NR 509 SOAP Note Week 4

15 July 2024

NR 509 SOAP Note Week 4

Advanced Physical Assessment (Chamberlain University)

Patient Information:

  • Initials: BF
  • Age: 58
  • Gender: Male
  • Height: 5’11”
  • Weight: 197 lbs
  • BP: 146/90
  • HR: 104
  • RR: 98
  • Temp: 36.7°C
  • SPO2: 98% RA
  • Pain Rating: Not reported

Allergies (and reaction):

  • Medication: Codeine (Nausea & Vomiting)
  • Food: N/A
  • Environment: N/A

History of Present Illness (HPI):

  • Chief Complaint (CC): Chest Pain
  • Onset: Earlier this month, has occurred three times in the past month
  • Location: Middle of the chest, over the heart, non-radiating
  • Duration: A couple of minutes
  • Characteristics: Tight and uncomfortable in the middle of the chest
  • Aggravating Factors: Worsens with physical activity
  • Relieving Factors: Lying still offers some relief
  • Treatment: No medications, just rest

Current Medications:

  • Metoprolol (Lopressor): 100 mg PO Daily (1 year) for BP
  • Atorvastatin (Lipitor): 20 mg PO Daily HS (1 year) for cholesterol
  • Omega 3 Fish Oil: Not reported

Past Medical History (PMHx):

  • Up to date on all immunizations
  • Denies previous hospitalizations or surgeries
  • Denies previous diagnosis of angina, CAD, DM, or previous chest pain treatment
  • Positive history for HTN and elevated cholesterol
  • Reports infrequent BP monitoring at home
  • Recent EKG test and annual stress test were “normal”

Social History (Soc Hx):

  • Employed at a civil engineering firm
  • Low stress lifestyle
  • Diet: Grilled meats (4-5 times a week), sandwiches, vegetables
  • Drinks 1-2 cups of coffee a day, denies tobacco use
  • Reports alcohol use (2-3 drinks a week in one sitting)
  • Denies soda consumption, drinks 4 glasses of water/day
  • Denies regular exercise routine

Family History (Fam Hx):

  • Maternal grandfather died of a heart attack at a young age
  • Father died of colon cancer
  • Mother and sister have DM
  • Daughter has asthma
  • All family members have elevated BP
  • Denies family history of stroke or PE

Review of Systems (ROS):

Constitutional:

  • Denies fatigue, weakness, fever/chills, weight gain/loss, trouble sleeping, night sweats

Skin:

  • Denies itching, rashes, nail changes, skin color changes

HEENT:

  • Denies diplopia, eye pain, eye redness, vision changes, photophobia, eye discharge, earache, tinnitus, epistaxis, vertigo, hearing changes, hoarseness, oral ulcers, sore throat, congestion, rhinorrhea

Respiratory:

  • Denies cough, hemoptysis, dyspnea, wheezing, pain on inspiration, sputum production

Neuro:

  • Denies syncope, lightheadedness, headache, numbness, tingling, sensation changes, speech deficits

Cardiac and Peripheral Vascular:

  • Reports chest pain (center chest, several minutes, 5/10 pain)
  • Reports exercise intolerance (pain with yard work/stairs)
  • Denies SOB, orthopnea, edema, murmurs, palpitations, faintness, claudications, PND

MSK:

  • Denies pain, stiffness, crepitus, swelling, limited ROM, redness, misalignment

GI:

  • Denies nausea/vomiting, dysphasia, diarrhea, appetite change, heartburn, blood in stool, abdominal pain, rectal bleeding
  • Reports food intolerance (chest pain with big meals/steak)

GU:

  • Denies urgency, dysuria, burning, hematuria, polyuria, nocturia, incontinence

PSYCH:

  • Denies stress, anxiety, depression, suicidal/homicidal ideation, memory deficits, mood changes, trouble concentrating

GYN:

  • Not applicable

Hematology/Lymphatics:

  • Denies anemia, easy bruising/bleeding, past transfusions, enlarged/tender lymph nodes, blood or lymph disorder

Endocrine:

  • Denies abnormal growth, increased appetite, increased thirst, thyroid disorder, heat/cold intolerance, excessive sweating, diabetes

Objective:

General:

  • Pleasant 58 y/o male, A&Ox3, clear speech, no physical distress or signs of pain currently

Skin:

  • No tenting

HEENT:

  • Unable to assess

Respiratory:

  • Fine crackles in posterior right and left lung bases
  • Respirations even and unlabored, breath sounds clear to auscultation in upper lobes and right middle lobe, chest symmetric, no visible abnormalities

Neuro:

  • Unable to assess

Cardiovascular:

  • Right side carotid bruit, S3 noted in mitral area
  • No JVD, JVP 3cm above sternal angle, no bruit in left carotid
  • Brachial, radial, femoral pulses 2+ without thrill
  • Popliteal, tibial, dorsalis pedis 1+ without thrill
  • Cap refill <3 in all extremities
  • S1 & S2 without murmurs or rubs
  • No edema in extremities
  • Abdominal aorta no bruit
  • No bruit in abdominal or lower extremity arteries
  • SR with no ST elevation on EKG

Musculoskeletal:

  • Unable to assess

Gastrointestinal:

  • Liver palpable
  • Bowel sounds normoactive in all quadrants
  • Spleen & kidneys not palpable
  • No friction rub present in organs
  • All abdominal areas and spleen tympanic on percussion
  • Percussed liver span between 6 and 12 cm

Problem List:

  1. Uncontrolled HTN
  2. Intermittent chest pain
  3. Activity intolerance
  4. Lung base fine crackles
  5. Moderate alcohol consumption
  6. Enlarged/palpable liver
  7. High red meat intake
  8. Right carotid bruit
  9. Mitral area S3 sound
  10. Congestive heart failure
  11. Family cardiac history
  12. Poor diet habits (fast food, multiple times/week)
  13. Increased caffeine consumption

Diagnosis & ICD-10 Codes:

  1. Atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm (I25.111): +Hypertension, +Dyslipidemia, -Smoker, +Family History of CAD, +Sedentary lifestyle, -DM, -CKD, +Angina
  2. Congestive Heart Failure (I50.20): +Chest pain, -Frothy sputum, -Blood tinged sputum, +Lung base crackles, -Edema, -Lethargy, -Wheezing
  3. Gastroesophageal Reflux Disease (K21.9): +Chest pain, +Chest pain after eating, -Nausea, -Vomiting, -Belching, -Regurgitation, -Difficulty swallowing, +Heartburn

Plan:

Diagnostics:

  • Lipid Panel, Fasting (LDL, HDL, Cholesterol, Triglycerides): Evaluate levels of lipids/cholesterol in blood for medication adjustment if necessary, to prevent further atherosclerosis
  • CK/ CK-MB Blood Test: Tests for elevated Creatine kinase in the blood, indicating muscle damage; CK-MB test more specifically for heart muscle damage
  • Troponin Blood Test: Elevated blood levels can indicate heart injury

Medications:

  • Continue Previous Medications as Prescribed
  • Aspirin (Bayer): 81 mg PO QD, long-term, continuous
  • Nitroglycerin: 0.3 mg pill sublingual q5min; maximum 3 doses within 15 minutes, PRN

Referral/Consults:

  • Cardiology: Consultation for further evaluation of heart disease, angina, and sclerosis; potential for additional testing such as stress test/heart cath

Education:

  • Utilize nitroglycerin for chest pain not resolved by rest
  • Decrease fats in diet, reduce red meat and fast food intake
  • Monitor weight daily, notify physician of significant changes or swelling

Follow-Up:

  • Follow-up within four to six months unless symptoms worsen; call the office for changes in physical activity, symptoms, adverse effects of medication, or new chronic conditions
  • Seek immediate medical attention for continuous chest pain not relieved by nitroglycerin, or worsening symptoms affecting breathing or spreading to limbs

References:

  • Katz, P. O., Gerson, L. B., & Vela, M. F. (2013). Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease. American Journal of Gastroenterology, 108(3), 308–328.
  • Levine, G. N., et al. (2016). 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease. Circulation, 134(10).
  • Nelson, A. J., Ardissino, M., & Psaltis, P. J. (2019). Current approach to the diagnosis of atherosclerotic coronary artery disease: more questions than answers. Therapeutic Advances in Chronic Disease, 10.
  • Stout, K., et al. (2019). 2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease. Circulation, 139(14).