SOAP NOTE for congestive cardiac failure PDF

Preview

Summary

SOAP NOTEStudent Name: Date: Course:1. SubjectivePatient Demographics: Mrs. X is a 40-year-old African-American woman. She ismarried, has 3 children, is a Christian, and attends Catholic church every Sunday. Besides, shestates that she works as an elementary school teacher in a nearby school.Chief C...

Description

1 SOAP NOTE Student Name:

Date:

Course:

1. Subjective Patient Demographics: Mrs. X is a 40-year-old African-American woman. She is married, has 3 children, is a Christian, and attends Catholic church every Sunday. Besides, she states that she works as an elementary school teacher in a nearby school. Chief Complaint: She presented with a chief complaint of midsternal "toothache like" chest pain of 15 hours duration. History of Presenting Illness: Mrs. X was well until 12th march, 2021, at 11 pm on the night before admission when she felt an "aching pain under her breast bone" while cooking. She described the pain as "heavy" and toothache" like and attributed it to 9 when presenting it on a scale of 1 to 10. It was not noted to increase with exertion or radiate to other parts of the body. Mrs. X denied having nausea, loss of consciousness, palpitations, vomiting or dizziness. She managed to sleep upon taking 2 tablespoons of antacids, even though she did not feel a sign of relief. In the morning, Mrs. X woke up free of pain; however, she started feeling an increased pain severity upon preparing breakfast. This prompted Mrs. X to call her daughter, who gave her a Panadol and immediately rushed her to the E.R. On presentation, her ECG indicated sinus tachycardia at 105, with leads I, AVL, V4-V6 marking S.T. elevations and occasional contractions of the ventricular paroxysmal. Mrs. X received thrombotic therapy and cardiac treatment immediately and was taken to the ICU. PMH: Mrs. X is a patient with a known long history of hypertension that has been previously controlled by diuretic therapy. In 2011, she was first admitted to CPMC due to intermittent midsternal chest pain complaints. Her EKG indicated 1st-degree atrioventricular

2 block, and the chest X-ray indicated mild pulmonary congestion with cardiomegaly. The physician ruled out myocardial infarction due to a lack of EKG and cardiac enzyme abnormalities. She was discharged following a brief stay on enalapril and Lasix regimens for presumed congestive cardiac failure (CCF). PSH: No history of surgery Allergy: Penicillin- she developed a diffuse rash 20 years ago after an injection. Immunization Status: Fully vaccinated against COVID-19, an annual flu vaccination. Pneumovax 1996 Screenings: FMH: Mrs. X was raised by her uncle following her mother's death, who died at the age of 30 from liver cirrhosis and her father, who died at the age of 40 in a road traffic accident. She also had one brother who died due to pneumonia. She currently lives with her husband and 3 daughters (ages 13, 16, 19), who are all healthy. There is no know family history of cancer or hypertension. Personal History/Social History: i.

Mrs. X is married and lives with her three daughters.

ii.

Occupation: she works as an elementary school teacher.

iii.

Habits: Drinks occasionally. No cigarettes.

iv.

Born in Kansa, Texas, came to New Jersey in 2000. She has never flown outside of America.

v. vi.

Present environment: lives n own apartment with an elevator. Financial: she is supported by her husband and receives Medicare and social security grants.

3 vii.

Psychosocial: Mrs. X is alert and active despite her rheumatoid symptoms. She comprehends her "cardiac attack" at present.

Females: Obstetric History: G3, P3, A0, L3 Sexual History: she has only one sexual partner, her male husband. They normally have unprotected sex. She does not use any contraceptives. Current Medications/OTCs/Supplements: Drug Digoxin Enalapril Lasix KCl Tylenol

Dosage 0..125mg 20mg 40mg 20mg 2 tabs

Route Oral Oral Oral Oral Oral

Frequency OD (Cardiac failure) BD (hypertension) OD (hypertension) OD (hypokalemia) BD (analgesics)

Review of System General: no fever, no chills, no sweats, no fatigue Skin: bluish skin HEENT: Head: recurrent headaches Eyes: wears glasses, no diplopia Ears: wears hearing aids due to hearing loss Nose: no obstruction or epistaxis Throat: no history of tonsillectomy or tonsillitis Breasts: tender, no discharges, atrophic and symmetric Respiratory: no history of T.B. exposure, wheezing, asthma, hemoptysis, pulmonary embolism, cough or pneumonia

4 Cardiovascular: PMI at the sixth ICS, 1 cm to MCL laterally. No heaves. Regular heartbeat rhythm with occasional extra beats. S2 narrowly Split; S4 positive gallop. Grade II/IV systolic ejection heart murmur is heard without radiation at the left upper sternal border. Sharp carotid upstrokes. Gastrointestinal: admitted to CPMC in 2012 following 2 days of melena and hematemesis. Endoscopy indicated gastritis' evidence caused by intake of ibuprofen even though upper G.I. series was negative. On admission, she received 4 units of blood due to her hematocrit being 24%. Colonoscopy indicated multiple diverticuli. Her stool has been Brown, and when hematest is taken, a negative result is reported. After a few months of admission, she was noted to have jaundice and had increased liver enzymes, which indicated that she had contracted hepatitis B from the blood transfusion. However, Mrs. X has not indicated any chronic hepatitis evidence since then. Genitourinary: History of multiple incidences of cystitis, most recently Escherichia coli 3/2/2013, and was treated with Bactrim. Three days before admission, she presented with dysuria. No hematuria, no fever. No history of STIs. Menarche was at 14 and had regular menstrual cycles. Three pregnancies with normal births. Peripheral Vascular: no history of gangrene, DVT, aneurysm. Musculoskeletal: Neurologic: Rheumatoid arthritis of both limbs and shoulder for more than 5 years. She took ibuprofen until 2011, has taken Tylenol since her gastrointestinal bleeding, with good relief of intermittent rheumatoid arthritis pain. No history of syncope, memory alterations, stroke, seizures. Hematologic: no known blood or clotting disorder.

5 Lymphatic: no lymphadenopathy Endocrine: no known thyroid diseases or diabetes Psychiatric: denies having depression, anxiety 2. Objective Physical Exam: Vital Signs: Blood Pressure-170/100 lying down, P- 95 (regular with an occasional extra beat) RR-24 T-37.5oC Height- 5 inches and 8 feet, Weight- 159 lbs. BMI- 24.2 (normal) General: Well developed, slightly overweight, mid elderly black American woman sitting up in bed, slight difficulty breathing. Resolving chest pain complaints. Skin: warm and smooth, cyanosis. HEENT: Head: Eyes: full extraocular motions, clear conjunctiva, equal round pupils and responsive to light and accommodation, possible cataracts presence due to fundis not well visualized. Ears: very poor bilateral hearing. Well, visualization of tympanic membrane landmarks. Nose: no deviation of the septum, no discharge, no obstruction Throat: gag reflex is normal; uvula moves up in the midline. Neck: no masses. No palpable thyroid, jugular venous pressure 8cm. Breasts: tender, no discharges, atrophic and symmetric Lungs: no wheezing/crackles/rales.

6 Heart: PMI at the sixth ICS, 1 cm to MCL laterally. No heaves. Regular heartbeat rhythm with occasional extra beats. S2 narrowly Split; S4 positive gallop. Grade II/IV systolic ejection heart murmur is heard at the left upper sternal border without radiation. Sharp carotid upstrokes. Abdomen: present bowel sounds, soft and flat abdomen, no brits. Nontender to palpation. Spleen, kidney not felt. Percussion reveals a liver span of 10cm. Rectal: no masses felt. Brown stool, negative for blood. Peripheral Vascular: Lymphatic: no swollen lymph nodes. Extremities: Musculoskeletal: 1+ edema to the knee joint, very tender to palpation and non-pitting. No clubbing. Neurological: Awake, alert and oriented fully. Intact cranial nerves 3-12 except for decreased hearing. Motor: Moves all extremities. Sensory: Grossly normal to pinpricks. Cerebellar: no dysmetria. 3. Assessment: Differential Diagnosis Diagnostic Reasoning Exercise: Differential Diagnoses 1. Congestive cardiac failure

Pathophysiology (include APA citations) CCF is whereby the cardio, through cardiac function abnormality, fails to pump blood at the rate required by the mobilizing tissues. Its ability depends on an increased diastolic filling pressure (Dumitru, 2022). It is caused by failure of the myocardial muscles but

Pertinent Positives   

S4 positive gallop Exertional chest pain Blood Pressure170/100 lying down

Pertinent Negatives none

7

2. Cardiogenic pulmonary edema

may occur in the nearnormal function's presence under conditions of increased demand. Regardless of the precipitating event, the common pathophysiologic state perpetuating the heart failure progression is extremely complex. From the subcellular through to organ interactions, compensatory mechanisms attenuate at every organizational level. Only when various adaptation networks like neurohumoral system activation, myocardial hypertrophy, changes in myocyte regeneration and necrosis become overwhelmed does heart failure occur (Dumitru, 2022). Pulmonary edema following an elevated capillary hydrostatic pressure due to increased pressure at the pulmonary vein (Iqbal & Gupta, 2021). Its pathophysiology can be linked to various causes such as starling forces' imbalance (elevated pulmonary capillary pressure, minimized pressure of the oncotic plasma, and elevated negative interstitial pressure), damaged alveolar-capillary

     

Lips cyanosis Confusion Cold extremities Tachypnea Dyspnea S1 pattern representing acute right heart strain

S3 gallop in volume overload No history of prevailing hypertension

8

3. Myocardial infarction

barrier, and obstruction of the lymph (Iqbal & Gupta, 2021). MI is characterized by the blood supply to the myocardium through coronary arteries being interrupted, leading to ischemia. MI follows a coronary vessel's thrombotic occlusion caused by vulnerable plaque rupture. This subsequently results in decreased oxygen delivery via the coronary artery leading to a decreased myocardium oxygenation. The inability of ATP production in the mitochondria results in an ischemic cascade, causing myocardial infarction (Jenča et al., 2020).

    

Chest pain radiating to the shoulder Anxiety SOB Palpitations Diaphoresis

    

No history of nausea S.T. elevation on EKG No history of substernal pain No N/V palpitations No radiation or pain

Evidence-Based practice: The patient fits the picture of heart failure. This is because, upon thorough physical examination and review of the system, Mrs. X's presentation does not typically conform to that on MI since her chest pain is not substernal but rather midsternal and does not radiate to the shoulder. Besides, her presentation does not match with that of cardiogenic pulmonary edema, which presents with an S1 pattern representing acute right heart strain, tachypnea, cold extremities, and confusion, unlike that of cardiac failure, which has no history of wheezing, tachypnea, normal S1 and positive S4 gallop, and extremities are warm and smooth. 4. Plan:

9 Diagnosis ICD-10 (must be related to CC/HPI) 

Treatment o Continue aspirin, nitrates, nasal oxygen, and beta-blockers as per the cardiologist's advice



Lab/test o Complete blood count o Urinalysis o Lipid profile o EKG to examine post-MI cardiac function and murmurs.



Referral o Dietitian to provide more information to the patient on managing symptoms. o Physiotherapist to help the patient in physical activities.



Education o Stress management o Deep breathing exercise o Relaxation techniques o Lifestyle changes that can assist in managing CCF



Follow up o Bed elevation o Patient to maintain the semi-Fowler's position...