Well being Assessment
Scholar’s Identify
Institutional Affiliation
Course
Professor’s Identify
Date
Well being Assessment
Episodic/Focused SOAP Note Chest Pain
S.
CC: “Chest ache”
HPI: Mr. Foster is a 55-year-old Caucasian male that seems comparatively wholesome and lively. He’s seen right now for brand new onset of chest ache. The chest ache started a few month in the past and its non-radiating. The ache is localized to the middle of his chest. He denies ache within the arms, legs and jowl ache. The affected person denies signs of nausea, vomiting, dizziness and shortness of breath. Mr. Foster denies numbness or tingling of the extremities and denies stomach ache through the episodes. The chest ache is “uncomfortable” and hurts within the middle of his chest. The ache is described as “tight, tightness” that provides him “anxiousness when it doesn’t subside.” Mr. Foster charges the chest ache a 5 out 10 depth on a 1-10 ache scale. The affected person states the chest ache episodes have occurred about 3 times within the final month. The ache is triggered by bodily exercise like climbing stairs or yard work and appears to final for a couple of minutes. The chest ache subsides after a interval of relaxation. Mr. Foster states he had a traditional EKG carried out about three months in the past.
S.
PMx: Constructive for hypertension and hyperlipidemia identified 1 yr in the past.
ROS:
Common: Affected person seems wholesome, presents with no ache or signs presently.
AAOx4, denies complications or facial ache, seizures, dizziness, numbness or tingling of extremities and denies lack of sensation.
HEENT: Denies visible or listening to deficit, Denies loud night breathing, insomnia, or sleep apnea, Denies problem of swallowing
RESP: Denies shortness of breath, Bronchial asthma and denies COPD
CV: Denies murmur, earlier chest ache, denies diaphoresis,
GI: Denies coronary heart burn or gastrointestinal points, denies modifications or irregular bowel actions
DIET: Detrimental for coronary heart nutritious diet (steak, purple meats)
GU: Denies problem with urination, denies prostate issues and is sexually lively
MUS/SKE: Denies joint, muscle, leg, ft or hip ache
SKIN: Denies pores and skin deformities or pores and skin illnesses
PSx: Denies surgical procedure of any type.
ADULT
ILLNESS: Denies hospitalization, damaged bones or any grownup sickness. Denies infections, flu, pneumonia or having shingles. Constructive for childhood rooster pox.
IMMUNIZATION: Updated, wants annual flu shot
ALLERGIES: Codeine: Causes nausea and vomiting
MEDICATIONS: *Lisinopril (Prinivil) 20 mg, PO Day by day, taken right now
*Atorvastatin (Lipitor) 20 mg, PO Day by day at bedtime, final dose yesterday (hyperlipidemia)
*Omega Three Fish Oil 1200 mg PO BID, final dose at 8am (OTC Complement).
FHx: Mom; kind 2 diabetes, hypertension, age 80.
Father: hypertension, hyperlipidemia, weight problems, died at 75 of colon most cancers.
Brother: died at 24 MVA.
Sister: kind 2 diabetes, hypertension, at 52.
Maternal grandmother: died of coronary heart assault.
No historical past of untimely heart problems in first diploma family.
S.
SHx : Detrimental for present or earlier tobacco use; consumes 2-Three alcohol drinks per week; denies use of marijuana, cocaine, heroin or different illicit medication prior to now thirty years. School graduate and employed full time as civil engineer and comfy with monetary state of affairs. Affected person experiences being married for 27 years and has two kids. He lives at dwelling together with his spouse and daughter. He enjoys spending time with household and is bodily lively with chores and every day job like yard work. He doesn’t have a routine train routine.
ROS
Common– Affected person seems wholesome and neurological intact. The affected person is AAOx4 and strikes all extremities. The affected person performs ADL independently. The affected person presents with no chest ache or signs of chest ache presently. Face is symmetrical, pores and skin is dusky to pale on his face and hair is plentiful all through head. The affected person just isn’t sporting any visible aids akin to glasses or listening to aids. The affected person is unfavourable for dyspnea at relaxation, chills, fatigue, and is afebrile.
Pulmonary: No irregular visible findings. No cough or hemoptysis. Chest is symmetrical, no intercostal respiratory seen. Trachea is midline. Inspected bilaterally palms and ft with no visible cyanosis, no clubbing of nails, no irregular colour famous of extremities on inspection. No obvious indicators of shortness of breath. Chest rise is equal upon inhale and exhale.
CV: Inspected neck for jugular venous distention. JVP Three cm above sternal angle. Chest is symmetrical and no abnormalities noticed. Affected person is afebrile, with no generalized edema. Higher and decrease extremities are pink, toenails are usually not thickened and seem wholesome. Upon inspection of decrease extremities, the left and proper legs seem to haven’t any hair current. Decrease extremities are with out edema and pores and skin colour is pink.
GI: Stomach is barely rounded with no irregular pores and skin deformities upon examination. Inspected entrance, proper and left sides of stomach and no irregular findings upon visible examination. Detrimental for nausea, vomiting, coronary heart burn or gastrointestinal points.
GU: No abnormalities in urination and continence.
O.
VS: BP (Rt Arm), Sitting 146/90; P (Monitor) 104; R 19; T 37.four; 02. 98%
Wt. 197 lbs.; Ht 5 ft 11 inches
Bodily Examination
GENERAL: Affected person just isn’t presently having chest pains and is asymptomatic. Affected person is neurologically intact, AAOx4, with no obvious bodily deficit.
HEENT: Face is symmetrical with no facial droop. No glasses, listening to aids and breaths nicely by his nostril. Speech is obvious.
NECK:
Trachea is midline. No lots palpated. Carotid arteries: Auscultated left and proper carotid pulse with bell of stethoscope. Left bruit current, Proper Bruit current. Palpated left and proper carotid pulse; BL No thrill, +2 left, +Three Proper. Inspected neck for jugular venous distention, JVP Three cm above sternal angle.
CHEST:
HEART: Auscultated pulmonic, aortic, Erbs level and tricuspid space with diaphragm first then used the bell on every space listed. S1, S2 heard on the apex and base of the center. S3, gallop auscultated with the bell and heard at cardiac apex. No different advinticous sounds upon auscultation.
PMI: Palpated PMI, Displaced laterally; brisk and tapping lower than Three cm
LUNGS: Breath sounds in all areas of lungs posterior and anterior. Anterior RUL, RLL clear. Anterior LLL, LUL all clear. Posterior RUL, LUL clear upon auscultations. High quality crackles posterior LLL and posterior RLL upon auscultation.
ABDOMEN: Detrimental bruit upon of stomach aorta upon auscultation. The suitable and left stomach arteries are unfavourable for bruits with bilaterally equal pulses upon auscultation. Iliac pulse bilaterally with no bruits discovered upon auscultation. Bilaterally femoral pulses audible with no bruits heard upon auscultation.
Belly bowel sounds audible in all 4 quadrants upon auscultation. Tympany over the stomach as percussed.
Stomach palpation with gentle and deep stress in LLQ, RLQ, URQ, ULQ. No irregular findings. No lots, guarding, tenderness or distention upon palpation.
LIVER: Detrimental for friction rub as auscultated over liver. Palpable 1 cm beneath proper costal margin. Liver span 7cm within the midclavicular line with dullness current upon percussion.
SPLEEN: Auscultation over spleen and no friction rub discovered upon examination. Not palpable, no lots or splenomegaly are famous. Percussion stays tympanic as percussed.
KIDNEYS: Left kidney, not palpable, proper kidney, not palpable.
SKIN: Heat, dry, non-tenting and regular for ethnicity. .
PERIPHERAL VASCULAR PULSES:
Brachial pulse palpable bilaterally. Brachial pulse left; No thrill +2, Brachial pulse proper: No thrill +2. Radial Pulses: Bilaterally, No thrill +2 left and proper upon palpation.
Femoral Pulses: Bilaterally equal with no thrill +2, left and proper upon palpation.
Popliteal Pulses: Bilaterally palpable with variations famous: Proper, No thrill +2, LEFT No thrill, +1 diminished and barely palpable.
Tibial Pulses: Bilaterally equal palpable with no thrill and +1 diminished on left and proper.
Dorsalis pedis pulse: Bilaterally equal upon palpation. No thrill, +1 diminished and barely palpable left and proper.
Diagnostic outcomes: EKG, CXR, CK-MB. EKG shows QRS modifications. The abnormalities within the coronary heart rhythm recommend some parts of the center are usually not getting ample blood (Joloudari et al., 2020). CXR reveals the form and dimension of the center to find out if coronary heart is enlarged because of a situation (Cagle Jr & Cooperstein, 2018). CK–MB isoenzyme take a look at values reveals presence of abnormalities.
Blood take a look at to examine levels of cholesterol, coronary calcium scan, CT Cornary angiogram or catherization lab to see the extent of potential blockage, echocardiogram stress take a look at to find out blood circulate (Alizadehsani et al., 2019).
A.
Differential Prognosis:
1) CAD – CAD signs and Mr. Foster signs extraordinarily comparable. CAD is frequent and he has hyperlipidemia and hypertension (Alizadehsani et al., 2019). The most typical symptom of CAD is chest ache described in Mr. Fosters’ interview. CAD may very well be a participant in Mr. Fosters’ signs. Different proof that results in CAD is the S3 gallop heard through the examination in addition to a speedy coronary heart charge of 104. Angina ache, pulses in his extremities are usually not all equal and lots of are faint to barely palpable. He is also lacking hair on his legs which leads towards peripheral vascular points r/t CAD.
2) Angina – Is frequent and is relieved with nitro or relaxation. We are able to carry out a stress take a look at to see the really stress on the center and take a look at nitro when the ache happens since we all know relaxation relieves the ache (Hu et al., 2018).
Three) CHF – His blood stress is excessive systolic and diastolic in addition to pulse is excessive. His coronary heart is working arduous and he has nice crackles within the bases of his lungs LLL LRL bilaterally which might point out fluid buildup r/t CHF (Hu et al., 2018). I really feel strongly he’s on this class based mostly on the proof offered in his examination
Want extra take a look at like stress take a look at to find out how arduous his coronary heart is working whereas he’s bodily lively. We want a doable echocardiogram to measure his cardiac output or ejection fraction. We want a troponin and CK enzymes drawn even when the final assault was greater than 24 hours. These take a look at can determine if he has coronary heart muscle harm, MI or underlying coronary heart points.
Main Prognosis/Presumptive Prognosis:
Coronary Artery Illness
P.
Therapy plan entails taking treatment since it’s the first line of therapy of CAD. Nitroglycerin tablets controls the ache and dilating the coronary arteries. The treatment reduces the center’s demand for blood (Chandra et al., 2017). The affected person ought to make life-style modifications together with keep away from smoking, consuming alcohol, begin exercising, and eat wholesome meals. A daily analysis is important to find out the extent of danger.
References
Alizadehsani, R., Roshanzamir, M., Abdar, M., Beykikhoshk, A., Khosravi, A., Panahiazar, M., … & Sarrafzadegan, N. (2019). A database for utilizing machine studying and knowledge mining methods for coronary artery illness analysis. Scientific Knowledge, 6(1), 1-13.
Cagle Jr, S. D., & Cooperstein, N. (2018). Coronary Artery Illness: Prognosis and Administration. Main Care, 45(1), 45.
Chandra, D., Gupta, A., Chief, J. Ok., Fitzpatrick, M., Kingsley, L. A., Kleerup, E., … & Sciurba, F. C. (2017). Assessment of coronary artery calcium by chest CT in contrast with EKG-gated cardiac CT within the multicenter AIDS cohort examine. PloS One, 12(four), 0176557.
Hu, T., Yang, C., Lin, S., Yu, Q., & Wang, G. (2018). Biodegradable stents for coronary artery illness therapy: Latest advances and future views. Supplies Science and Engineering: C, 91, 163-178.
Joloudari, J. H., Hassannataj Joloudari, E., Saadatfar, H., GhasemiGol, M., Razavi, S. M., Mosavi, A., … & Nadai, L. (2020). Coronary artery illness analysis; rating the numerous options utilizing a random timber mannequin. Worldwide Journal of Environmental Analysis And Public Well being, 17(Three), 731.
