Soap Note

SOAP NOTE

Name:  R.G Date: 08/21/2019 Time: 10 AM   Age: 56 y/o Sex: Female SUBJECTIVE CC:

“I have been experiencing increasing shortness of breath, fatigue and problems sleeping”

HPI:

R.G, a 56 y/o African American female presents to the office with complaints of increasing shortness of breath on exertion and mild fatigue for the past five days. The patient reports that he has been experiencing shortness of breath after climbing stairs or walking two to three blocks he also reports difficulty sleeping at night and states that he often need two pillows to feel comfortable. Patient reports that 2 years ago, she suddenly started experiencing shortness of breath after hurrying for an aeroplane. Following the incidence, she was admitted to hospital and treated for acute pulmonary edema. After the pulmonary edema episode, the patient reports that his blood pressure had been high consistently. Patient denies chills, cough, chest pain, palpitations, vomiting, diarrhea abdominal pain/distension

Medications:

Diltiazem 180 mg/d for HTN

Hydrochlorothiazide 50 mg/d for HTN and heart failure

Lopressor 25mg orally BID HTN and heart failure

Glyburide 5 mg/d for diabetes

Indomethacin 25 mg TID for pain

PMH

Allergies:  No known Drug allergies

Medication Intolerances: None

Chronic Illnesses/Major traumas: Diastolic dysfunction with diastolic congestive heart failure, Hypertension (diagnosed 5 years ago), type 2 diabetes mellitus (diagnosed 4 years ago), arthritis (diagnosed two years ago). Denies a history of asthma

Hospitalizations/Surgeries: patient was admitted to hospital and treated for acute pulmonary edema. Patient has no history of surgeries

Family History: Coronary heart disease, hypertension, arthritis ( father), Type 2 diabetes mellitus ( mother), Hypertension ( older brother), other siblings and her children alive and well.

Social History: Patient lives with her husband and youngest son. She works as a teller at one of the local banks. Patient reports that she takes two glasses of wine after work, reports a 6-year history of tobacco smoking but states that she quit. Denies use of illicit drugs

ROS General

Complains of mild fatigue and weakness. Denies fever chills, night sweats and any recent unexplained weight loss or gain

Cardiovascular

Patient reports dyspnea especially when trying to sleep, which is relieved with elevation of the head with two pillows. Patient also reports swelling in lower limbs and a history of HTN. Denies chest pain, palpitations, and PND

Skin

Denies delayed healing, rashes, skin discolorations or changes in moles or lesions

Respiratory

Reports exertional dyspnea and wheezing by denies cough, sputum production and hemoptysis

Eyes

Patient is short sighted, uses corrective lenses. Denies blurring

Gastrointestinal

Patient reports nausea and bloating but denies abdominal pain or distension,

vomiting, diarrhea, and constipation.

Nose/Mouth/Throat

Denies sinus problems, dysphagia or sore throat

Genitourinary

Denies frequent urination at night, frequency burning, or changes in color of urine.

Heme/Lymph/Endo

Denies bruising, blood transfusion, swollen glands, increase thirst, and increased hunger

Musculoskeletal

Patient reports a history of degenerative joint disease and muscle weakness.

Psychiatric

Reports sleeping problems due to shortness of breath. Denies depression, anxiety, or a history of mental disorders

Neurological

Denies syncope, seizures, paresthesias. Patient complains of weakness

OBJECTIVE Weight   190lbs       BMI 33.7 Temp 36.3 BP 110/50 Height 5’3” Pulse 78 Resp 24 General Appearance

Well-developed and well-nourished, dyspneic with moderate activity but in no distress following a few minutes of rest. AAOX3, good speech and eye contact. Responds to questions appropriately.

Skin

Skin is warm, dry and intact. No skin discolorations, lesions or rashes

HEENT

Head: Normocephalic, atraumatic. Eyes:  PERRLA. Conjunctiva and EOM normal. No scleral injection. Mouth: oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Neck: supple, No JVD and masses.

Cardiovascular

Prominent S3 and S4 gallops. No clicks, rubs or murmurs. Bipedal oedema

Respiratory

Chest wall symmetric. Respirations are tachypneic. No use of accessory muscles. Became more short of breath and tachypneic when in supine position. Audible expiratory wheeze with prolonged expiratory phase. Vesicular breath sounds with reduced breath sounds at bases, right greater than left with inspiratory rales bilaterally. No consolidation signs

Gastrointestinal

Normoactive bowel sounds in all quadrants. Moderately obese, soft, nontender abdomen. No hepatosplenomegaly.

Musculoskeletal

Full ROM in all 4 quadrants

Neurological

Speech is clear with good tone. Posture erect with stable balance and normal gait

Psychiatric

Patient is awake and oriented X3

Lab Tests

Lab: Na 132, K 3.8, HCO3 21. BUN 17. Cr 1.1. Glucose 120 mg/dL. WBC 4.8, hemoglobin and hematocrit 11.1 and 32.6

Special Tests

Transthoracic echocardiogram- LVEF normal but LVH and abnormal diastolic filling patterns

EKG- reveals atrial fibrillation at the rate of 75 beats/min, normal intraventricular

conduction. QRS duration of 350 ms

Chest X-ray- reveals cardiomegaly and pleural fluid reveals pulmonary edema

Diagnosis  Differential Diagnoses

o 1-Acute on Chronic diastolic (congestive) heart failure. This is a complex condition that results from structural and functional cardiac disorders that impair the capability of the ventricle to eject or fill blood (Yusuf, 2019). The key signs and symptoms of the condition include dyspnea, and fatigue, which often limit the patients exercise tolerance and fluid retention, which is associated with pulmonary congestion along with peripheral edema (Yusuf, 2019). Dyspnea on exertion is most common associated with left-sided heart failure. Physical examination often reveals tachycardia, jugular venous pressure, S4 and S3 gallop and peripheral edema (Yusuf, 2019).

o 2-Chronic Pericarditis. This defines the inflammation of the pericardium which starts gradually and results into accumulation of the fluid in the pericardial space. According to Yusuf (2019), the condition is characterized by coughing, shortness of breath and fatigue. It can also be caused by TB, heart surgery and frequent radiation therapy to the chest. Other less causes for the condition include viral infections, bacterial infection and mesothelioma (form of cancer caused when exposed to asbestos).

o 2- Cardiac tamponade. A clinical syndrome caused by the accumulation of fluid in the pericardial space. This cause a reduction in ventricular filling which is followed by hemodynamic compromise. The condition also results into shock, pulmonary edema and eventually death of the patient. The patient with this condition experiences reduced arterial blood pressure, muffled heart sound and distended neck veins (Yusuf, 2019).

Diagnosis

o Acute on Chronic diastolic (congestive) heart failure (ICD code I50.33)

Plan/Therapeutics

Further testing None Medication Initiate captopril 6.25 mg orally three times daily- Captopril is an ACE inhibitor, which are the first line treatment for patients with mild to moderate heart failure symptoms and left ventricular dysfunction (Yusuf, 2019). ACE inhibitors reduce heart failure symptoms including dyspnea, peripheral edema and fatigue and reduce the risk of heart attack. Captopril was started at a lower dose given that Ponikowski et al. (2018) recommends

that patients not taking ACE inhibitor to be started at a lower dose. Continue Lopressor 25mg orally BID- Lopressor is a beta1-adrenergic blocker at lower doses. Ponikowski et al. (2018) state that selective beta1-adrenergic blockers such as Lopressor are used in heart failure to reduce heart rate along with blood pressure. The medication has been shown to reduce mortality and morbidity in patients with heart failure. A meta-analysis by Bavishi, Chatterjee, Ather, Patel, and Messerli (2015) found that irrespective of pretreatment heart rate, beta-blockers decreased mortality in patients with heart failure with reduced ejection fraction in sinus rhythm Continue Hydrochlorothiazide 50 mg PO once daily- Hydrochlorothiazide is a diuretic which are used as an adjunct treatment in patients with fluid retention and should be combined with an ACE inhibitor and a beta-blocker. Yancy et al. (2017) state that all symptomatic patients with signs of congestion should receive a diuretic, irrespective of LVEF. Diuretics produce various symptomatic benefits than other heart failure drugs. These drugs have been shown to relieve pulmonary and peripheral edema (Rickers, et al., 2017). Education Educating the patient on heart failure including the conditions disease process, signs and symptoms, causes and possible complications. Patient was also instructed to restrict sodium intake to at least 3 g/day (Ponikowski et al., 2018). Patient was advised to keep a daily fluid intake/output at home and to restrict fluid intake when necessary. She was also advised to monitor her weight daily and to increase her engagement in exercise, which is critical in the control of blood pressure (Ponikowski et al., 2018). Additionally, she was informed on the importance of blood pressure control and diabetes management on the prevention of exacerbations of heart failure. Lastly, patient was educated on the importance of continuous and close monitoring of her health and was referred to a specialized heart failure clinic-based care (Ponikowski et al., 2018). Non-medication treatments Sodium restriction and fluid restriction-reducing sodium intake and fluid restriction when necessary reduces water retention, which is associated with peripheral edema (Ponikowski et al., 2018). Cardiac rehabilitation and exercise training- this improves exercise tolerance, and quality of life with reduced morbidity and mortality in patients with heart failure (Ponikowski et al., 2018).

Evaluation of patient encounter- The patient encounter was well, and the patient was cooperative throughout the session. The education given to the patient was well received as she was attentive to all the guidelines and other procedures. She admitted complying with all the guidelines. The encounter provided me with increased insight on the evaluation and treatment of patients presenting with signs and symptoms of acute on chronic diastolic (congestive) heart failure.