Pharmacist SOAP Notes

Case 4

Work on a two SOAP notes. One SOAP note per day.

Day 1:

Patient Details:

· Age: 79 years and 65 kg

· Gender: Male

· Medical History:

· Hypertension (well-controlled)

· History of smoking (20 pack-years)

· Home medications:

· Lisinopril 40 mg PO QD

Presenting Symptoms:

The patient presented to the emergency department with severe chest pain (rated 9/10 on the pain scale), radiating to the left arm, associated with shortness of breath and nausea. He appeared anxious and diaphoretic.

Initial Examination:

· BP: 85/50 mmHg

· HR: 112 bpm

· RR: 28 breaths/min

· Oxygen saturation: 92% on room air

· Temperature: 37.2°C

· Heart Sounds: S1, S2 normal; no murmurs

· Lung Sounds: clear

· Extremities: Cool, clammy, and edematous with peripheral cyanosis

ECG Findings:

· ST Elevation in leads II, III, aVF, and V1-V4, consistent with Inferior + Anterior STEMI.

Significant Labs:

· Troponin I: > 1000 ng/L

· Creatinine: 1.8 mg/dL

Day 4:

The patient became progressively hypotensive. ECG showed rapid atrial fibrillation with a ventricular rate of 140 bpm. Patient has been having orthopnea and difficulty breathing since day 2. Increased jugular venous distension (JVD) was noted.

Vital signs:

· BP: 124/90 mmHg

· HR: 135 bpm

· RR: 26 breaths/min

Significant Labs:

· Creatinine: 2.4 mg/dL

· BNP: 1324 pg/mL (elevated, suggestive of heart failure)

Chest X-Ray:

· Lungs: Bilateral rales at the bases

CT pulmonary angiogram:

· was performed after the patient developed sudden hypoxemia, and it revealed a pulmonary embolism (PE) affecting the right lung