13 May The patient is a 69-year-old male presenting for a medication refill request for Coreg (carvedilol) 12.5 mg.
ASSESSMENT: Primary diagnosis provided ICD-10 code. The plan was supported with 1-2 reference(s) and provided at least 2-3 differential diagnosis with rationales with ICD-10 codes in APA format. A reflection note provided.
PLAN: A pertinent plan of care, follow-up instructions, and patient education was developed and supported with at least one to two references in APA format.
SOURCES( please provide pertinent sources.) No Limit.
USE the Soap Template attached for reference
CC
Med refill
Subjective
The patient is a 69-year-old male presenting for a medication refill request for Coreg (carvedilol) 12.5 mg. The patient reports this is the only medication he currently takes and states he takes it once daily, despite it being prescribed twice daily. He reports not taking any other antihypertensive medications listed in his medication profile, including nifedipine, losartan, and hydrochlorothiazide.
During the visit, the patient was noted to be incontinent of stool, with stool present on clothing and lower extremities. The patient stated, “I had an accident on the way here.”
The patient is alert and oriented ×4 (self, place, date, and situation). He denies chest pain, shortness of breath, dizziness, or headache.
Medications
Coreg 12.5 mg tablet, daily
Allergies
No known allergies
Mental/Functional
Mental Status:
The patient is alert and oriented ×4 to person, place, date, and situation. Speech is clear and coherent. Thought process is logical. Mood and affect are appropriate. No acute confusion noted.
Functional Status:
The patient is ambulatory and able to present independently to the clinic; however, he experienced bowel incontinence prior to arrival, reporting an accident on the way to the visit. He is able to communicate needs appropriately. No focal functional deficits observed at this time
Vitals
26 Jan 2026 – 12:02 PM –
BP:
208.0 / 100.0
HR:
72.0 bpm
RR:
16.0 rpm
Ht/Lt:
5′ 11″
Wt:
245 lbs 0 oz
BMI:
34.17
SpO2:
97.0%
Objective
The patient appears in no acute distress (NAD) and is cooperative with the examination. He is obese. Noted to be poorly groomed with greasy, disheveled hair and wearing visibly soiled clothing. Stool was observed on pants and shoes. The patient had a noticeable odor consistent with fecal soiling.
RESPIRATORY:
No respiratory distress noted. Respirations nonlabored.
CARDIOVASCULAR:
Regular rate and rhythm. No acute abnormalities appreciated.
GASTROINTESTINAL:
Evidence of stool incontinence noted during the visit.
EXTREMITIES:
No cyanosis, clubbing, or edema.
PSYCHIATRIC:
The patient is alert and oriented to person, place, and time. Mood and affect are appropriate overall; however, the patient became visibly upset and verbally resistant when advised to seek emergency department evaluation due to significantly elevated blood pressure. The patient stated, “Just give me my meds, I am not going to the ER.”
Assessment
Noncompliance with medication regimen (Z91.148) Patient’s other noncompl with meds regimen for other reason
Chronic kidney disease stage 3A (N18.31) Chronic kidney disease, stage 3a
Vitamin D deficiency (E55.9) Vitamin D deficiency, unspecified
Incontinence of feces (R15.9) Full incontinence of feces
Hypertensive emergency (I16.1) Hypertensive emergency
Plan
The patient was strongly and extensively advised to proceed to the emergency department due to critically elevated blood pressure and acute stool incontinence, which raised concern for a possible medical emergency. The patient was informed that his condition could not be safely managed in the clinic setting given the severity of his blood pressure elevation.
The patient declined emergency department evaluation and became visibly upset when informed that treatment could not be provided in the office under these circumstances. The patient is alert and oriented ×4, answers all questions appropriately, and demonstrates understanding of the situation. The patient was counseled on the risks of uncontrolled severe hypertension, including stroke, myocardial infarction, organ damage, permanent disability, and death. Despite this, the patient assumed full responsibility for refusing immediate emergency care and declined transfer to the emergency department.
Noncompliance with medication regimen
Taking medications exactly as prescribed is essential to prevent serious complications such as stroke, heart attack, and kidney damage.
Stopping or changing medications without medical guidance can cause dangerously high blood pressure and other health risks.
Discuss any side effects or concerns with your provider so medications can be adjusted safely rather than discontinued.
Chronic kidney disease stage 3A
Kidney function is moderately reduced and requires regular monitoring to prevent further decline.
Blood pressure and blood sugar control are critical to slow kidney disease progression.
Avoid NSAIDs and stay well hydrated unless otherwise directed by your provider.
Vitamin D deficiency
Low vitamin D levels can weaken bones and increase the risk of fractures and muscle weakness.
Take vitamin D supplements as prescribed and include vitamin D–rich foods in your diet.
Follow-up blood tests may be needed to ensure levels improve with treatment.
Incontinence of feces
Bowel incontinence may be related to nerve, muscle, or gastrointestinal conditions and should be evaluated further.
Report any new or worsening bowel control issues, especially if sudden in onset.
Proper hygiene and timely medical evaluation help prevent skin breakdown and infection.
Hypertensive emergency
Severely elevated blood pressure is a medical emergency that can cause stroke, heart attack, kidney failure, or death.
Immediate evaluation and treatment in an emergency setting are often required.
Strict adherence to blood pressure medications and close follow-up are critical to prevent recurrence.
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