HF SOAP NOTE - Cardiovascular cases in a SOAP note format to practice for exam and APPE rotations PDF

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Summary

Cardiovascular cases in a SOAP note format to practice for exam and APPE rotations...

Description

SUBJECTIVE: DS is a 69-year-old female, who presented to the ED with a complaint of cough for 1 week with chills, shortness of breath and fatigue. She was admitted on 04/03/20 and discharge on 04/06/20. She also has exposure to positive COVID-19 patient and therefore quarantine herself for 1 week. However, she was tested negative for COVID-19. She has those above symptoms due to not taking her diuretic medication for 1 week. However, she receives diuretic in hospital with significant improvement and discharged for home. Official diagnosis: Heart failure exacerbation PMH: Hypertension, Heart failure preserved ejection fraction, protein C and S deficiency with multiple VTEs, obstructive sleep apnea, asthma, vitamin D deficiency

OBJECTIVE: o

Allergies and Reaction 

o

NKDA

Medications as of discharge: o

Albuterol (ProAir HFA) – 2 puff inhalation four times a day PRN for SOB/wheezing

o

Atorvastatin 20mg – 1 tablet by mouth daily

o

Calcium Carbonate 750mg -- 4 tablet by mouth daily

o

Enoxaparin 100mg/ml – Inject 1 ml subQ every 12 hours

o

Ergocalciferol 50,000 IU – 1 capsule by mouth every 10 days 

Additional instruction - take with meal and take calcium 1200-1500mg a day

o

o

Liraglutide 18mg/3ml – Inject SubQ daily

o

Magnesium oxide 400mg -- 1 tablet by mouth daily

o

Olmesartan 20mg -- 1 tablet by mouth daily

o

Omeprazole 20mg -- 1 capsule by mouth daily

o

Torsemide 20mg -- 2 tablet by mouth daily

o

Verapamil 120mg -- 1 capsule by mouth daily

Vitals o

BP = 108/65

o

HR = 79

o

RR = 17

o o

SpO2 = 94%

Lab Values/Trend o

o

o

Cardiac testing 

NT-proBNP = 295pg/ml



CRP 90.20 mg/L (High)



Troponin...