Chamberlain College of Nursing - NR 509NR509_SOAP_Note_on chest pain week 4. FULLY FILLED AND PASSED. GRADE A

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SOAP Note Template Initials: BF Age: 58 Gender: M Height Weight BP HR RR Temp SPO2 Pain Allergies 5’11 97kg 146/ 90 104 19 36.7C 98% Choose an item. Medication: Codiene( Nausea/Vomitting) Fo... od: NFA Environment: NA History of Present Illness (HPI) Chief Complaint (CC) I have been having some troubling chest pain in my chest now and then for the past month. CC is a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance "headache", NOT "bad headache for 3 days”. Sometimes a patient has more than one complaint. For example: If the patient presents with cough and sore throat, identify which is the CC and which may be an associated symptom Onset Early this month. Location Middle chest. Duration Last a minute or more. Characteristics Tight and uncomfortable in the middle of chest that does not radiate. Aggravating Factors Yard work and climbing stairs. Relieving Factors Rest Treatment None Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. Medication (Rx, OTC, or Homeopathic) Dosage Frequency Length of Time Used Reason for Use Metoprolol 100mg PO daily 1 year High blood presure Atorvastatin 20mg PO bedtime 1 year High cholesterol Tylenol 650mg PO Q 8 hours PRN Headaches Fish oil 1200mg 1 tab PO daily 1 year supplements . enter text. tap here to . Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses, hospitalizations, and surgeries. Depending on the CC, more info may be needed. S: Subjective Information the patient or patient representative told youPatient is hypertensive and high cholesterol. No surgery, reports immunization is up to date. Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent data. Include health promotion such as use seat belts all the time or working smoke detectors in the house. Patient is married, lives with his wife and 2 children.He is a civil engineer and enjoys riding his bike a lot but has not done so in 2 years since it got stolen. Denies illcit drug use or tobacco.Social drinker,drinks 2 to 3 bottles on the weekends. Uses his seatbelt while driving and has working smoke detectors at home. Denies routine exercise. Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent. Dad : Died of Colon cancer. Mom: Living High blood pressure and Type 2 Diabetics. Brother: passed at 24 years old from a MVA. Sister:Living 52yo Type 2 diabetics and hypertension. Paternal grand dad: Died at 85yo unknown causes. Paternal grand mom: Died at 78 from pneumonia. Maternal grand dad: Died at 54 from a heartattack. Maternnal grand mom:died at 65 from Breast cancer. Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive symptom and provide additional details. Constitutional Skin HEENT ☐Fatigue tap here to ☐Weakness tap here to ☐Fever/Chills tap here to ☒Weight Gain Gained 15 pounds in a couple of yearschest ☐Weight Loss tap here to ☐Trouble Sleeping ☐Itching tap here to ☐Rashes tap here to ☐Nail Changes Click or enter text. ☐Skin Color Changes ☐Other: ☐Diplopia tap here to ☐Eye Pain tap here to ☐Eye redness . ☐Vision changes . ☐Photophobia . ☐Eye discharge . ☐Earache tap here to ☐Tinnitus tap here to ☐Epistaxis tap here to ☐Vertigo tap here to ☐Hearing Changes Click or . ☐Hoarseness tap here to ☐Oral Ulcers tap here to ☐Sore Throat tap here to ☐Congestion tap here to ☐Rhinorrhea tap here to ☐Other: .. ☐Night Sweats tap here to ☐Other: enter text. Respiratory Neuro Cardiovascular ☐Cough enter text. ☐Hemoptysis ☐Dyspnea enter text. ☐Wheezing enter text. ☐Pain on Inspiration tap here to ☐Sputum Production . . . ☐Other: enter text. ☐Syncope or Lightheadedness tap here to ☐Headache tap here to ☐Numbness tap here to ☐Tingling ☐Sensation Changes . ☐Speech Deficits tap here to ☐Other: ☒Chest pain chest pain my chest now and then for the past month. ☐SOB . ☒Exercise Intolerance Experienced while climbing the stairs at work. ☐Orthopnea enter text. ☐Edema . ☐Murmurs enter text. ☐Palpitations tap here to ☐Faintness tap here to ☐OC Changes tap here to ☐Claudications tap here to ☐PND ☒Other: S3 sound heard MSK GI GU PSYCH ☐Pain enter text. ☐Stiffness ☐Crepitus ☐Swelling ☐Limited ROM . ☐Nausea/Vomiting ☐Dysphasia enter text. ☐Diarrhea enter text. ☐Appetite Change ☐Heartburn enter text. ☐Urgency ☐Dysuria ☐Burning ☐Hematuria tap here to ☐Polyuria ☐Stress ☐Anxiety ☐Depression tap here to ☐Suicidal/Homicidal Ideation . ☐Memory Deficits tap here to ☐Redness ☐Misalignment ☐Other: enter text. ☐Blood in Stool ☐Abdominal Pain ☐Excessive Flatus ☐Food Intolerance ☐Rectal Bleeding ☒Other: Liver palpated 1cm beleow costal margin ☐Nocturia ☐Incontinence tap here to ☐Other: ☐Mood Changes tap here to ☐Trouble Concentrating Click or . ☐Other: GYN ☐Rash . ☐Discharge . ☐Itching . ☐Irregular Menses . ☐Dysmenorrhea . ☐Foul Odor . ☐Amenorrhea . ☐LMP: . ☐Contraception . ☐Other: . Body System Positive Findings Negative Findings General . NA Pt is alert and oriented x4.No sign pf distress noted.denies pain or shortness of breath. Able to follow commands. Skin . NA Skin warn and dry to touch.No tenting. HEENT . NA Head and neck is symmetrical, no sweeling noted. Vision 20/20 in L,R and both eyes.PERRL noted. O: Objective Information gathered during the physical examination by inspection, palpation, auscultation, and palpation. If unable to assess a body system, write “Unable to assess”. Document pertinent positive and negative assessment findings.Nose at midline and pink and mosit Mucosa memberane pink and mosit. Ears symmetrical bilaterally. Respiratory . Fine crackles in right and left posterior lower lobes. Chest is symmetrical. Breath sounds clearclear in all anterior lobes. No shortness of breath noted. Neuro . NA Alert and oriented X4. No loss of consciousness noted. No dizziness or light headness noted. Cardiovascular . BP 146/90, HR 104 S3 hear sound heard. PMI displaced laterally brisk and tapping less than 3cm Bruit presence and +3 thrill in right carotid artery. Popliteal,tibal aned dorsalis pedis pulse no thrill +1, Chest symmetrical S1 and S2 heart sounds heard. JVP 3cm above sternal angle. Cap refill less than 3 seconds in all extremities. Brachial,radia, femoral pulses no thrill +2 Musculoskeletal . NA Range of motion equal in all exteimities. Gait is steady Gastrointestinal . Liver palpated 1cm below costal margin Abdomen soft and round. No tenderness or distention or masses noted.Bowel sounds present in all 4 quadrants.Spleen and kideneys not palpable .All areas of the abdomen are tympanic. Genitourinary . NA Kidneys are not palpable bilaterally. Psychiatric . NA No history of mental illness. Gynecological . NA NAProblem List 1. Chest Pain 6 PMI displaced baterally brisk and tapping 11 Weight gain 2 High blood pressure 7 RUQ Abdomen light tenderness 12 Diminshed popliteal arteries 3 Tachycardiac 8 RLQ/LLQ abdomen Light tenderness 13 Popliteal,tibal and dorsalis pedis pulses. No thrill +1 4 Bruit and +3 Thrill found in right Carotid pulse 9 liver palpated 1cm below costal margin 14 . 5 Fine crackles in lungs 10 Activity intolerance 15 . Diagnostics: List tests you will order this visit Test Rationale/Citation Chest Xray Chest Xray will shows images of the heart, lungs which can help diagnose heart failure.Fine crackles in lungs shows some heart problems as evidence by S3 and bilaterally displaced PMI.Also chest xray helps to depict changes in the lungs that sterm from heart failure. Fluid in the lungs will mean pulmonary edema present in heart failure (mayoclinic.org 2019) Echocardiogram Because pf the S3 sound heard around the mitral area and Echo will be recommended. An echocardiogram uses sound waves to produce images of your heart. Parts that move weakly may have been damaged during a heart attack or receiving too little oxygen. This may indicate coronary artery disease.(mayoclinic.org 2019) Diagnosis ICD-10 Code Pertinent Findings Coronary artery disease with stable angina 125.119 Chest pain and tightness,High BP, tachycardia. Congestive heart failure 150.20 Fine crackles, hypertension, S3 heart sound and weight gain. Carotid artery disease 165.21 Presence of bruit and thrill +3 on right carotid pulse. P: Plan Address all 5 parts of the comprehensive treatment plan. If you do not wish to order an intervention for any part of the treatment plan, write “None at this time” but do not leave any heading blank. No intervention is self-evident. Provide a rationale and evidence-based in-text citation for each intervention. A: Assessment Medical Diagnoses. Provide 3 differential diagnoses which may provide an etiology for the CC. The first diagnosis (presumptive diagnosis) is the diagnosis with the highest priority. Provide the ICD-10 code and pertinent findings to support each diagnosis.Stress Test Mr Fosters exhibits chest pain during activities making this test appropriate. ‘A stress test, also called an exercise stress test,shows how your heart works during physical activity(mayoclinic.org.2019). This test can also help diagnose CAD. Carotid doppler The presence of bruit and +3 thrill may indicate carotid artery stenosis. Helps reveals structural details of carotid arteries so as to look for blood clots, arthereosclerotic plague build up and the presence of blood flow problems (Koons et al, 2016). Cardiac Enzymes This tells what damage has been done to the heart muscules. Medications: List medications/treatments including OTC drugs you will order and “continue previous meds” if pertinent. Drug Dosage Length of Treatment Rationale/Citation Metoprolol 50mg PO once daily 30 days I will lower the dosage on this medication because his blood pressure is not being controlled with it alone adding a ACE inhibitor will help regulate BP better since his heart is doing enough work thereby making patient patient tachycardaic.Metoprolol is used alone or combination with other medication to treat high blood pressure.It also used to prevent angina (chest pain)and to improve survival after a heart attack. Metoprolol is also used in combination with other medication to treat heart failure.(Medlineplus.gov.2019) Lasix 40mg PO once daily 30 days Patient has fine crackles in posterior and anterior lower lobes this medication can help reduce fluids building around the heart.Furosimide is used to treat edema (fluid retention; excess fluid held in body tissues) caused by various medical problems, includes heart kidney and liver disease. (medlineplus.gov.2019) Lisinopril 10mg PO once daily 30 days This medication will help reduce the workload of the heart and alsocontrol his blood pressure.Lisinoprl oral tablet is used to treat hypertension (high blood pressure) and heart failure.(healthline.com.2019) Liptor 20mg PO once daily 30 days Because of the patient history of high cholesterol continuing this medication is ideal and also his presenting symptoms during his visit.(chest pain and heart failure). Lowering your blood level of cholesterol and fats with atorvastatin has been shown to prevent hearts disease, angina (chest pain), strokes and heart attack. (medlineplus.gov.2019) Nitroglycerin 0.4mg sublingual Q 5mins X 3 doses. If chest pain is unrelieved PRN Nitroglycerin SL tablets are used to treat episodes of angina(chest pain)in people who have coronary artery disease(narrowing of the blood vessels that supply blood to the heart). (Medlineplus.gov) Referral/Consults: Cardiologist Vascular surgeon Rationale/Citation Mr Foster will be refered to a cardiologist because of his hypertension as evidenced by his BP and heart rate and the S3 heart sound. Also because of his chest pain. Cardilogist will review your signs and symptoms and evaluate you to diagnose your heart condition.(mayoclinic.org 2019) He will be needing this specialist for carotid evaluation as evidence by the bruit and +3 thrill found in the right carotid artery as this might indicate some blockage. CAD is caused by the buildup ofplaques in arteries that deliver blood to your brain(mayoclinic.gov 2019) Education: I will educate patient on the importance of taking medication as prescribed and checking blood pressure regularly before taking medication. Record blood pressure daily and present it at the follow up visit. Teach patient to place nitroglycerin tablet underneath the tongue until it dissolve, check blood pressure before taking the second dose 5 mins later and repeat the same for the 3rd dose 5mins later. If blood pressure low do not take 2nd dose. Teach patient to store bottle in at room temperature and should always have it on him. Rationale/Citation Pts should be aware of signs and symptoms of their presenting symptoms and should seek immediate help. It is important to pay attention to your signs and symptoms. Know which adult health warning signs merit medical attention(mayoclinic.org.2019) Eating health and execrsing has proved to help reduce heart disease or stroke. Nitroglycerin tablet is usually taken as needed either 5 to 10 mins before activites that may cause attacks of angina or the first sign an attack.(medlineplus.gov 2019). Keep this medication in the container it came in, tightly closed after each use and out of reach of children.(medlineplus.gov.2019) Follow Up: Indicate when patient should return to clinic and provide detailed instructions indicating if the patient should return sooner than scheduled or seek attention elsewhere. He needs to return to the clinic in 7 days for evaluation Rationale/Citation A follow up is important because of his presenting symptoms to the clinic and tesst ran, he needs to come back for reevaluation. References Include at least one evidence-based peer-reviewed journal article which relates to this case. Use the correct APA 6th edition formatting. Koons, K., Glaser, J. D., Sehgal, C., Davis, J., Foley, P., Wang, G. J., . . . Jackson, B. M. (2016). IP099. Turbulence in Carotid Stenosis byDuplex Ultrasound Imaging. Journal of Vascular Surgery, 63(6). doi:10.1016/j.jvs.2016.03.087 https://www.healthline.com/health/lisinopril-oral-tablet https://medlineplus.gov/druginfo/meds/a682858.html https://www.mayoclinic.org/diseases-conditions/heart-disease/diagnosis-treatment/drc-20353124 [Show More]

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