Soap Note on Chest pain

Soap Note on Chest pain

 

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Name xxx

United State University

Primary Healthcare if Chronic Client/Families Across the Lifespan-Clinical Practinum

xxxxxx

Professor xxxx

Date xxxxx

Subjective

ID: Mr.

Client’s initials: G.H, Age: 65, Gender: Male, Race: Caucasian, Date of Birth: January 01, 1962. Patient presents as a reliable historian.

CC: “I am experiencing chest pains.”

HPI: Mr. G.H, 65 years old, Caucasian man with a health history of high blood pressure, came to the clinic complaining of having chest discomfort for a span of about 2 months. In his description, the chest pain felt like an excruciating burning pain in the center of his chest. Mr. G.H described the rate of his pain as 5/10. Patient noted that the pain occurred slowly over a few minutes before going away. Most frequently while performing physically demanding tasks, such as climbing stairways; nevertheless, it might occur while seated as well as while standing up. On the other hand, Mr. G.H claims he has never felt dizzy or fainted before. The patient denied experiencing any discomfort in his neck or jaw. He attempted treating his chest pain with over-the-counter Advil 200 mg 2 tablet every 6 hours for 3 days, but the medication did not help. He denies using any herbal medications.

Past Health General:  He was diagnosed with hypertension in 2017. He is currently on metoprolol 100 mg orally once daily for the treatment of high blood pressure. Patient stated that he is non compliant with his blood pressure medication. He has also had a history of the common flu in the past.

Social History: He has never smoked tobacco or any hard substances in his life. For numerous years he has abstained from the consumption of alcoholic beverages and strong drugs. He is a retired soldier. He is a married man with two grown sons. He is not a regular participant in physical activities. He acknowledged that a large portion of his diet consisted of fast food.

Family History: Father died at the age of 83 due to complications from ischemic heart disease. Mother, who is 84 years old, is in good health except for a vision problem and tinnitus, which are both common side effects of old age. His sister has hypertension and diabetes. He has two adult children who do not have any medical issues. His wife has had UTIs and stomach ulcers in the past.

Surgical History: No surgeries.

Allergies: He has no food or drug allergies.

Review of System

General: Patient has steadily gained weight over the previous ten years. In fact, he denied experiencing weariness, fevers, memory abnormalities, discomfort, or even suicidal thoughts.

Skin: No rashes, blisters, irritation, dryness, or discoloration. There were no wounds or bruises, as well as there was no extreme sweating; also, he does not experience high and low-temperature hypersensitivity. No hair loss and no nail alterations.

Head: Patient claims that he has no headache, dizziness, or a concussion.

Eyes: There are no adverse effects, such as blurred vision or excessive tearing, that need the use of corrective lenses.

Ears: Patient claims to experience no ringing in the ears, no infection, and no other form of ear discharge to be found.

Nose: No rhinitis, sneezing, a runny nose, or epistaxis were experienced.

Mouth: Patient has no bleeding gums, oral ulcer, as well as no cracked lips. A dental exam has not taken place in four months.

Throat: There was no painful throat or swelling in the throat.

Neck: Goiter, lymphoma, and other malignancies of the neck, as well as any other enlarged glands, are not present.

Neuro: No syncope or tremors are present in this patient. There are no aberrant movements in this patient’s extremities either.

Cardiac: In the two months prior, the patient had been experiencing pressure, and burning chest pain. In the midst of his chest, the agony felt like a scorching and tingling. He gave it a score of five out of ten, describing his discomfort.

Musculoskeletal: No muscle or joint discomfort or stiffness.

Gastrointestinal: He did not have any alterations in appetite, severe thirst or food desire, no swallowing problems, no heartburn, no stomach pains, and no changes in bowel patterns.

Genitourinary: No urgency or increased urination; no hesitancy or decreased stream; no incontinence; as well as no blood in urine, no renal pain, or cramping in the genitals were reported.

Objective

Vital Signs

Temperature: 37.5°F, His height: 5’5” ft, His weight: 199 lbs., BMI: 33.11, Blood Pressure: 154/88, RR: 19, SpO2: 98%

Physical Examination

Constitutional: He has a decent physique; however, he is a touch overweight.

HEENT: Head: Normocephalic, as well as no palpable masses. Eye: Extensive extraocular movements, large visual ranges to confrontation, and clean conjunctivae are present in both eyes. Icterus does not exist, pupil size and shape are equal, light sensitivity and correction are present, and the eyes have a chance of developing cataracts. Ears: His hearing accuracy is quite poor on both sides of the ears. The tympanic membrane’s markers were plainly visible on the slide. Nose: No abnormal discharge, obstruction, or deviation of the septum can be found in the nose. Mouth: A complete set of dentures, upper and lower. The pharynx has no exudates since nothing has been injected into it. The uvula, which is located in the center of the body, moves upward. Gag reflexes are quite natural.

Neck: No lumps. No thyroids, and the pressure in the jugular veins is 8 cm. No masses.

Lymph nodes: There are no enlarged lymph nodes.

Chest: It appears that the breasts have no lumps or discharges. Lung sound is reduced, but there is no reduction in percussion. The diaphragm’s breathing is effortless. No rhonchi, rubs, or wheezes.

Heart: The PMI is positioned at the sixth ICS one centimeter laterally to the MCL. This film fails to excite or excite the audience. The tempo is steady, with the exception of a few extra beats. Carotid upstrokes, which characterize normal S1 and S2 splits, are prominent in pulses. A positive carotid, brachial, and femoral pulse round out the electrocardiogram.

Abdomen: There is normal bowel sound in all four quadrant of the abdomen.. Palpation reveals that it is not sensitive in the least. Neither the liver, and spleen could be felt on the surface. The liver grows by 7cm when percussion is applied.

Rectal: There is a noticeable external hemorrhoid, but no masses are seen. The stool is darkish and contains no blood.

Skin: There are visible changes in leg vein stasis despite the skin being generally healthy. A grade of 1+ knee edema is present; however, it is non-pitting. Cyanosis and clubbing are not present.

Neurologic: Has complete awareness. The cranial nerves are intact. Patient moves all extremities without being tested for strength. The cerebellum exhibits neither tremor nor dysmetria. The reflexes are symmetric 2+ throughout, and there is no Babinski sign.

Labs: A portable chest x-ray shows moderate Premature Ventricular Contractions, which are consistent with the presence of cardiomegaly. Other test to consider are resting EKG, cardiac enzymes echocardiogram, CMP, Complete Blood Count , Lipid profile, and HbA1c (Cash et al., 2017).

 

Diagnostic Plan

Differential Diagnoses

Stable Angina (I20. 9): When under physical exercise or are under stress, you may experience stable angina, which is chest discomfort that does not go away. A blockage in the blood vessels, which may result in less blood flow to the heart, is the underlying cause of angina (Lanza, 2019). Primarily as a result of the client’s medical assessment and the similarities between his complaints and the symptoms of stable angina, therefore, diagnosis of stable angina was confirmed. Also, an exercise stress echocardiogram is needed to assess the ability of the heart to resist physical exercise.

GERD (K21.9) – Epigastric or retrosternal pain radiating to the throat or chest is a common symptom of esophageal reflux (Chen & Brady, 2019). This condition might be a possible differential diagnosis; therefore, some tests should be assessed to rule out.

Costochondritis (M94. 0) – Costochondritis is inflammatory in the muscle tissue that lies between the rib bone and the sternum, or breastbone. This inflammatory can be very painful. Costochondritis is a condition that can be caused by physical activity or joint illnesses such as osteoarthritis (Schumann et al., 2019). Chest pain can result from this inflammation.

Final  Differetial: Stable Angina (I20.9)- The signs and symptoms the patient is presenting most correlate to stable angina. Stable angina discomfort usually starts slowly and worsens over a few minutes before disappearing (Lanza, 2019).

Diagnostic Plan

Exercise Stress Echocardiogram

The ability of the heart to resist physical exercise should be evaluated. Investigates the functioning of the heart’s valves and other internal organs. This will assist you in determining whether or not you have a substantial chance of acquiring heart disease in the future (Lanza, 2019). As a result, it will be possible to examine the outcomes of the existing cardiac therapy plan. Upon evaluation, the EKG revealed changes in the Q-waves, which suggested the presence of stable angina.

Bravo reflux testing

The pH acidity of the esophagus is measured by the Bravo reflux testing instrument, which uses unique capsule technology. Additionally, this test measures how PPIs affect blood pH and how severe reflux symptoms are. Individuals can continue their daily activities and normally eat while the doctor does a more exact diagnosis of Bravo Reflux (Chen & Brady, 2019). This procedure is also preferred by the majority of patients over catheter-based examinations.

Costochondritis test

There is no specific test that may be used to diagnose costochondritis. In order to effectively rule out more serious heart or costochondritis that might be causing chest pain, doctors frequently perform a chest X-ray and an echocardiogram (ECG). Whether the discomfort is in the rib cartilage, which is normally placed between the 4th and 6th ribs, will be discernible by the doctor during the examination (Schumann et al., 2019).

Treatment Plan

Among the therapeutic objectives for stable angina patients is the reduction in cardiovascular-related mortality and prevention of angina complications such as unstable angina and heart attack, among other things. Anginal symptoms can be completely eliminated by maintaining an active lifestyle and a positive outlook on life.

Pharmacotherapy

The use of aspirin for an indefinite period of time is suggested for patients, but if low-dose aspirin medication causes an adverse reaction, clopidogrel is a suitable substitute (Valgimigli et al., 2018). Therefore, Mr. G.H is instructed to start taking Aspirin 75 mg orally once daily  or clopidogrel 75 mg orally once daily for six months. Atrovastastin 20 mg orally daily. Metoprolol 100 mg orally once daily, this will help to treat his high blood pressure and angina (Cash et al., 2017).

Education

Education and regular checkups are critical parts of the therapy process, as are offering recommendations to patients on how they might improve their health. In order to aid in his recovery, the medical professional will urge that he get enough rest and sleep (Meeder et al., 2021). The patient’s weight can be managed by avoiding fast foods and engaging in modest physical activity. He should consume a healthy diet rich in fresh produce such as vegetables, fruits, whole grains, and legumes. He should eat fish, chicken meat, and beans are all excellent sources of lean protein. He should avoid foods with high salt content, and also, he should consume low-fat products like yogurt or skim milk, or no-fat dairy (Evans, 2018). Stop using asprin and call your PCP if have ringing in your ears, confusion , hallucination, stomach pian, blood or tarry stool. Advice patient that non-compliant with his blood pressure medication could leaf to health consequences.

Follow Up

In two week’s time,  Mr. G.H is requested to come back to the clinic, to assess the efficacy of his drugs, and to monitor his lab results.

 

References

Cash, J., & Glass, C (2017). Family practice quideline (4th ed.). Springer Publishing Company, LLC.

Chen, J., & Brady, P. (2019). Gastroesophageal reflux disease: Pathophysiology, diagnosis, and treatment. Gastroenterology Nursing: The Official Journal of the Society of Gastroenterology Nurses and Associates42(1), 20–28. https://doi.org/10.1097/sga.0000000000000359

Evans, M. (2018). Blood Pressure: Solution-The Ultimate Guide To Naturally Lowering High Blood Pressure And Reducing Hypertension (Vol. 1). Alakai Publishing LLC.

Lanza, G. A. (2019). Diagnostic approach to patients with stable angina and no obstructive coronary arteries. European Cardiology14(2), 97–102. https://doi.org/10.15420/ecr.2019.22.2

Meeder, J. G., Hartzema-Meijer, M. J., Jansen, T. P. J., Konst, R. E., Damman, P., & Elias-Smale, S. E. (2021). Outpatient management of patients with angina with No Obstructive Coronary Arteries: How to come to a proper diagnosis and therapy. Frontiers in Cardiovascular Medicine8, 716319. https://doi.org/10.3389/fcvm.2021.716319

Schumann, J. A., Sood, T., & Parente, J. J. (2018). Costochondritis. https://europepmc.org/article/NBK/nbk532931

Valgimigli, M., Bueno, H., Byrne, R. A., Collet, J. P., Costa, F., Jeppsson, A., … & Levine, G. N. (2018). 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS. European journal of cardio-thoracic surgery53(1), 34-78. https://doi.org/10.1093/ejcts/ezx334

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