Soap note
SOAP NOTE
Name: G.P Date: 08/30/2019 Time: 1500 Age: 65 Sex: M SUBJECTIVE CC:
“Increased leg pain with walking and other exercises”
HPI: G.P, a 65 y/o Caucasian male presents to the clinic with complaints of increasing leg pain with walking and other exercises. Patient reports that the pain started 2 years ago and over the past few weeks it has become more severe. He states that the pain in his calves starts/gets worse after walking around 200 yards and is relieved with rest. The pain resolves within 10 minutes of rest. As a consequence, patient reports that he has become less physically active. Patient denies rest pain. He states that the pain is worse on his right calf compared to his left calf. Patient reports that he was diagnosed with type 2 diabetes mellitus ten years ago which he manages using daily Metformin. He also has stable angina, for which he takes atenolol in addition to occasional nitroglycerin. Patient denies numbness, burning sensation, or reduced feeling in lower extremities, leg ulcers, blackening over toes, thickening of toenails, swelling, discoloration along superficial veins, and skin discoloration. Medications:
Metformin 500 mg bid for type 2 diabetes mellitus
Atenolol 100 mg PO daily for Angina pectoris
Nitroglycerin 2.5 mg PO q6-8hr for Angina pectoris
PMH
Allergies: No known drug or food allergies
Medication Intolerances: None
Chronic Illnesses/Major traumas: Type 2 diabetes mellitus (diagnosed ten years ago), Stable angina diagnosed 3 years ago, atherosclerosis (diagnosed 5 years ago)
Hospitalizations/Surgeries: Patient was hospitalized for 3 days because of chest pain 3 years ago. No history of surgeries
Family History
Father had peripheral vascular disease, type 2 diabetes mellitus, HTN, died from a stroke at the age of 82. Mother had HTN and colon cancer, died at the age of 85. Brother had PAD.
Social History
Patient is married and has two sons. Lives with wife and youngest son. He is a retired mechanical engineer, currently operates car workshop/garage. Reports drinking alcohol (1-2 beers per week). Reports smoking history (7 cigarettes per day for the past 40 years). Reports that he tried to quit smoking after developing angina but “After nearly 30 years of smoking, I think it’s not possible”. Denies illicit drug use
ROS General
Denies recent weight change/loss, fever, chills or weakness
Cardiovascular
Denies chest pain, dyspnea on exertion, orthopnea, PND, or edema
Skin
Denies delayed healing, rashes, pallor, Shiny/scaly skin or any skin discolorations
Respiratory
Denies dyspnea or cough
Eyes
Reports that he is short-sighted and uses corrective lenses. Denies blurring, or visual changes
Gastrointestinal
Denies abdominal pain, NV/D, constipation, hepatitis, or black tarry stools
Ears
N/A
Genitourinary/Gynecological
Denies urgency, frequency burning, or changes in urine color
Denies erectile dysfunction
Nose/Mouth/Throat
Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain
Musculoskeletal
Reports calf cramping with walking that is relieved by rest. Denies back pain, joint swelling, pain or stiffness.
Breast Neurological
N/A
Denies paralysis, paresthesia, numbness, weakness, blackout spells, or loss of consciousness.
Heme/Lymph/Endo
Denies bruising, swollen glands, increased thirst and hunger, or cold or heat intolerance
Psychiatric
Denies depression, sleeping problems, and anxiety
OBJECTIVE Weight: 216 lb BMI: 32.7 Temp: 97.6°F BP: 13878 Height: 68 inches Pulse: 66 Resp: 18 General Appearance
Obese adult male in no acute distress. Alert and oriented to time, place and person.
Skin
Skin warm and dry. No jaundice, or cyanosis. Negative for lesions or rashes. Skin in lower extremities below knees cool and pale. HEENT
N/A
Cardiovascular
S1, S2 with RRR. No murmurs, extra sounds, rubs or clicks. Radial and branchial pulse 2+ bilaterally. Posterior tibial pulses weak bilaterally (1+), weak pedal pulse (1+) on right foot, unable to palpate on left foot; 1+ to 2+ edema both feet and ankles. Delayed capillary refill in lower extremities nailbeds. No carotid bruit.
Respiratory
Chest wall symmetric. Respirations regular and non-labored. Lungs CTAB
Gastrointestinal
Abdomen soft, flat and non-tender. Normoactive BS in all 4 quadrants. No hepatosplenomegaly. On percussion, no free fluid present. No dilated veins, scar or striae
Breast
N/A Genitourinary
N/A Musculoskeletal
Full ROM in lower extremities. Back and spine normal. Muscle wasting evident in calf muscles of right lower limb compared to left. Neurological
Posture erect, balance stable, gait normal. Speech is clear with a good tone
Psychiatric
Alert and oriented X3. Maintains eye contact.
Lab Tests
Complete blood count- WNL
HbA1c – 6.9 %
Total cholesterol - 205 mg/dL (Elevated)
LDL- 162 mg/dL (Elevated)
HDL- 50 mg/d
Triglycerides- 149 mg/dL
Special Tests
Ankle-brachial index (ABI): Right leg ABI - 0.83 (< 0.9), Left leg ABI – 0.81 (<0.9).
Diagnosis Differential Diagnoses o 1- Peripheral neuropathy. I rule out this diagnosis because patient denies
numbness, burning sensation in lower extremities. During physical examination
there are not ulcers or infections in feet (Hollier, 2018). o 2- Deep Venous Thrombosis (DVT). Deep venous thrombosis describes the
manifestation of the venous thromboembolism (Armstrong, 2018). The primary signs and symptoms of the DVT include leg pain, edema, tenderness, skin erythema, and clinical symptoms of PE as the initial manifestation (Armstrong, 2018). The leg pain is usually worse in the thigh and groin region, and it is worsened by walking, relieved by resting or leg elevation.
o 3- Spinal Stenosis-Lumbar spondylosis refers to degenerative conditions that affect the lumber spine (Armstrong, 2018). The condition is prevalent among individuals aged 50 years or older and it is characterized by pain in the back, leg, thighs or buttock that worsens with standing and relieved by position change such as sitting or stooping forward (Armstrong, 2018). The pain can also occur in the leg with exercise. Other symptoms include abnormality walking, muscle weakness and cramping in addition to leg numbness, or reduced sensation on touch (Armstrong, 2018). Risk factors of the condition include age (50 years or older), previous injury or surgery of the spine, osteoarthritis, Inflammatory spondylarthritis, Paget’s disease and spinal tumors (Armstrong, 2018)
Diagnosis Peripheral Artery Disease (ICD-10 code I73.9). This patient has risk factor such as Type 2 DM, atherosclerosis, smoking history, advancing age, obesity, and family history of peripheral vascular disease. Patient reports calf cramping with walking that is relieved by rest. During examination, skin in lower extremities is pale and cool. Posterior tibial pulses weak bilaterally (1+), weak pedal pulse (1+) on right foot, unable to palpate on left foot; 1+ to 2+ edema both feet and ankles. Delayed capillary refill in lower extremities nailbeds. Muscle wasting evident in calf muscles of right lower limb compared to left. Ankle-brachial index (ABI): Right leg ABI - 0.83 (< 0.9), Left leg ABI – 0.81 (<0.9).
Peripheral artery disease is a peripheral vascular disease that is caused by atherosclerotic obstruction of the arteries of the lower extremities. The condition can be symptomatic or asymptomatic. In symptomatic patients, the condition is mainly characterized by claudication including fatigue, discomfort or pain in the leg/hip with walking that is typically relieved by rest (Kullo & Rooke, 2016). Claudication is caused by inadequate blood flow to the lower extremities. The signs of critical limb ischemia may also be present including limb pain at rest, ulcers or gangrene, hair loss over the dorsum of foot, muscle atrophy shiny/scaly skin and thickened toenails (Kullo & Rooke, 2016). Also, acute limb ischemia may be present as characterized by pain, paralysis, pulselessness, paresthesia, pallor, and perishing with cold (Kullo & Rooke, 2016). Physical exam findings often include diminished pulse in extremities, gangrene, muscle atrophy, dependent rubor, and pallor with leg elevation (Aboyans et al 2017). Risk factors of the condition include age of 65 years or older, atherosclerosis, diabetes mellitus, smoking, hypertension, hyperlipidemia, family history of PAD or medical history of atherosclerotic disease (Kullo & Rooke, 2016).
Plan/Therapeutics Further testing Color-flow Doppler ultrasound - Ordered to assess the location and degrees of stenosis.
The imaging test is highly accurate in the diagnosis of PAD (Armstrong, 2018). Medication Aspirin 81 mg/ day PO-Antiplatelet therapy with aspirin is the first line treatment of claudication associated with PAD. Evidence shows that antiplatelet therapy significantly reduces cardiovascular events in patients with claudication (Basili & Violi, 2019). Aspirin works by inhibiting prostaglandin synthesis this preventing the formation of platelet aggregating thromboxane A2 (Basili & Violi, 2019). This reduces thrombin generation and formation of fibrin thus minimizing clot propagation. Atorvastatin 40 mg PO at bedtime- The medication is a statin used to lower serum cholesterol levels in the blood so as to prevent cardiovascular events including heart attacks and strokes. Statins are indicated for all patients with PAD to help them achieve LDL less than 100 mg/dL (Gerhard-Herman et al., 2017). According to Raymond et al. (2017) lipid-lowering therapy has been shown to reduce cardiovascular events as well as the progression of PAD. Education Patient was educated on peripheral artery disease including the condition's signs and symptoms, causes, risk factors, prognosis, and complications. Patient was also educated regarding the importance of treatment adherence, smoking cessation, limiting alcohol intake, diabetes control and cholesterol control (Gerhard-Herman et al., 2017). The impacts of smoking on blood vessel was discussed with the patient and the patient was helped to identify smoking cessation strategies including support groups and nicotine patches. The importance of exercise in the treatment of claudication and weight management was discussed with the patient and he was advised to walk at least 15 mins three to four times a day, gradually increasing his duration and pace of exercise. Patient was advised to stop exercise and rest for 3 mins if claudication develops then resume exercising. The importance of dietary interventions for reducing the risk of cardiovascular events including intake of low calorie, low-fat and low-cholesterol was also discussed with the patients. An appointment with a dietitian was scheduled to help the patient develop an ADA diet that includes the preferred foods as well as puts into consideration usual eating patterns. Lastly, the previous foot care teaching was reinforced to help patient prevent diabetic foot neuropathy and measures to prevent injury were also discussed. Non-medication treatments Supervised exercise program for 3 months- As first-line therapy for patients with intermittent claudication, exercise therapy in the form of supervised training program has been shown to be effective in improving walking ability and functional outcomes in patients with claudication (Ehrman, Lui & Treat-Jacobson, 2017). The exercise should include walking a minimum of at least 3 times per week (30-60 min/session) for at least 3 months as recommended by AHA/ACC, and Trans-Atlantic Inter-Society Consensus Document on Management of PAD (Gerhard-Herman et al., 2017). Follow-up- Patient was scheduled to return to the clinic after 3 weeks for reevaluation and to receive lab/diagnostic test results Evaluation of patient encounter- The patient encounter went well as the patient was cooperative throughout the session. The education given to the patient was well received as she was attentive to all the guidelines and other procedures. The patient admitted adhering to the treatment regimen and follow-up as instructed. The encounter provided
me with increased insight on the evaluation and treatment of patients presenting with signs and symptoms of peripheral arterial disease (PAD).
Reference:
Aboyans, V., Ricco, J. B., Bartelink, M. L. E., Björck, M., Brodmann, M., Cohnert, T., ... & Espinola-Klein, C. (2017). 2017 ESC guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the European Society for Vascular Surgery (ESVS) document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries endorsed by: the European stroke organization (ESO) the task force for the diagnosis and treatment of peripheral arterial diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular .... European heart journal, 39(9), 763-816
Armstrong, E. (2018). Peripheral arterial disease - Symptoms, diagnosis, and treatment | BMJ Best Practice. Retrieved 28 August 2019, from https://newbp.bmj.com/topics/en-gb/431/differentials.
Basili, S., & Violi, F. (2019). Antiplatelet Drugs in the Management of Thrombotic/Ischemic Events in Peripheral Artery Disease. In Platelets (pp. 1059-1066). Academic Press.
Ehrman, J. K., Lui, K., & Treat-Jacobson, D. (2017). Supervised exercise training for symptomatic peripheral artery disease. Journal of Clinical Exercise Physiology, 6(4), 78- 83.
Gerhard-Herman, M. D., Gornik, H. L., Barrett, C., Barshes, N. R., Corriere, M. A., Drachman, D. E., ... & Lookstein, R. (2017). 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology, 69(11), e71-e126.
Hollier, A. (2018). Clinical guidelines in primary care. Scott, LA: Advanced Practice
Education Associates.
Kullo, I. J., & Rooke, T. W. (2016). Peripheral artery disease. New England Journal of Medicine, 374(9), 861-871.
Raymond Foley, T., Singh, G. D., Kokkinidis, D. G., Choy, H. H. K., Pham, T. H., Amsterdam, E. A., ... & Laird, J. R. (2017). High‐Intensity Statin Therapy Is Associated With Improved Survival in Patients With Peripheral Artery Disease. Journal of the American Heart Association, 6(7), e005699.