Critique the Lipid Follow Up Soap note

Critique the Lipid Follow Up Soap note

Critique the Lipid Follow Up Soap note .You must use clinical practice guidelines in your post.  Your critique should identify at least one positive and one area for future growth.

CC: Lipid follow-up

Subjective: Pt is a 60-year-old male that presents for follow-up, 3 months after starting Crestor 5mg QHS for LDL 147, pt denies any concerns or complaints. Pt denies muscle aches and states he has tolerated the medication without issue. Pt has history if hyperlipemia, hypertension, and obstructive sleep apnea. Pt currently works as a local truck driver for a food service company. Pt denies alcohol, recreational drugs, and tobacco usage. Medication include Bystolic 10mg daily and Crestor 5mg daily (which was started 3 months ago). Pt has no known drug allergies.


Vital signs: BP 129/73 HR 76 RR 20 Temperature 97.8 (temporal) O2 saturation 98%
Physical Exam
General: Pt is alert, no distress, does not appear toxic or diaphoretic
Neuro: No focal sensory or motor deficits noted, pt alert and oriented x4, able to answer
Psychiatric: Pt calm and cooperative,
HEENT: Normocephalic, atraumatic, mouth moist, PERRLA
Cardiac: No chest pain or palpitations, heart sounds normal, no murmur
Respiratory: No dyspnea, lungs clear to auscultation, respiratory effort normal, no cough
GI: soft, no masses, tenderness or guarding note
GU: Continent, no dysuria or increased frequency or urgency.
Musculoskeletal: ROM in all extremities

Skin: Warm. Dry and intact


Problem: elevated LDL
·       Labs: Lipid Panel
·       If his LDL remains above 150 and his HDL is not above 60, his Crestor will be increased to 10mg QHS and lipid panel re-checked in 3 months. Pt also encouraged to decrease amounts of total and saturated fats and attempt to consume more fruits, vegetables, lean meats, and whole grains (Keller et al., 2019). Keller et al. (2019) notes that a desirable LDL is between 70-100 and an HDL above 60 for cardioprotective benefits.

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Critique the Lipid Follow Up Soap note

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