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41_NR509_SOAPcardiovascularanginachestpain.odt

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SOAP Note Template

Initials: B.F.						Age: 59					Gender: male
Height	Weight	BP		HR				RR	Temp		SPO2
5’11 ft	197 lbs	146/90		104				19	36.7 C		98% room air
History of Present Illness (HPI)
Chief Complaint (CC)			chest pain
O nset			3 episodes within last month
L ocation			middle of chest
D uration			several minutes
C haracteristics			tightness to chest, rates worst pain at 5, not radiating. Triggered by yard work and taking stairs. Not triggered by eating
A ggravating Factors			activity
R elieving Factors			rest
T reatment			none
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication (Rx, OTC, or Homeopathic)					Dosage		Frequency			Length of Time Used	Reason for Use
Metoprolol					100mg		once daily			1 year	hypertension
Lipitor					20mg		at bedtime			1 year	hyperlipidemia
Fish oil					1200mg		twice daily			1 year	hyperlipidemia
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Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses, hospitalizations, and surgeries. Depending on the CC, more info may be needed.
Allergic to codeine: nausea and vomiting. Immunizations: Tdap 10/2014 and current influenza shot. History of hypertension and hyperlipidemia for 1 year. Report annual stress test and recent EKG, without abnormalities. Denies previous chest pain, past history of angina, coronary artery disease, diabetes mellitus, blood clots, rheumatic fever, murmurs, easy bleeding, cough, orthopnea. Denies BP monitoring at home. Reports recent visit to cardiologist and visits to primary every 6 months (last visit 3 months ago). Denies surgical history .
Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent data. Include health promotion such as use seat belts all the time or working smoke detectors in the house.
Engineer. Reports low stress life at home and work. Denies recent major life events such as death in the family. Denies regular exercise. Breakfast:granola bar and instant breakfast shake.Lunch:turkey sub. Dinner: grilled meat and vegetables. Denies moderation of salt intake. Regular water intake, 1 liter daily, no sodas, 2 cups of coffee daily. Denies tobacco, illicit drugs. Reports alcohol 2-3 drinks per week, on weekends.
Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
Maternal grandfather: heart attack at age 54. Diseased. Maternal grandmother: diseased: breast cancer Paternal grandmother:Pneumonia at 78 Paternal grandfather:diseased at 85, not known medical conditions Mother: diabetes and hypertension Father: hypertension, high cholesterol. Diseased: colon cancer at 75. Sister: diabetes and hypertension Brother: diseased car accident at 24 Son: healthy- daughter: asthma Denies family history of stroke, pulmonary embolism.

Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive symptom and provide additional details.

Constitutional

Skin

HEENT

☐Fatigue: denies to r/o cardiac issues

☐Weakness .

☐Fever/Chills: denies to r/o infectious process

X Weight Gain: 20 lbs in last couple of years.

☐Weight Loss: denies to r/o other conditions

☐Trouble Sleeping: denies to r/o other conditions

☐Night Sweats: denies: to r/o infection.

☐Other:

☐Itching .

☐Rashes .

☐Nail Changes .

☐Skin Color Changes .

☐Other:

☐Diplopia .

☐Eye Pain .

☐Eye redness .

☐Vision changes .

☐Photophobia .

☐Eye discharge .

☐Earache .

☐Tinnitus .

☐Epistaxis .

☐Vertigo .

☐Hearing Changes .

☐Hoarseness .

☐Oral Ulcers .

☐Sore Throat .

☐Congestion .

☐Rhinorrhea .

☐Other:

Respiratory

Neuro

Cardiovascular

☐Cough: denies to r/o cardiac and respiratory causes

☐Hemoptysis .

☐Dyspnea: denies to r/o cardiac causes

☐Wheezing .

☐Pain on Inspiration .

☐Sputum Production

Choose an item.

☐Other:

☐Syncope or Lightheadedness .

☐Headache .

☐Numbness .

☐Tingling .

☐Sensation Changes

Choose an item.

☐Speech Deficits .

☐Other: .

X Chest pain

SOB .

☐Exercise Intolerance .

☐Orthopnea: to r/o cardiac, respiratory causes

☐Edema: denies:to r/o cardiac and other causes

☐Murmurs .

Denies dizziness or palpitations: to r/o cardiac causes

MSK

PSYCH

☐Pain:denies shoulder to r/o MI

☐Stiffness .

☐Crepitus .

☐Swelling .

☐Limited ROM Choose an item.

☐Redness .

☐Misalignment .

☐Other: .

☐Nausea/Vomiting:denies to rule out GI cause

☐Dysphasia .

☐Diarrhea: denies to r/o abdominal issues

☐Appetite Change .

☐Heartburn:denies to r/o GI cause

☐Blood in Stool .

☐Abdominal Pain:denies to r/o GI cause

☐Excessive Flatus .

☐Food Intolerance .

☐Rectal Bleeding .

☐Other:

☐Urgency .

☐Dysuria .

☐Burning .

☐Hematuria .

☐Polyuria .

☐Nocturia .

☐Incontinence .

☐Other: .

☐Stress:denies to r/o anxiety

☐Anxiety:denies to r/o anxiety

☐Depression .

☐Suicidal/Homicidal Ideation .

☐Memory Deficits .

☐Mood Changes .

☐Trouble Concentrating .

☐Other: .

GYN

☐Rash .

☐Discharge .

☐Itching .

☐Irregular Menses .

☐Dysmenorrhea .

☐Foul Odor .

☐Amenorrhea .

☐LMP: .

☐Contraception .

☐Other:.

Body System

Positive Findings

Negative Findings

General

Choose an item.

Pleasant 59 year old male, good eye contact, good posture, well articulated.

Skin

Choose an item.

no cyanosis, flushed face, or pallor present. No tenting

HEENT

Choose an item.

not assessed

Respiratory

Choose an item.

fine crackles heard to posterior bilateral bases

no rhonchi, coarse crackles, wheezing or stridor heard

Neuro

Choose an item.

not assessed

Cardiovascular

Choose an item.

Right carotid: bruit heard, +3 increased amplitude. Heart sounds: S3 auscultated-gallop. PMI: displaced laterally

JVD:3 cm above the sternal angle, chest:symmetrical

Fingers and fingernails:no Redness, Moles or skin tags, Masses, Freckles, birthmark, or other discoloration, Excessive dry or flaking skin, Purpura, Scarring, Laceration, lesion, Bruises, or Rash, Pallor,Cyanosis, Splinter hemorrhages, Clubbing observed.

Lower extremities and toenails: no Visible distortion or swelling,Brownish pigmentation,Skin thickening,Ulceration, Varicose veins, Pallor,Cyanosis, Splinter hemorrhages or Clubbing. No edema.

Capillary refill of fingers and toes: less than 3 seconds.

Left carotid:no bruit Heart sounds:S1,S2 present-no murmurs, friction rub or clicks heard. No bruit to abdominal aorta. Lower extremities and abdominal arteries: no bruit auscultated.

Left carotid artery: amplitude+2, no bruit. PMI:brisk, diameter less than 3 cm.

Palpated Brachial, radial, femoral,popliteal, tibial, dorsalis pedis arteries: no bruit, +2 amplitude.

EKG: normal sinus rhythm, no ST elevation

Musculoskeletal

Choose an item.

not assessed

Gastrointestinal

Choose an item.

Abdomen: rounded

Abdomen:symmetric. Normoactive bowel sounds to all quadrants. Light palpation to abdomen: no masses, guarding,distention, or rigidity. Deep palpation to abdomen: no masses. Liver or kidney: not palpable. Liver: palpable. No friction rub auscultated to organs. Percussed abdomen: All areas generally tympanic. Percussed spleen: tympanic. Liver span: between 6-12 cm.

Genitourinary

Choose an item.

not assessed

Psychiatric

Choose an item.

No signs of anxiety or depression

Gynecological

Choose an item.

Problem List
1 chest pain	6 coronary artery disease
2 CHF	7 pulmonary embolism
3 hypertension	8 hyperlipidemia
4 Angina pectoris	9 fine crackles
5 Overweight	10 Sedentary Lifestyle

Diagnosis	ICD-10 Code	Pertinent Findings
Angina pectoris	I20	chest pain on exertion relieved by rest, recent diagnosis of hyperlipidemia, Right carotid: bruit heard, +3 increased amplitude
Heart failure	I50	2 major criteria met: fine crackles heard to posterior bilateral bases, Heart sounds: S3 auscultated-gallop. Also, PMI: displaced laterally
Coronary artery disease	I25.1	chest pain on exertion relieved by rest, recent diagnosis of hyperlipidemia, Right carotid: bruit heard, +3 increased amplitude

Diagnostics: List tests you will order this visit
Test	Rationale/Citation


Echocardiogram Blood work: A1C, Lipid panel and basic metabolic panel	The diagnosis of angina is usually suspected from a thorough history and examination. Patients should have an ECG and undergo assessment for cardiovascular risk factors such as diabetes and hyperlipidemia. An echocardiograph can help with the assessment of left ventricular function and best tool for prediction of survival. Once the clinical diagnosis of stable coronary artery disease is established, the patient’s risk of future cardiovascular events is evaluated. Patient has a family history of diabetes (Wee et. al, 2015). Metabolic panel to assess renal function to prescribe drugs that are metabolized by the kidneys such as Lasix and Lisinopril.
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Medications: List medications/treatments including OTC drugs you will order and “continue previous meds” if pertinent.
Drug	Dosage	Length of Treatment
Lasix	40mg once daily - 30 days	Crackles to lung bases. Establishing an effective diuretic regimen is crucial for achieving decongestion (JACC, 2019).
Potassium chloride	20 mEq once daily - 30 days	Prescription of oral diuretics should also trigger consideration of how potassium supplements should be prescribed (JACC, 2019).
Lipitor (continue)	20mg daily at bedtime	(see below)
Lisinopril Lopressor (continue) Fish oil (continue) Aspirin Nitroglycerine	2.5 mg once daily- 30 days 100mg once daily 1200mg twice daily 81mg once daily - 30 days 0.4mg 1 tab sublingual every 5 minutes (up to 3 tabs) as needed for chest pain	Medical treatment aims to relieve angina and prevent cardiovascular events. Beta blockers and calcium channel antagonists are first-line options for treatment. Short-acting nitrates can be used for symptom relief. Low-dose aspirin and statins are prescribed to prevent cardiovascular eventsAngiotensin converting enzyme (ACE) inhibitors should be prescribed for patients with stable angina, particularly those who have hypertension, left ventricular dysfunction, diabetes or chronic kidney disease Low-dose aspirin reduces major cardiac events by up to 30% and should be prescribed to patients with coronary artery disease. Sublingual glyceryl trinitrate tablets or nitroglycerin spray remain the treatment of choice for rapid relief of acute symptoms and anticipated angina (Wee et. al, 2015)
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Referral/Consults:
Cardiologist		Rationale/Citation Pt needs to follow up with his cardiologist given the extensive cardiac findings and associated life threatening risks.
Education:
Daily weights 150 minutes a week of moderate-intensity physical activity or 75 minutes a week at a vigorous pace Diet rich in vegetables and whole grains		Rationale/Citation Assess how much extra fluid is being held in body by weighing daily at the same time of day. If gain more than 2 lbs in 1 day or 5 lbs in 1 week call the office to report findings.. At this point Pt is experiencing chest pain on exertion so I wouldn’t tell him to start exercise immediately. But he should start slowly and progressively, as soon as symptoms go away The guidelines are based on current scientific evidence supporting the connections between physical activity, overall health and well-being, disease prevention and quality of life. (AHA, 2019). All adults should consume a healthy diet that emphasizes the intake of vegetables, fruits, nuts, whole grains, lean vegetable or animal protein, and fish and minimizes the intake of trans fats, red meat and processed red meats, refined carbohydrates, and sweetened beverages. For adults with overweight and obesity, counseling and caloric restriction are recommended for achieving and maintaining weight loss. (AHA, 2019)
Follow Up: Indicate when patient should return to clinic and provide detailed instructions indicating if the patient should return sooner than scheduled or seek attention elsewhere.
Follow up in 1 week to evaluate effectiveness of medications, blood pressure, serum potassium, cardiac and respiratory status. If symptoms worsen call 911 or go to nearest emergency room. Follow up with your cardiologist		Rationale/Citation
References Include at least one evidence-based peer-reviewed journal article which relates to this case. Use the correct APA 6th edition formatting.	American Heart Association (2019) American Heart Association Recommendations for Physical Activity in Adults and Kids https://www.heart.org/en/healthy-living/fitness/fitness-basics/aha-recs-for-physical-activity-in-adults Dancy, L., O’Gallagher, K., Milton, P., & Sado, D. (2018). New NICE guidelines for the management of stable angina. Br J Gen Pract, 68(669), 202-203. https://chamberlainuniversity.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=mdc&AN=29592946&site=eds-live&scope=site Journal of the American College of Cardiology (2019). 2019 ACC Expert Consensus Decision Pathway on Risk Assessment, Management, and Clinical Trajectory of Patients Hospitalized With Heart Failure. http://www.onlinejacc.org/content/74/15/1966 Wee, Y., Burns, K., Bet, N. (2015). MEDICAL MANAGEMENT OF CHRONIC STABLE ANGINA. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4653970/pdf/austprescr-38-131.pdf
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