SOAP CASE #1 Cardiology Focus CC: “It feels like someone is sitting…
QuestionAnswered step-by-stepSOAP CASE #1 Cardiology Focus CC: “It feels like someone is sitting… SOAP CASE #1 Cardiology Focus CC: “It feels like someone is sitting on my chest.” HPI: EV is a 64yom presenting to the emergency department. He was outside spreading mulch in his flowerbeds when a tight, vice-grip-like pain appeared. The pain lasted about 3 minutes and then went away. He did not take any medications for it. Instead, he called 911 right away and came to the ED. He states he has been having similar symptoms on multiple occasions over the past 4 months with activity. PMH: Type II Diabetes Mellitus Transient Ischemic Attack Hypertension Stable Ischemic Heart Disease COPD Peripheral Vascular Disease Hx of DVT 20 years ago FH: Father deceased due to colon CA Mother deceased due to natural causes Brother with DMII, CAD, HTN, Hyperlipidemia SH: 20 py history, quit 12 years ago Drinks 4-6 beers per day Works as a forklift operator Diet is high in saturated fats, red meats, and vegetables Participates in a cardiac rehabilitation program 3 days per week (30minutes) Meds: Metformin 1000mg BID, Clopidogrel 75mg daily, Albuterol 2 puffs Q4h PRN SOB Atorvastatin 40mg daily Lisinopril 10mg daily Metoprolol succinate 25mg daily Famotidine 20mg Immunizations up to date All: Aspirin (difficulty breathing) ROS: No palpitations , dizziness or abdominal pain reported. Denies cough or sputum production. Denies radiation of chest pain to other parts of the body. Denies dyspepsia. No changes in appetite or body weight. Complaints of cramping in his left calf when he walks. PE: Gen: Overweight male in some distress Vit: BP- 118/70mmHg HR- 58bpm RR- 19 T- 37.1C (oral) Pulse Ox: 98% (RA) H6’3″ W-98kg HEENT: PERRLA, TM clear, NCAT, moist membranesNeck: No LAD, no thyromegaly Chest: Barrel chested, no wheezing CV: RRR, normal S1 and S2, no S3 or S4, no murmurs Abd: (+) BS, ntnd, no rebound tenderness or guarding Skin: Warm and dry, normal turgor Rect/GU: Guaiac (-) Ext: strength 4/5 all extremities, mild 1+ pedal edema bilaterally, lack of hair on left calf and foot Neuro: A&Ox3, CII-XII intact, DTR normal Labs: MCV: 91fL MCHC: 34% Troponin: <0.04ng/mL x3 Hemoglobin A1c: 6.8% INR: 1.1 AST:20 units/L ALT:32 units/L Alk Phos:100 units/L Alb: 2.7g/dL LDL: 78mg/dL HDL: 40mg/dL Trig: 140mg/dL Ca: 8.0mg/dL Mg: 2.0mg/dL Urine Macroscopic analysis: Color: Straw color Clarity: Clear Protein: negative Glucose: negative Leukocyte Esterase: negative Nitrite: negative EKG: NSR Ankle Brachial Index: 0.85 Angiography (1 month ago): CAD present but no blockage >80% CXR: No acute cardiopulmonary findings. Venous Ultrasound: No occlusive thrombi identified in lower extremities Problem list:Medical Problem Drug Therapy Problem Supporting Evidence Status Intervention1) 2) 3) 4) 5) 6) 7) 8) 9) 10) *You may subtract or add more boxes if needed Calculated objective data (must include units and show calculations to receive credit) IBW: ______ CrCl: ______ BMI: ______ BMI classification (circle one of the following): underweight normal overweight obesity class ____ Other: Any other calculation that may be pertinent to the specific case (Example: LDL-C, corrected calcium, anion gap, etc.) S: (All pertinent subjective findings for all problems) O: (All pertinent objective findings for all problems) A:(Assessment statements for each problem)1) 2) 3) 4) P: (Complete plan for each assessment statement)Recommendation(s): Efficacy Monitoring:Safety Monitoring:Patient Education/Counseling:Follow-up: Recommendation(s): Efficacy Monitoring:Safety Monitoring:Patient Education/Counseling:Follow-up:Recommendation(s): Efficacy Monitoring:Safety Monitoring:Patient Education/Counseling:Follow-up:Recommendation(s): Efficacy Monitoring:Safety Monitoring:Patient Education/Counseling:Follow-up: BiologySciencePharmacologyNURS 645Share Question
