Digital Clinical Experience: Assessing The Heart, Lungs, And Peripheral Vascular System

Focused SOAP Note

Patient Information: 

Initials: B.F.

Age: 58

Sex: Male

Race: Caucasian 

S(subjective)

CC (chief complaint): Chest pain for several months. 

HPI (history of presenting illness): Mr. B.F. is a 58-year-old Caucasian male who has presented for evaluation with complaints of chest pain that has been present for several months now. He reports that the chest pain is worsened with exertion and relieved upon having a rest. The patient is hypertensive and has hyperlipidemia, for which he is on medications and reports compliance. He reports having a strong family history of hypertension, hyperlipidemia, and cancer. 

Current Medications: Lisinopril (Prinivil) 20 mg P.O. daily, Atorvastatin (Lipitor) 20 mg P.O. daily at bedtime with the last dose taken yesterday at 10 pm, Omega-3 Fish oil 1200 mg PO BID, with the last dose taken today at 8 am. Omega-3 Fish oil obtained over the counter (OCT). 

Allergies: Codeine causes nausea and vomiting. 

PMHx: Stage II hypertension and hyperlipidemia were all diagnosed one year ago. He has no relevant surgical history. He received his influenza vaccine this season, and the Tdap vaccine was given on 10/2014. 

Soc and Substance Hx: He has no history of tobacco use in his past or currently. He admits consuming alcoholic beverages, 2-3 beers per week. He reports no history of marijuana, cocaine, heroin, or any illicit drug use. 

Fam Hx: His father died at 75 years due to colon cancer and was hypertensive, obese, with hyperlipidemia. His mother is aged 80 and has type 2 diabetes and hypertension. His brother died at age 24 after getting involved in a motor vehicle accident. His sister, aged 52, has type 2 diabetes and hypertension. His maternal grandmother died of breast cancer at age 65, while his maternal grandfather died of a heart attack at 54. His paternal grandmother died of pneumonia at age 78, while his paternal grandfather died of old age. He has aged 26 and is healthy, and his asthmatic daughter is 19. 

Surgical Hx: No surgical history. 

Mental Hx: No depression or anxiety history. 

Violence Hx: None.  

Reproductive Hx: Married and has two children. 

ROS (review of symptoms): 

GENERAL: No weight loss, fever, or night sweats. 

HEENT: No vision or hearing loss. Denies epistaxis and sore throat. 

SKIN: No rashes, reports of bluish fingers and toenails. 

CARDIOVASCULAR: Endorses chest pain, no awareness of heartbeat, or lower limb swelling. 

RESPIRATORY: Reports of chest pain, difficulty breathing, no cough or wheeze. 

GASTROINTESTINAL: No changes in appetite. Reports nausea and vomiting after using codeine. 

GENITOURINARY: No reported dysuria, frequency, or hematuria. 

NEUROLOGICAL: No headache or syncope. 

MUSCULOSKELETAL: No bone pain or joint stiffness.

HEMATOLOGIC: No anemia or easy bruising. 

LYMPHATICS: No enlarged lymph node group. 

PSYCHIATRIC: No depression.

ENDOCRINOLOGIC: No dysphagia, polyuria, polydipsia, heat, or cold intolerance. 

REPRODUCTIVE: No history of STI treatment. 

ALLERGIES: Codeine causes nausea and vomiting. 

O (objective)

Physical exam: 

Vital Signs: Blood pressure (B.P.) 146/90mmHg, oxygen saturation 98% at room air, pulse rate 104, respiratory rate 19, temperature 36.7, weight 197lbs, Height 5’11’’, BMI 27.5 (overweight).

General: Oriented and alert.

HEENT: Normocephalic head, pupils equal and reactive to light bilaterally, normal anatomy of ears and nose, no neck swelling, no tonsillar enlargement. 

Cardiovascular: Heart rate of 104, BP 146/90mmHg, palpable pulse on upper extremities and diminished in lower extremities, no heave or thrill palpated, S1S2 sounds and S3 gallop sound auscultated.  

Respiratory: Trachea centrally placed, bilateral air entry, no wheezing sound, bilateral crackles auscultated on the posterior lung bases. Cyanotic finger and toenails. 

Gastrointestinal: Normal fullness, warm on touch, non-tender with hepatomegaly (liver size percussed 7cm in mid-clavicular line). 

Musculoskeletal: Normal ranges of movement at all joints. 

Skin: No skin eruptions. 

Diagnostic results:

Electrocardiogram (EKG): Sinus rhythm with no ST-segment elevation. 

A (assessment)

Differential diagnoses: 

Coronary Artery Disease (CAD) with Stable Angina (Primary Diagnosis)

CAD, also referred to as atherosclerotic heart disease, is a disease of the heart’s major vessels, the coronary arteries, which cause their narrowing and blockage due to the build-up of plaque. It is the most common cause of angina and acute coronary syndrome and is a leading cause of death worldwide (Shahjehan & Bhutta, 2021). Angina pectoris is chest pain caused by transient myocardial ischemia due to an imbalance in the demand and supply of oxygen to the myocardium (Gillen & Goyal, 2021). The main characteristics of angina are constricting discomfort that is localized to the chest center, neck, shoulder, and jaws, whose precipitant is physical exertion and becomes relieved with rest or sublingual nitroglycerin (Hermiz & Sedhai, 2020). The most common cause of angina is coronary atherosclerosis, whose risk factors include hypertension, smoking, alcoholism, hyperlipidemia, male sex, advancing age, genetics, diabetes, obesity, and physical inactivity (Shahjehan & Bhutta, 2021). B.F. carries almost all these risk factors for atherosclerosis implicated in CAD and hence angina. He is hypertensive with hyperlipidemia, overweight, and with a strong genetic risk. His presentation is in alignment with typical stable angina. 

Acute Coronary Syndrome (ACS)

It is a term describing unstable angina and myocardial infarction (MI), S.T. elevation, and non-ST elevation. Unstable angina is associated with rapidly worsening chest pain, angina on mild exertion, or even at rest. ACS always occurs in patients with CAD (Singh & Grossman, 2019). Patients report crushing substernal chest pain that radiates to the jaw or left arm. On examination, gallops or murmurs can be elicited (Singh & Grossman, 2019). This makes ACS a possible differential, and with no EKG changes, the appropriate entity is non-ST elevation MI.

Heart Failure

Heart failure is a clinical syndrome described as the failure of the heart muscles to effectively pump blood to all vital body systems at a rate that is commensurate with the metabolic demands of the tissues (Malik et al., 2022). The etiologies include hypertension, CAD, valvular heart diseases, and cardiomyopathies. It causes breathlessness, reduced exercise tolerance, fatigue, orthopnea, and leg swelling (Malik et al., 2022). Upon examination, specific signs include third heart sound, hepatojugular reflux, and elevated jugular venous pressure (Malik et al., 2022). In B.F., he has a third heart sound auscultated, and the basal crackles would be due to pulmonary edema, a complication associated with heart failure. 

Pneumonia

Pneumonia refers to inflammation of the lung parenchyma (Jain & Bhardwaj, 2022). It is classified as lobar or bronchopneumonia. It can be due to viral, bacterial, or fungal infections. The pathophysiology is due to the disturbance of the protective factors within the respiratory system, such as mucociliary clearance and secretory IgA (Jain & Bhardwaj, 2022). Patients develop respiratory distress, cough, and fevers. Upon auscultation, crackles can be felt in the lung bases, and a chest X-ray may reveal areas of consolidation depending on the pattern of lobar or bronchopneumonia. In B.F., the presence of crackles on the posterior lung bases may point toward pneumonia.  

P (plan) 

Diagnostics:

Complete blood count (CBC)

CMP

Cardiac enzymes

Troponin levels

Stress Echocardiogram

Chest X-ray

Ultrasound of the lower extremities. 

Electrocardiogram (EKG)

Interventions 

Treatment principles aim to identify and treat risks, advise smoking cessation, provide drugs to control symptoms, assess the severity of CAD, and identify high-risk patients to lengthen their life expectancy. Anti-anginal drugs include nitrates (sublingual nitroglycerin), beta-blockers, and potassium channel activators (Hermiz & Sedhai, 2020). 

Patient Education

Alcohol cessation, physical exercise to curb overweight, and maintaining compliance with current medications.

Follow-up

Four weeks.

References

Gillen, C., & Goyal, A. (2021). Stable angina. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK559016/

Hermiz, C., & Sedhai, Y. R. (2020). Angina. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557672/

Jain, V., & Bhardwaj, A. (2022, August 1). Pneumonia Pathology. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK526116/

Malik, A., Brito, D., Vaqar, S., & Chhabra, L. (2022, November 7). Congestive heart failure. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430873/

Shahjehan, R. D., & Bhutta, B. (2021). Coronary Artery Disease. StatPearls. https://www.statpearls.com/ArticleLibrary/viewarticle/20009

Singh, A., & Grossman, S. A. (2019, November). Acute Coronary Syndrome. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459157/

 

Get the best expert writers with just a few clicks. At online nursing paper writers we offer quality and original nursing papers at an affordable cost. Contact us today!