Soap Case Key

KEY Subjective CC: “This is the worst pain I have ever felt in my life.” ML is a 68 y/o male admitted to the ED. HPI: ML is admitted to the ED complaining of chest pain and pressure lasting 20 – 30 minutes occurring at rest. ● Describes pain as crushing, substernal, and pressure-like that radiates to his jaw. ● Diaphoresis and nausea. ● Pain first started approximately 8 – 10 hours ago after he ate breakfast and was unrelieved by antacids or SL NTG x 3. ● He also states he has been experiencing intermittent chest pain over the past 6 – 7 weeks with minimal exertion. PMH: Diagnosed with HTN, Type 2 DM, dyslipidemia, CAD with percutaneous coronary intervention (PCI) with a bare metal stent (BMS) 12 years ago. FH: Father suffered from DM type 2 and died from heart failure. Mother is alive and diagnosed with HTN and type 2 DM. SH: (+) tobacco x 30 years (quit when received BMS 12 years ago); drinks beer usually on weekends; denies illicit drug use. ROS: Positive for some baseline CP on exertion for the past 6 weeks, now with CP at rest. Objective Allergies: NKDA Medications: Aspirin 81 mg PO daily, metoprolol tartrate 25 mg PO BID, Pravastatin 20 mg PO qHS, Metformin 500 mg PO BID, SL Nitroglycerin PRN Chest Pain. Omeprazole 20 mg po once daily. Amlodipine 5 mg PO QD. Immunizations: Flu Vaccine 0.5 mL IM, Tdap 0.5 mL IM in October 2016 PE: Gen. WDWN man, A&O x 3, still with ongoing chest pain, somewhat anxious. Neck: mild JVD. Lungs: Few dependent inspiratory crackles, bibasilar rales, muscle strength right 5/5 UE/LE, left 4/5 UE/LE, pulses 2+, DTRs decreased on left. All other PE WNL. Vital Signs: BP 144/94 mmHg (elevated) P 100 (higher range of normal) RR: 27 (elevated) Weight 98 kg, Height 5’9”, Scr 1.2 IBW : 50 + 2.3 (9) = 70.7 = 71kg Actual Body weight is > 130% of IBW use adjusted body weight Adjusted BW : IBW + 0.4 ( ABW-IBW) Adj BW : 71 + 0.4 (98-71) = 81.8 Kg BMI : Weight (kg)/ height 2 in meters BMI : 98kg/ (3.068) = 31.9 kg/m2 Obese BSA = 2.13 m2 eCrCl with CG and AjBW : (140 – 68) x 81.8 = 68.2 mL/min 72 x 1.2 eGFR with 2021 CKD-EPI creatinine = 66mL/min/1.73m2 66mL/min/1.73m2 / 2.13m2 = 81.26 mL/min eGFR with 2021 CKD-EPI creatinine-cystatin c = 81 mL/min/1.73m2 81ml/min/1.73m2/2.13m2 = 99.72 ml/min = 99.7 mL/min Labs: All WNL except Glucose 145 mg/dL (elevated) , Troponin I 8.8 ng/mL (elevated), LDL 110 mg/dL (elevated), HDL 34 mg/dL, A1C 7.9% (elevated) ECG: Two- to 3mm ST-segment elevation in leads II, III, and aVF consistent with acute inferior myocardial infarction. Right bundle branch block is also present in leads V1 – V3. Assessment/Plan 1. Atypical Angina with STEMI: A. High risk, STEMI (Atypical Angina, ST Elevation, Positive Troponin I 8.8 ng/m). Goal Stabilize patient and reperfuse area as soon as possible per ACCF/AFA 2021 guidelines P. Initiate stabilization with Aspirin 325 mg non-enteric coated tablet chewed and swallowed immediately. If pt’s O2 saturation < 90% administer O2 at 2 L/min oxygen through nasal cannula. Administer fentanyl 50 mcg IV q 5 – 15 min PRN (alternative answer: Morphine 2-4 mg IV q5-15 min) pain due to renal function. If pt’s HR lowers < 100 bpm, start Nitroglycerin drip 10 mcg/min IV (increase by 10 mcg/min every 3 – 5 minutes until ischemia resolved). Monitor pt’s HR and BP closely for signs/symptoms of tachyphylaxis (d/c if this occurs) and for HA side effects. Perform PCI within 90 min of medical contact. Administer clopidogrel 600 mg PO x 1 then maintenance dose 75 mg PO daily (alternative answer: Ticagrelor 180 mg PO x1 then maintenance dose 90 mg PO BID). Monitor pt’s CBC and bleeding. Counsel pt on SE of HA and risk of bleeding. Initiate Unfractionated Heparin (UFH) 4000 units IV x 1 then discontinue after PCI. Counsel pt on risks/benefits, and possible complications of bleeding. Monitor pt’s ACT before and after PCI then monitor aPTT until 1.5 – 2 x baseline, platelets, H/H, and bleeding. Follow up with laboratory for measurement of lipid profile within 24 hours of admission. (alternative can add GP IIb/IIIa inhibitor if justify reasoning but not necessary and then the heparin dose will change) 2. Post ACS Management: A. High risk, STEMI (Atypical Angina, ST Elevation, Positive Troponin I 8.8 ng/m). Goal Initiate post ACS management to prevent MI and death, reduce symptoms of angina and occurrence of ischemia so increase in “quantity” of life and improved quality of life per ACCF/AHA 2021 guidelines P. Once pt is stabilized and ready for discharge post-ACS management should include: Aspirin 81 mg PO daily continued indefinitely. Continue clopidogrel 75 mg PO daily for 12 months. See Atypical Angina with STEMI for monitoring and counseling parameters. Discontinue Omeprazole 20mg and initiate famotidine 20 mg po bid for up to 6 weeks. Omeprazole interacts with Plavix while famotidine is a safer alternative. Avoid omeprazole with Clopidorgrel. Omeprazole may diminish the antiplatelet effect of Clopidogrel. Omeprazole may decrease serum concentrations of the active metabolites of Clopidogrel (Lexicomp) Discontinue pravastatin 20 mg and initiate high dose statin using atorvastatin 80 mg PO daily. Counsel on s/sx of statin associated muscle symptoms and adverse effects. Monitor lipids, LFT, and diabetes labs. Discontinue metoprolol tartrate 25 mg. Discontinue Amlodipine 5mg. Initiate metoprolol succinate 100 mg PO daily with food. Counsel on s/sx of dizziness, weakness, diarrhea, and GI upset. Monitor BP, HR. Initiate Lisinopril 5 mg PO daily, continued indefinitely. Counsel pt on s/sx of dry cough, angioedema, and other adverse effects. Monitor BUN, K+, and changes in SCr. Ensure patient has 0.4 mg sublingual nitroglycerin at home for relief of angina pain. Counsel on proper use of SL NTG. Counsel patient on medication adherence, weight loss, exercise modifications with 30 – 60 min moderate-intensity aerobic activity, and dietary interventions. Follow up with PCP in 4 weeks to assess effectiveness of therapy or need for titration/intensification of therapy, follow-up labs and assess LV function/cardiac rehabilitation. 3. Dyslipidemia: A. Very High Risk; Uncontrolled at high LDL 110 mg/dL and low HDL 34 mg/dL, non HDL-c 129 mg/dL, Goal Achieve LDL-C threshold of 70 mg/dL or a non-HDL-C level of ≥ 100 mg/dL per ACC/AHA 2018 guidelines P. Due to pt’s dyslipidemia classification and post-ACS management, discontinue pravastatin 20 mg and initiate high dose statin using atorvastatin 80 mg PO daily. See Atypical Angina with STEMI for counseling and monitoring parameters for statin. Monitor lipids and LFTs. Follow up with PCP in 4 weeks for repeat lipid measurement to see effectiveness of therapy. If at goal, continue therapy and repeat every 3 months as needed. If not at goal, consider intensifying to maximally tolerated LDL lowering therapy with ezetimibe 10 mg PO daily then reassess in 4 weeks. 4. Hypertension: A. Stage 2, uncontrolled at BP 144/94 mmHg. High risk. Goal <130/80 mmHg per ACC/AHA 2018 Hypertension guidelines. P. Due to post-ACS management and ACC/AHA first line medication recommendations, initiate Lisinopril 5 mg PO daily, continued indefinitely. See Atypical Angina with STEMI for counseling and monitoring parameters for ACE-I. Advise purchase of personal BP monitor; provide education on BP monitor use and personal BP goal (< 130/80 mmHg). Follow up progress phone call in 1 week w/ RPh and continue follow up with PCP in 4 weeks or sooner if pt experiences adverse events. If BP goal is met, continue therapy. If goal not met, assess adherence and consider intensification of therapy. 5. Acute Kidney Injury: A. Uncontrolled, Possible prenal AKI (BUN:SCr ratio 13:1 < 20:1) BUN:SCR= 13.3. Clinical presentation: HTN, JVD, and nausea. eCrCl 68.2 mL/min. Goal minimize degree of kidney insult, reduce extrarenal complications, expedite recovery of renal function per KDIGO 2012 guidelines P. Prevent occurrence of contrast induced nephropathy but minimizing the volume of contrast necessary and discontinue metformin while hospitalized. Monitor fluid status, hemodynamic status, SCr, and urine output. Follow up with labs within 48 hours to assess AKI progression. 6. Type II Diabetes Mellitus: A. Uncontrolled; A1C 7.9% Goal A1C < 7%, FPG 80 – 130 mg/dL, PPG < 180 mg/dL per ADA guidelines P. While in hospital, maintain BG levels < 180 mg/dL using insulin sliding scale to avoid episodes of hyperglycemia and while holding metformin to prevent contrast-induced nephropathy. Monitor glucose with AccuChek every 2 hours. After discharge, consider intensifying therapy to metformin 1000 mg BID. Promote weight loss, exercise modifications, and dietary interventions with education and referral to nutritionist. Monitor and counsel pt on BG, FPG, PPG, and s/sx of hypoglycemia/hyperglycemia and goals. Follow up with A1C and FPG labs with PCP in 3 months to assess control. 7. Preventative Care: A. Last immunizations in 2016. Goal disease prevention and patient wellness per CDC/ACIP recommendations. Screen for history of colonoscopy (colon cancer), PSA lab (prostate cancer), skin checks (skin cancer screening), annual eye exam, annual dentist exams. Order these labs or refer to PCP to discuss. P. Once pt is stabilized, try to assess if family or community pharmacy has an immunization record. If no record, deliver Pt received Tdap 0.5 mL IM in October 2016 (Tdap is good for 10 years), Prevnar 13 0.5 mL IM, and Shingrix 0.5 mL IM, COVID-19 0.5 mL IM, RSV 0.5 mL IM. Monitor for and counsel pt on s/sx of allergic rxn: itchiness, rash, angioedema, SOB, and injection site pain – for which acetaminophen 500 mg q 4 – 6 hrs PRN pain can be used for relief. Follow up with PCP regarding other routine vaccinations if needed after discharge, next dose of Shingrix (at 2-6 months) and PPSV23 in one year, and required annual immunizations in 1 year. 8. Obesity: A. BMI is elevated at >30 kg/m2. BMI is 31.9 kg/m2 P. Educate patient on body movement. Based on his current regimen, help him come up with ideas on how to move body (might be starting with walking to the mailbox or walking 10 minutes a day to start before increasing to 30 minutes in a few months or swimming or an activity he enjoys). Based on his current eating habits, decrease how to minimize 1 area in his life (i.e. smaller plates or bowls to use at home, 1 less dessert, 1 less processed food bought at the grocery store, etc) to ease into this and slowly change over time.