NRNP 6539 Week 2 Hyperlipidemia SOAP Note Example

SOAP Note: A Flagged Cholesterol Result and a Father Lost Young in a 46-Year-Old Smoker

Student Name

College of Nursing, Walden University

NRNP 6539: Advanced Nurse Practice in Primary Care Adult Gerontology I

Instructor Name

Month Day, Year

SOAP Note: A Flagged Cholesterol Result and a Father Lost Young in a 46-Year-Old Smoker

Subjective

Reason for visit: J.K., a composite 46-year-old white man who works as a hospital security officer on rotating shifts, comes in because a cholesterol result from a workplace screening was flagged high, and because a heart attack killed his father at 49. He wants to know whether he is "headed the same way."

Tobacco: smokes about 15 cigarettes a day for 25 years, about 19 pack-years; has tried to quit twice without medication. Diet on shift: gas station breakfast sandwiches, fast food on night shifts, and energy drinks; rarely eats vegetables at home. Activity: walks his rounds but does no deliberate exercise. Alcohol: two or three beers on days off.

Symptoms: denies chest pain or pressure, breathlessness with exertion, palpitations, and calf pain when walking. No history of diabetes, kidney disease, or stroke. No medications. Family history: father died of myocardial infarction at 49; mother has type 2 diabetes; no known familial hypercholesterolemia.

Objective

Blood pressure 138/86 and 136/84, seated, appropriate cuff. Heart rate 78. Body mass index 29.8; waist circumference 40 inches. Heart regular without murmur; peripheral pulses normal; no carotid bruits; no xanthomas or corneal arcus, findings that would suggest familial hypercholesterolemia at his age (Dains et al., 2020).

Fasting lipid panel as supplied: total cholesterol 248 mg/dL, LDL cholesterol 168 mg/dL, HDL cholesterol 38 mg/dL, triglycerides 210 mg/dL. Hemoglobin A1c 5.8 percent. Creatinine normal.

Assessment

1. Hyperlipidemia with elevated 10-year atherosclerotic cardiovascular disease risk. Using the Pooled Cohort Equations with his inputs, age 46, male, white, total cholesterol 248, HDL 38, untreated systolic blood pressure 137, current smoker, and no diabetes, his estimated 10-year risk is about 12.7 percent. That places him in the intermediate-risk category of 7.5 to under 20 percent, in which the guideline recommends a clinician-patient risk discussion and, if risk is confirmed, a moderate-intensity statin (Grundy et al., 2019).

Risk-enhancing factors named in the guideline strengthen the case: premature heart disease in his father, who died before 55, persistently elevated LDL, metabolic features with an enlarged waist, triglycerides above 175, and borderline blood pressure (Grundy et al., 2019). With several risk enhancers in an intermediate-risk man, the estimate is more likely to understate his risk than overstate it.

A coronary artery calcium score is an option for the uncertain middle, where it can reclassify risk: a score of zero can support deferring statin therapy in some patients, while a positive score supports treatment. It is not an automatic order here, because his smoking and family history already point toward treatment, and the guideline notes that a zero score is less reassuring in current smokers.

Before attributing the lipid pattern to lifestyle and genetics, secondary causes were considered. Hypothyroidism raises LDL and is common, so a thyroid-stimulating hormone is added to today's orders. Nephrotic-range proteinuria and cholestatic liver disease raise cholesterol; his creatinine is normal, a urinalysis for protein is added, and liver enzymes will be checked with the statin baseline. No medications that raise lipids, such as corticosteroids or anabolic steroids, are being taken. Heavy alcohol use raises triglycerides, and his weekend drinking may contribute to the triglyceride level. His LDL of 168 is high but below the level of 190 at which familial hypercholesterolemia should be strongly suspected, and he has no tendon xanthomas, so genetic testing is not pursued now, although his father's early death keeps it in mind if his LDL fails to respond as expected.

2. Tobacco use disorder, the single most modifiable risk factor he has.

3. Prediabetes and elevated blood pressure, both part of the same metabolic picture.

Plan

Risk discussion: we reviewed his estimate, what it means (about 13 of 100 men with his profile would have a heart attack or stroke in ten years without treatment), the risk enhancers, and the expected benefit of each intervention. He chose to start a statin and to work on quitting smoking.

Statin: moderate-intensity statin therapy, atorvastatin 20 mg daily, the intensity recommended for intermediate-risk adults in primary prevention, with a goal of at least a 30 percent LDL reduction (Grundy et al., 2019). Muscle symptoms to report were reviewed.

Smoking cessation: combination nicotine replacement with a patch and a short-acting form, plus referral to the state quit line; varenicline discussed as an alternative if he prefers, since it is among the most effective single agents for cessation (Rosenthal & Burchum, 2021). Quitting would lower his risk more than any other single step.

Lifestyle: specific swaps for night-shift meals, water in place of energy drinks, and a goal of 150 minutes a week of brisk walking. Referral to a dietitian offered.

Blood pressure and glucose: home blood pressure readings for two weeks; repeat A1c in six months.

Follow-up: a fasting lipid recheck roughly two to three months after starting, to judge response and adherence, and a visit then to review blood pressure and smoking progress.

Baseline safety: liver enzymes are checked before starting the statin, as a baseline rather than for routine repeat monitoring, and a baseline creatine kinase is not routinely needed unless he develops muscle symptoms. He was told that the small increase in diabetes risk with statins is outweighed by the cardiovascular benefit at his level of risk.

References

Dains, J. E., Baumann, L. C., & Scheibel, P. (2020). Advanced health assessment and clinical diagnosis in primary care (6th ed.). Elsevier.

Grundy, S. M., Stone, N. J., Bailey, A. L., Beam, C., Birtcher, K. K., Blumenthal, R. S., Braun, L. T., de Ferranti, S., Faiella-Tommasino, J., Forman, D. E., Goldberg, R., Heidenreich, P. A., Hlatky, M. A., Jones, D. W., Lloyd-Jones, D., Lopez-Pajares, N., Ndumele, C. E., Orringer, C. E., Peralta, C. A., . . . Yeboah, J. (2019). 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation, 139(25), e1082-e1143. https://doi.org/10.1161/CIR.0000000000000625

Rosenthal, L. D., & Burchum, J. R. (2021). Lehne's pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.). Elsevier.