Nursing
Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities and psychosocial issues.
Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 code for the diagnosis. What was your primary diagnosis and why?
Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?
USE TEMPLATE FOR THE CASE STUDY
Episodic/Focused SOAP Note Template
Patient Information:
55 years, Male
S.
CC (chief complaint): Complains of chest torment that is stable with angina. He experiences a chest distress when stretching.
HPI: A 55 year old Male complains of chest torment that is stable with past angina during his follow of HTN. The patient had Coronary Artery Disease in his 20s, strolls daily and negates of edema. He also encountered hypercholesterolemia.
Location: Chest
Onset: N/A
Character: Chest torment
Associated signs and symptoms: Chest discomfort while stretching, experienced hypercholesterolemia.
Timing: N/A
Exacerbating/relieving factors: ASA 325mg per day, Atenolol 50gm per day, Lisinopril 20gm daily.
Severity: 7/10 pain scale
Current Medications: ASA 325mg per day, Atenolol 50gm per day, Lisinopril 20gm daily.
Allergies: No known allergies
PMHx: History of hypertension and hypercholesterolemia.
Soc & Substance Hx: He strolls everyday
Fam Hx: The wife was diagnosed of hyperlipidemia ten years ago. The father died 3 years ago of congestive diagnosis.
Surgical Hx: No prior surgical procedures.
Mental Hx: Unknown mental health history
Violence Hx: No violence history
Reproductive Hx: Unknown reproductive history
ROS:
GENERAL: Complains of chest torment with past angina. No fever, weight loss, weakness, chills or fatigue.
HEENT: Denies any headache
Eyes: Denies any visual loss
Ears: Denies any ear pain or hearing impairment
Nose: No nasal obstruction, running or nose bleeds
Throat: Denies any sore throat
SKIN: No itching, rashes or open wounds.
CARDIOVASCULAR: Complains of Chest pains and chest discomfort but denies edema.
RESPIRATORY: Coughing but no shortness of breath.
GASTROINTESTINAL: Denies nausea, vomiting, diarrhea or abdominal pains.
GENITOURINARY: No urinary leakage or inconsistencies.
NEUROLOGICAL: No headache, numbness, paralysis, ataxia, syncope or dizziness.
MUSCULOSKELETAL: No muscle pains
HEMATOLOGIC: No bruising, anemia or bleeeding.
LYMPHATICS: No history of splenectomy or enlarged nodes
PSYCHIATRIC: No anxiety or depression.
O.
Physical exam: The initial examination of patient with chest torment and history of hypertension needs a systematic approach to understand the probable causes. The physical examination of the patient will begin with general medical conditions such as the patient’s medical history, their personal history as well as characterization of different symptoms. The physical examination was tailored to the specific patient medical history and consistence complaints. The patient’s mass index, height, weight, pulse and blood pressure were recorded. With regards to the HPI and CC of the patient, the physicians conducted CT scans, Chest X-Ray, MRI scan and Electrodiogram, exercise tolerance tests, blood cell counnt and blood chemistry which include total cholesterol and fasting glucose.
Diagnostic results. The diagnostic tests included CT scans, Chest X-Ray, MRI scan, Electrodiogram and blood test. The diagnostic results indicated that the patient is having CAD which he had in his 20s. The symptoms and diagnostic results of the patient support existence of CAD.
A.
Differential Diagnoses
Coronary artery disease: The health history of the patient indicates that he had CAD in his 20s. Angina is the most common symptom for coronary artery disease. Angina linked to Coronary artery disease is described as chest pain, chest discomfort, pressure, tightness, squeezing and fullness (Malakar et al., 2019). Individuals with high BP are likely to have CAD have high BP which leads to more force on the walls of the artery. With time, the extreme pressure can lead to damage of the arteries which makes these individuals more vulnerable to coronary artery disease (Hajar, 2017).
Malignant Hypertension: Malignant hypertension is considered as the most severe type of hypertension. This is defined by two major features; hypertensive retinopathy grades III or IV and extreme high blood pressure with diastolic blood pressure that is above 130mmHg (Domek, Gumprecht, Lip and Shantsila, 2020). Chest pain is among the major symptoms of malignant hypertension. Relatively, the patient has been having a follow up for his hypertension state.
Atherosclerosis: Atherosclerosis is hardening and thickening of the arteries causes building up of the plaque within the inner lining of the artery. Some of the risk factors include high blood pressure, high cholesterol, and deposits of fatty substances, smoking, diabetes and obesity (Pothineni et al., 2017). The patient has experienced hypercholesterolemia which is related to atherosclerosis. Hypocholesteremia entails high blood cholesterol level.
Building a health population requires health promotion and disease prevention. The treatment plan requires understanding of the patient condition through physical examination, socio-economic factors among other patient factors. Focusing on social history, personal history, medical and family history helps in diagnosis and treatment of the health condition. The treatment will be based on the condition and diagnosis in the assessment. Controlling conditions such as high cholesterol, high blood pressure and staying physically active will help treat coronary artery disease. Several oral and parenteral agents would be used in the treatment of hypertensive emergencies. Physical exercise, low-fat diet and cholesterol medication will be used in the treatment of hypercholesterolemia. The treatment plan will be a detailed plan that follows a simple format which typically includes the diagnosis of the health problem, patient’s personal information, measurable objectives, high priority treatment goals, treatment progress timeline and tracking progress. I have learnt that the treatment and diagnosis should be customized based on the patient history, medical history, age and related complication as well as severity of the condition. However, I would focus on more conservative treatment options that will lower the risks of chest pains and activities that will facilitate health promotion.
References
Domek, M., Gumprecht, J., Lip, G. Y., & Shantsila, A. (2020). Malignant hypertension: does this still exist?.
Hajar, R. (2017). Risk factors for coronary artery disease: historical perspectives. Heart views: the official journal of the Gulf Heart Association, 18(3), 109.
Malakar, A. K., Choudhury, D., Halder, B., Paul, P., Uddin, A., & Chakraborty, S. (2019). A review on coronary artery disease, its risk factors, and therapeutics. Journal of cellular physiology, 234(10), 16812-16823.
Pothineni, N. V. K., Subramany, S., Kuriakose, K., Shirazi, L. F., Romeo, F., Shah, P. K., & Mehta, J. L. (2017). Infections, atherosclerosis, and coronary heart disease. European heart journal, 38(43), 3195-3201.
