Cardiovascular SOAP Note

2 Cardiovascular SOAP Note Subjective ID: Pt is a 43 y.o. B.M. presents to the clinic alone with complaints of chest pain for the past four days pt. is a reliable historian and does not partake in any substances such as drugs, alcohol, or tobacco products past or present. CC: “…chest pain which started four days ago…” HPI J.H., a 43 y.o. A.M. presents to the clinic with complaints of chest pain that he states started four days ago. He states that his pain is a 7/10. Pt says that he does not take any overthe-counter mentions mitigating his health or symptoms. Pt states he is not the type to go in to see a provider and assumes his symptoms while resolving and go away on their own. Pt shares that he came in today to see a provider for his complaints due to his nagging long-term partner. Pt reports that four days ago, pt felt sweaty and nauseous, his chest felt heavy, and he had complications with his breath. However, the feeling only lasted for five minutes and has not recurred. He reports that he has felt a little bit exhausted since. PMHx Pt reports that his general health is excellent. His health has been good ever since he started his workouts which led to a loss of ten kilograms in weight as he had anticipated. He was energetic until the episodes began four days ago. His main worry is the fatigues quickly after his working outs, a scenario that he did not experience four days ago. He also mentions that he has been doing strenuous jogging in the morning and the evening but stopped once he experienced the issue four days ago. Vaccinations: Pt shares that he has received his annual flu vaccine and had his last Tdap vaccine in the previous five years. Pt states that he had his previous coronavirus disease 2019 3 (COVID-19) vaccine in October 2021 and the second dose in December 2021. He says that he recently received his booster in March 2022. Chronic Illnesses: Elevated cholesterol but controlled by a change in lifestyle modifications and changes, such as regular exercise and healthier food choice consumption. Hypertensionthe patient was asked to change his lifestyle to manage the illness. Childhood Illnesses: Historically had, chickenpox around the age of nine with no complications or reinfection. Surgeries: vasectomy, cholecystectomy, tonsillectomy, and adenoidectomy as a teenager. Hospitalizations: Denies ever being hospitalized, minus the above states surgeries that were planned Blood Transfusions: Denies blood transfusion Current medications: Denies being on any supplements or over counter medications at this time, and pt. shares that he would like to keep it that way. Allergies: No known allergies to medication, food, or environmental factors. Family History: Pt reports that his parents are deceased, passing away a decade ago. J.H. shares that his mother died from stroke complications, and his father passed from lung cancer. He also shares that his older brother passed away from kidney disease but states he is unaware of what depth and complications his older brother had other than he mentions he was a heavy drinker. Pt continues to share that his other two living siblings, who are both younger than him, are alive and healthy with no underlying comorbidities. Social History: J.H. is a plumber who lives with his long-term partner of eight years, and they practice monogamy. Pt states that he has no children, but his partner does have children who don’t live in the house with them but with their biological father. He says he is sexually active with just his partner and does not currently have any sexually transmitted infections. He denies using tobacco products such as vaping, cigarettes, or cigars; and denies drinking 4 but seldom on special occasions such as a significant celebration. He states that he sleeps eight hours a night and mentions that he has been trying his hardest to be mindful of the foods and drinks. ROS General: J.H. confirms that he lost 22lbs of weight from workouts before having chest pain. He also notes that the event of chest pain has made him feel tired even when he has not worked out. HEENT: Pt. reports a scant amount of watery discharge from his eyes but states that there are no other complications. He also uses eye lenses to prevent his short-sightedness from affecting his vision. There is no reported history of ear discharge, ringing in the ear, or ear pain. Denies sinus pressure in his frontal/maxillary, discharge, or nasal congestion. He also states that he is not experiencing any throat pain, hoarseness, detention intake with no s/sx related to infections to the oral cavity or challenges with swallowing. Respiratory: Denies any history of hemoptysis or wheezing. He reports shortness of breath whenever he works out, accompanied by fatigue. Cardiovascular: Denies edema affecting his extremities, orthopnea, palpitations, or paroxysmal nocturnal dyspnea. Gastrointestinal: Denies history of hemorrhoids, ulcers, hepatitis, constipation, eating disorders, diarrhea, vomiting, nausea, or abdominal pain. Genitourinary: Pt. denies the presence of change in color, sensations such as burning, frequency, or urine urgency. Musculoskeletal: He denies a history of pain or stiffness, swelling, or osteoporosis. Neurological: Pt reports that he has not had any episode of blackout spells, numbness, or experienced seizures. Psychiatric: Pt reported no history of suicidal ideation, insomnia, anxiety, or depression. 5 Hem/Lymph/Endo: Pt states that he has never received a blood transfusion. There are no previous or current reports of night sweats, bruising, increased hunger, increased thirst, swollen glands, or heat intolerance. Skin: Pt denies a history of skin discolorations, bruising, changes in moles or lesions, bleeding, rashes, or bruising. Objective PE: Weight: 220.0lbs; Height 5’9” Body Mass Index: 32.5 [indicating pt as obese] (National Heart, Lung, and Blood Institute, 2022) V/S: B/P: 146/90, P: 85, T: 98.2F, SaO2 97% at RA General: Pt is a 43 y.o. A.M. is cooperative with the exam and appears to be alert and oriented, and alert to time, place, and situation. Speaks with sensical speech and answers appropriately. Noting that this pt. Presents to the clinic clean, well-groomed, and nourished in no significant acute distress. HEENT: The distribution of hair on J.H.’s scalp is uneven. Pt has thick hair with baldness approaching the middle of the scalp from the front. No visual observations of AV nicking or cotton wool spots of the disc/nerve, noting that PERRLA, the sclera is white, intact EOMS. Non-tender tragus and pinna with no notable drainage to the external canal. Pt nose has a slight right-sided deviation, with the sinuses being non-tender to palpation. Pt. tongue is pink, smooth, and with no lesions present; pt teeth have scattered fillings noted, and he appears to have slight gum recession and redness to the gums. Pt presents with mild JVD positioned recumbently and carotid amplitude of +2 bil. The thyroid is midline firm and small, with no palpable masses. Cardiovascular: S1/S2 present with regular rate and rhythm (RRR) and no murmurs or extra sounds upon auscultation. 6 Respiratory: Pt’s lungs are clear to auscultation bilaterally with no parasternal thrills, heaves, and lifts. Pt has no evidence of edema lower extremities. No notable presence of blisters or rashes on chest; no unlabored respirations or distress noted upon observation of pt. Abdomen: Pt’s abdomen is soft and round. There is no noted organomegaly; bowel sounds are active in all four quadrants with tympanic sounds throughout. No CVA tenderness; no bruits heard over the abdominal aorta, renal, iliac arteries. Skin: Intact, dry, and warm with pallor appropriate for ethnicity, as well as no cyanosis noted to the lips or fingertips and toes. Assessment Diagnostics Total cholesterol 230 Hdl 38 Ldl 180 ST depression as the Electrocardiogram (EKG) in office DDx: Non-ST elevation myocardial infarction (NSTEMI)(I2.4) is an illness that happens when a person’s oxygen demand cannot be met. Unlike other heart attack conditions, the NSTEMI does not have an identifiable ST alleviation. The condition is life-threatening and demands immediate treatment (Marfella et al., 2017). It can be caused by other conditions such as coronary embolism, vasospasm, and plaque (Wu et al., 2019). It is characterized by nausea, depressed ST, tiredness, sweating, a heavy feeling in the chest, shortness of breath, and chest pain. Viral Pleuritis (R091) affects the transparent, thin, and two-layered membranes covering the lungs (the pleura), prompting chest pain while coughing or breathing. This condition makes a person’s pleura swell and inflame (Karpathiou et al., 2019). The two layers then start rubbing 7 against each other during breathing or coughing, making it painful (Baraldi et al., 2019). Pt may have this illness since his chest pain elevates during exercises since he experiences rapid breathing during activity. Asthma (J45.909)- This illness makes a person’s airways swell and become narrow, producing extra mucus in other incidences. Such swelling brings about the difficulty in breathing and makes breathing painful (Boonpiyathad et al., 2019; Barrett et al., 2017). It also leads to chest pains and coughing. However, it can be managed by breathing inhalers used to prevent the symptoms. Pts’ shortness of breath and chest pain might indicate asthma illness. Final Dx: NSTEMI Rationale: Pt has a history of nausea, depressed ST, tiredness, sweating, a heavy feeling in the chest, shortness of breath, and chest pain (Wu et al., 2019). Plan Pt will be prescribed 0.3mg of Nitroglycerin, which he will be required to take after every five minutes but restricted to a maximum of three doses when he experiences chest pain. He will also be prescribed 325mg OD of PO Aspirin prophylactically to treat pts unstable angina. As the provider, I would inquire with pt. Regarding the start taking a single tablet a day of simvastatin 20mg to aid pts LDL levels (Boland et al., 2018) as well as proposing that the also takes 25mg OD of PO Hydrochlorothiazide will also be prescribed to him to manage his blood pressures (Korayem et al., 2018). Referral: Cardiologist Following up: Pt to seek care and services from the nearest emergency department if pts airway, breathing, and circulation become compromised or if pt appears takes a second dose of nitroglycerin and symptoms are not relieved with this double dose.