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

 
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:

 	
Uncontrolled HTN
 	
Intermittent chest pain
 	
Activity intolerance
 	
Lung base fine crackles
 	
Moderate alcohol consumption
 	
Enlarged/palpable liver
 	
High red meat intake
 	
Right carotid bruit
 	
Mitral area S3 sound
 	
Congestive heart failure
 	
Family cardiac history
 	
Poor diet habits (fast food, multiple times/week)
 	
Increased caffeine consumption




Diagnosis & ICD-10 Codes:

 	
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
 	
Congestive Heart Failure (I50.20): +Chest pain, -Frothy sputum, -Blood tinged sputum, +Lung base crackles, -Edema, -Lethargy, -Wheezing
 	
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.