, no redness, exudate, or swelling around folds.

HEAD, Neck, Throat: Head normocephalic, oval without deformities. Hair is clean, black,
evenly distributed throughout without infestation. Skin is pink and dry without lumps, lesions, or
scales. Temporal arteries without bruits. Trachea midline without tugging. Cervical range of
motion intact. Carotid arteries symmetrical, pulse waveform with distinct beginning and end
without bruit. Thyroid symmetrical, no enlargement, no tenderness, no lumps. No jugular venous
distension. No lymphadenopathy.

EYES: symmetrical, irises brown, pupils equal and reactive to light bilaterally. Eyes blood shot,
watering and sensitive to light. Conjunctiva pink, no drainage or discharge bilaterally. No
strabismus. No nystagmus. Normal eye movement bilaterally. Visual fields intact bilaterally.

EARS: rounded, even with outer eye canthus, helix firm bilaterally. Ear lobes symmetrical. No
deformities, no lesions, no drainage externally. Internal auditory canal without drainage, redness,
edema, pain, and tenderness bilaterally. Tympanic membrane visible, grey, translucent without
inflammation. Landmarks visible, cone of light at 5 o clock in right ear and 8 o clock in left ear.
Air conduction greater than bone conduction. No lateralization.
Alyssa Matulich

NOSE and mouth: appropriate size for face, color confluent with entire face. Nasal mucosa
pink and moist no turbinates visible. No discharge, no sinus swelling or tenderness. Septum
midline. Lips pink, moist, symmetrical. Buccal mucosa pink and moist without lesions. Teeth
clean, with braces, no dental carries. Gums pink and moist without bleeding and tenderness.
Tongue soft, pink, midline with full range of motion intact. Tonsils +1 without swelling, exudate,
or drainage. Uvula midline. Hard and soft palates intact. Palatine arch rounded.

CHEST/LUNGS: Skin pink and warm. No pallor. No cyanosis. AP/Lateral Ratio 1:2, no barrel
chest, no pectus excavatum, no pectus carinatum. Chest movement symmetrical, Respirations
equal and regular, non-labored, no accessory muscle use. Chest expansion symmetrical.
Resonance on percussion over all lung fields. Breath sounds clear in all fields. No adventitious
breath sounds.

HEART/ blood vessels: PMI nondisplaced at 5th intercostal space at the midclavicular line.
Regular heart rate and rhythm. S1 and S2 equal. No splitting, no murmurs, no bruits, no lifts, no
heaves, no thrills. Carotid pulses equal bilaterally with crescendo and decrescendo, rate regular.
No JVD. Pulses 2+ bilaterally on upper and lower extremities. No edema.

ABDOMEN: Skin pink, no venous pattern visible. Abdomen rounded and symmetric and soft.
No distension. Umbilicus midline, no herniations, no masses. Bowel sounds active in all four
quadrants. No hepatomegaly, no splenomegaly. Tympany predominant in all four quadrants. No
tenderness on palpation. No bruit over aorta no aortic pulsation. No CVA tenderness

MUSCULOSKELETAL: Gait is uneven, left leg drags slightly along the floor. Curvature of
cervical, thoracic, and lumbar spine is appropriate. No kyphosis, no lordosis. Joints appropriate
size and contour with no swelling or crepitus. All joints have full range of motion. Muscle
strength 4/5 in all extremities. No edema, spasms, masses, atrophy, hypertrophy in any muscle
groups bilaterally.

NEUROLOgIC: Pt awake and oriented to place. Coordination and fine motor skills intact. All
reflexes 2+ bilaterally. Flat affect. Not talkative responding with one word answers.

ASSESSMENT:

HTN: I10

Hyperlipidemia E78.5

Arthritis M19.90

Visit Code: 99213

Diagnostic Criteria:

HTN diagnostics according to up to date:

Alyssa Matulich

Basile, J., & Bloch, M. (2018, January). Retrieved from https://www.uptodate.com/contents/overview-of-hypertension-

in-adult

In patients who have an elevated office blood pressure, the diagnosis of hypertension should be
confirmed using out-of-office blood pressure measurement whenever possible. Ambulatory
blood pressure monitoring (ABPM) is considered the “gold standard” in determining out-of-
office blood pressure. However, many payers require evidence of normal out-of-office readings
(suspected white coat hypertension) for reimbursement of ABPM. As such, we suggest home
blood pressure measurement as the initial strategy to confirm the diagnosis of hypertension in
most patients:

●Hypertension is diagnosed if the mean home blood pressure, when measured with
appropriate technique and with a device that has been validated in the office,
is ≥130/≥80 mmHg.

●ABPM is an alternative to home blood pressure monitoring in settings where ABPM is

readily available, particularly if adequate home blood pressures cannot be obtained, if there
is doubt about the validity of home readings or if there is a large discrepancy between office
and home readings. When using ABPM, hypertension is diagnosed if the mean daytime
blood pressure is ≥130/≥80 mmHg.

● Occasionally, out-of-office confirmation of hypertension is not possible because of issues

with availability of equipment, insurance, and cost. In these situations, a diagnosis of
hypertension can be confirmed by serial (at least three) office-based blood pressure
measurements spaced over a period of weeks to months with a mean of ≥130/≥80 mmHg.

Hyperlipidemia diagnostic criteria according to Epocrates:

(n.d.). Retrieved from https://online.epocrates.com/diseases/17036/Hypercholesterolemia/Diagnostic-Criteria

LDL-cholesterol:
 Optimal: <100 mg/dL (<2.6 mmol/L)
 Near or above optimal: 100 to 129 mg/dL (2.6 to 3.3 mmol/L
 Borderline high: 130 to 159 mg/dL (3.367 to 4.1 mmol/L )
 High: 160 to 189 mg/dL (4.1 to 4.9 mmol/L)
 Very high: ≥190 mg/dL (≥4.9 mmol/L).
Total cholesterol:
 Desirable: <200 mg/dL (<5.2 mmol/L)
 Borderline high: 200 to 239 mg/dL (5.2 to 6.2 mmol/L)
 High: ≥240 mg/dL (≥6.2 mmol/L).
HDL-cholesterol:
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 Low: <40 mg/dL (<1 mmol/L)

 High: ≥60 mg/dL (≥1.554 mmol/L).

PLAN:

No labs today. Fasting labs and BP check scheduled in one week. Follow-up in 3 months

Polypharmacy: Went through patient’s medications today and only kept necessary medications.
STOPPED Naproxen, Ibuprofen, cialis and colrite. Made a list of patient’s current medications
(8 total) with instructions. Pt agrees to take all medications as directed.

Dementia: referred pt to neurology for a decrease in memory and a score of 9 on slums. Pt told
he can no longer drive due to safety and memory concerns.

HTN: NOT controlled well. Pt does not take medications correctly. Reviewed medications with
pt and his fiancé and discussed importance of taking medications as scheduled every day. Fiancé
agrees to monitor and give the medications to pt daily and get a weekly pill container to organize
medications.

Hyperlipidemia: continue Pravastatin. Pt and Fiancé agree to eat low fat and low cholesterol diet.

Health maintenance: Pt is in need of a colonoscopy and agrees to call and schedule one through
project access as soon as possible.