Soap Note – HPI: BJ a 68 year old AA female presents to the clinic for prescription refills
Soap Note – HPI: BJ a 68 year old AA female presents to the clinic for prescription refills
PLEASE READ SOAP NOTE. ANSWER QUESTIONS BELOW. MUST USE ACC/AHA Guidelines AND MUST HAVE 2 REFERENCES ONE REFERENCE MUST BE ACC/AHA WEBSITE. BOTH REFERENCES MUST BE SCHOLARLY. EBP, IN APA, AND WITHIN 5 YEARS OR LESS.
SOAP:
Chief complaint: medication refill “ran out of medicine”
HPI:BJ, a 68 year old AA female presents to the clinic for prescription refills. The patient also indicates that she has noticed shortness of breath which started about 3 months ago. The SOB gets worse with activity, especially when she is playing with her grandchildren but it goes away once she sits down to rest. She reports that she is also bothered by shortness of breath that wakes her up at night, but it resolves after sitting upright on 3 pillows. She also has lower leg edema which started 1 week ago. She also indicates that she often feels light headed and faint while going up the stairs, but it subsides after sitting down to rest. She has not tried any OTC medications at home. She never filled her prescriptions, which she received at her checkup 6 months ago, she did not think it was important.
KINDLY ORDER NOW FOR A CUSTOM-WRITTEN AND PLAGIARISM-FREE PAPER
PMH:
Hypertension
Previous history of MI in 2010
Surgeries:
2010-Left Anterior Descending (LAD) cardiac stent placement
Allergies: Amoxicillin
Vaccination History:
She receives an annual flu shot. Last flu shot was this year
Has never had a Pneumovax
Has not had a Td in over 20 years
Has not had the herpes zoster vaccine
Social history:
High school graduate, a widow with one son who loves out of state. She drinks one 4-ounce glass of red wine daily. She is a former smoker that stopped 20 years ago.
Family history:
Both parents are deceased. Father died of a heart attack; mother died of natural causes. She had one brother who died of a heart attack 20 years ago at the age of 52.
ROS:
Constitutional: Lightheaded and faint with exertion.
Respiratory: Shortness of breath with exertion (playing with grandchildren and stairs). + Orthopnea
Cardiovascular: + leg and ankle swelling x 1 week
Psychiatric: Not taking medications for 6 months – “ran out”
Physical examination:
Vital Signs
Height: 5 feet 2 inches Weight: 163 pounds BMI: 29.8 BP 150/86 T 98.0 po P 100 R 22, non-labored; Ur
HEENT: normocephalic, symmetric. Bilateral cataracts; PERRLA, EOMI; Upper and lower dentures in place a fitting well. No tinnitus
NECK: Neck supple; non-palpable lymph nodes; no carotid bruits. Thyroid non-palpable
LUNGS: inspiratory crackles
HEART: Normal S1 with S2 split during expiration. An S4 is noted at the apex; systolic murmur noted at the right upper sternal border without radiation to the carotids.
ABDOMEN: Normal contour; active bowel sounds all four quadrants; no palpable masses.
PV: Pulses are 2+ in upper extremities and 1+ in pedal pulses bilaterally. 2+ pitting edema to her knees noted bilaterally
GENITOURINARY: no CVA tenderness; not examined
MUSCULOSKELETAL: Heberden’s nodes at the DIP joints of all fingers and crepitus of the bilateral knees on flexion and extension with tenderness to palpation medially at both knees. Kyphosis and gait slow, but steady.
PSYCH: normal affect; her Mini-Cog Score is 3. Her PHQ-9 score is 22.
SKIN: Sparse hair noted on lower legs and feet bilaterally with dry skin on her ankles and feet.
Labs:: Hgb 12.2, Hct 37%, K+ 4.2, Na+140, Cholesterol 230, Triglycerides 188, HDL 37, LDL 190, TSH 3.7, glucose 98
A:
Primary Diagnosis:
Congestive Heart Failure (CHF) (150.9)
Secondary Diagnoses:
Primary Hypertension (I10)
Depression F32.3:
Obesity (E66):
Osteoarthritis (OA) (715.90)
Differential Diagnosis:
Peripheral Vascular Disease (PVD) (173.9)
P:
Medications:
Sertraline 25 mg. Take 1 tab PO QD disp#30, 1 refill
Tylenol 650 mg PO Q4 hours as needed for arthritis pain
Labs:UA; Brain natriuretic peptide (BNP); LFTs and TSH.
12-lead EKG, Chest X-ray; Initial 2D echo with Doppler; Ankle-brachial index
Education:
Congestive heart failure is caused by the inability of your heart to pump blood effectively enough to meet the demands of your body. If you think of your body as any other pump, if fluid does not move well through the system, then it will back up into other spaces. When blood backs up it puts a lot of pressure on the blood vessels, which forces fluid to leak out into the nearby tissue. With CHF, this fluid usually moves into your lungs, legs, or abdomen.
The signs of worsening CHF include decreased energy level, shortness of breath during your normal routine, increased swelling to your legs and feet, your clothes feel tight, or a wet sounding cough. Call the office if these symptoms occur.
Weigh yourself every morning at the same time. If you have a 3 pound weight gain in 24 hours, or a 5 pound weight gain over a week, you should call the office.
Exercise and maintaining a normal weight is very important. You should try to exercise at least 20-30 minutes a day, more if possible. Start slow with walking.
Decrease your salt intake. Do not add any extra salt to foods. Salt makes you retain fluid, and it makes you want to drink more fluid. Avoid fast food and prepared food as they are usually very high in sodium.
If you notice your legs swelling, elevate them up and rest. Do not drink alcohol and continue to avoid smoking or second hand smoke.
Take your medications as directed, with water. Do not stop them abruptly or skip doses.
I have started you on a medication for depression. It can take 2 weeks to start to feel it working and up to a month until you can fell the real benefits.
If you start to feel more depressed, like you want to harm yourself or others, please contact me right away or got to the ER.
Referrals: may refer based on lab results
Follow up: return to office in 2 weeks
Additional lab results:
Echo results: LVEF 39%
BNP – 682 pg/ml
Questions: You determine the medications for CHF/ASCVD
1) According to the ACC/AHA Guidelines, what is BJ’s heart failure stage?
2) According to the ACC/AHA Guidelines, what medications should BJ be prescribed? Does she need medication given her history of MI? Write her complete prescriptions using the prescription writing format.