Clinical Log One-SOAP Note Assignment Paper
Clinical Log One-SOAP Note Assignment Paper
Bio Data
Patient’s initials: G.N
Age: 54
Sex: male
Race: African American
Subjective Data
Chief complain: chest pain
History of presenting Illness: Mr. G.N 54-years-old African American male, is accompanied by his wife and has presented with chest pain for the last one month. It was sudden onset, on and off; he describes it as tight and sharp, lasting for a few minutes. The pain is aggravated by slight movement and exertion, especially when doing his farm work. It is non-radiating and is relieved on resting. There is a positive history of easy fatigability and shortness of breath. Clinical Log One-SOAP Note Assignment Paper
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Current medications
PO Nifedipine 20mg 12 hourly
PO Lisinopril 10mg 24 hourly
PO Metformin 500mg 12 hourly
Allergies
No known food or drug allergies
Past medical history
He is a known hypertensive and diabetic patient on medications. His wife, however, reports that he is not compliant.
Surgical history
Had appendectomy done 15 years ago
Family history
He is the 3rd born in a family of five. All siblings are alive and well with no underlying medical conditions.
Maternal grandparents are deceased secondary to old age.
The paternal grandmother died from a stroke, whereas the grandfather suffered a heart attack.
His mother is alive and has dementia, while his father is alive and has hypertension.
Social History
He is married and has five living children.
He occasionally takes alcohol during the weekend with his friends. Currently smokes cigarettes about one pack per day. Denies illicit substance abuse.
Occupation
He is a businessman.
Immunization
Recently had the Johnson and Johnson covid 19 vaccine.
Health Maintenance
He regularly takes grilled meat about three times per week. Rarely does physical exercise, even taking walks. He only seeks medical attention whenever he feels it’s necessary. Clinical Log One-SOAP Note Assignment Paper
Review of systems
General: denies chills, fever, or weight loss.
Neurologic: denies headache, dizziness, loss of consciousness, or convulsions.
HEENT: denies blurry vision or eye pain. Denies ear pain, discharge, or ringing in the ears. Denies sores or ulcerations in the cheeks, tongue, or gums. Denies pain or difficulty in swallowing or hoarseness of voice. Denies nasal discharge, pain, or congestion.
Neck: denies swelling or lump in the neck. Denies history of neck stiffness.
Cardiovascular: positive complaints of chest pain and easy fatigability. Denies orthopnea, palpitations and PND.
Respiratory: denies difficulty in breathing, cough, and hemoptysis.
Gastrointestinal: denies abdominal pain, nausea, diarrhea, or vomiting.
Genitourinary: denies dysuria, increased urinary frequency, and hematuria.
Psychiatric denies hallucinations, suicidal ideations, anxiety, or depression.
Endocrinology: denies weight loss or weight gain.
Musculoskeletal: denies joint muscle and joint pain. No history of swelling or stiffness.
Hematologic: denies spontaneous bruising or bleeding.
Allergies
No history of eczema, hay fever, or asthma.
Objective
General: Mr. G.N 54-year-old African American male, is in a fair general condition, oriented in time, place, and person, and has no respiratory distress.
Vital signs: BP-130/86mm/hg, PR 78b/min, RR 18breaths/min, spo2 98% RA, RBS 10mmol/l, temperature 27.20c, weight 204lbs, height 5’8, BMI 31.0kg/m2
HEENT: normocephalic, no bruising, lesions, or masses noted. There is equal distribution of hair. Eyes: no eye discharge, redness, cataract, periorbital edema, exophthalmos, or exophthalmos observed. Ears: hearing for high, medium, and low is intact bilaterally, no pain on moving the pinna, and no ear discharge or redness on the outer and inner ear. The tympanic membrane is gray, shiny, and intact bilaterally. Dark brown cerumen is noted bilaterally. Nose, mouth, and throat: mucous membranes are moist, pink, and intact, with no evidence of bruising, swelling, or bleeding in turbinates. The septum is centrally located. No sores or wounds on the gums, cheeks, tongue, or soft or hard palate. No halitosis or untreated dental carriers. Clinical Log One-SOAP Note Assignment Paper
Neck: no lumps or swellings were observed, and the trachea is centrally located. The thyroid gland is symmetrical with no masses, lumps or goiter observed.
Neurological: he is oriented in time, place, and person. He follows both simple and complex commands. Cranial nerves are grossly intact. Pupils are bilaterally and equally reactive to light.
Respiratory System: no chest wall deformities, no scars, or obvious masses. There is a normal rate, rhythm, depth, and breathing effort. Normal chest expansion and tactile fremitus. No tenderness was elicited. There is a resonance note on percussion and equal and bilateral air entry with no added sounds.
Cardiovascular: normoactive prechondium.no heaves or thrills, and the apex beat is not displaced. S1 and S2 were heard with no murmurs. S3 is pointed out at the mitral area with the PMI felt in this area. There was mild lower limb edema noted.
Gastrointestinal: the abdomen is moving with respiration; no scars or masses are noted. Bowel sounds are present, and no vascular bruits were heard. No tenderness on light palpation or organomegaly on deep palpation. Tympanic note heard on percussion.
Musculoskeletal: mild pitting lower limb edema to the level of the mid-leg. Normal muscle power and tone in all groups of muscles. No joint pain or stiffness was reported.
Diagnostic tests
- Lipid profile: check the cholesterol levels and help rule out hyperlipidemia.
- CBC: check the hemoglobin and white blood cell levels.
- BNP: essential in assessing cardiac function to help rule out cardiac failure.
- CMP: a panel of tests that measures the current status of the body’s metabolism. It consists of electrolytes fluids, blood glucose levels kidney and liver function tests. Clinical Log One-SOAP Note Assignment Paper
- HBA1C: evaluate the blood glucose control over the last 90 days.
- Cardiac enzymes: a biomarker for evidence of heart muscle damage. They include; troponin T troponin I, myoglobin, and creatinine phosphokinase.
- Chest X-ray: assess the trachea, lungs, and heart, and look for surrounding pathology. Helps evaluate the size of the cardiac shadow.
- ECG: monitor the heart’s electrical activity and identify abnormal heart rhythms.
- Echocardiogram: assess the anatomy of the heart and its vessels and their function.
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Assessment
Coronary Artery Disease (I25.111): a disease that results from a reduced supply of oxygen and blood to the myocardium. It is caused by occlusion of the coronary arteries that leads to a demand-supply mismatch of oxygen levels. It primarily involves the formation of fatty plaques in the lumen of the coronary arteries, which then obstruct blood flow (Rai Dilawar Shahjehan & Bhutta, 2022). Common risk factors associated with the disease include; hypertension, diabetes, hyperlipidemia, and familial history. The clinical presentation includes; chest pain after a light physical exercise or even at rest and shortness of breath.
Congestive heart failure (428.0): a condition with impaired heart function to meet the body’s needs. Risk factors predispose patients to include; hypertension, diabetes, chronic lung diseases, coronary artery disease, pulmonary embolism, and others (Malik et al., 2022)Clinical Log One-SOAP Note Assignment Paper. Patients typically present with chest pain, shortness of breath, easy fatiguability, orthopnoea, edema, and PND
GERD (K21.9): occurs when the gastric contents reflux back into your esophagus, irritating the lining. Patients commonly present with acidity after ingestion of food, epigastric pain, chest pain, and a chronic cough (Clarrett & Hachem, 2018). Some risk factors associated with GERD include; obesity, intake of spicy food, cigarette smoking, and others.
Plan
It is advised that Atherosclerotic Cardiovascular diseases-related risk factors be controlled through a team-based approach by both pharmacological and non-pharmacological interventions. Pharmacological consist of anti-anginal and cardio protective medications. According to American Heart Association, every patient should be given guideline directed medical therapy that consist of; beta-blocker low dose aspirin nitroglycerin as needed, and a moderate to high intensity statin. If the symptoms are still not well controlled with this, titrate the beta blocker therapy, add a calcium channel blocker and consider use of long-acting nitrates. If the arteries are severely narrowed, surgical intervention is sought to widen the arteries, a process known as cardiac catheterization (Shah, 2021). Patient should be educated on medication compliance to ensure well controlled hypertension, diabetes and lipid levels. In addition encourage cessation of smoking, weight loss and physical exercises.
Research Article
The American college of cardiology emphasizes on lifestyle modification as the basis for ASCVD risk reduction efforts. They include; regular exercise, avoiding tobacco products, intake of heart-healthy diet and maintenance of a healthy weight. This is used together with cholesterol-lowering drug therapies (Grundy et al., 2019). Drug therapy for the lifestyle-related risk factors such as diabetes, hypertension and smoking cessation should also be encouraged. Statin therapy is recommended for people who are at increased risk of ASCVD as they help in reduction of LDL levels.
References
Clarrett, D. M., & Hachem, C. (2018). Gastroesophageal Reflux Disease (GERD). Missouri Medicine, 115(3), 214–218. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6140167/
Grundy, S. M., Stone, N. J., Bailey, A. L., Beam, C., Birtcher, K. K., Blumenthal, R. S., Braun, L. T., de Ferranti, S., Faiella-Tommasino, J., Forman, D. E., Goldberg, R., Heidenreich, P. A., Hlatky, M. A., Jones, D. W., Lloyd-Jones, D., Lopez-Pajares, N., Ndumele, C. E., Orringer, C. E., Peralta, C. A., & Saseen, J. J. (2019). 2018 Clinical Log One-SOAP Note Assignment Paper AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation, 139(25). https://doi.org/10.1161/cir.0000000000000625
Malik, A., Brito, D., Sarosh Vaqar, & Chhabra, L. (2022, May 5). Congestive Heart Failure. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430873/
Rai Dilawar Shahjehan, & Bhutta, B. S. (2022, February 9). Coronary Artery Disease. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK564304/
Shah, S. N. (2021, October 17). Coronary Artery Atherosclerosis Guidelines: Guidelines Summary, 2020 ACC Guidelines on CV Disease Risk Reduction in T2D, 2018 ACC Expert Consensus Decision Pathway on Novel Therapies for CV Risk Reduction in TD2 and ASCVD. Medscape.com; Medscape. https://emedicine.medscape.com/article/153647-guidelines
Please write up a focused note , based on a cardiac chief complaint/disease being the patients are being seen in an interventional cardiology office. Patients we see just had cardiac stents placed. A lot of them have valve disease, congestive heart failure. Professor doesn’t want a simple disease… something more graduate level. look at attachment for what must be included. Must cite where you get your main diagnosis from as well as differential diagnosis. Must also cite management goals , non pharm therapy’s and pharm therapy’s.
Clinical Log One-SOAP Note
Bio Data
Patient’s initials: G.N
Age: 54
Sex: male
Race: African American
Subjective Data
Chief complain: chest pain
History of presenting Illness: Mr. G.N 54-years-old African American male, is accompanied by his wife and has presented with chest pain for the last one month. It was sudden onset, on and off; he describes it as tight and sharp, lasting for a few minutes. The pain is aggravated by slight movement and exertion, especially when doing his farm work. It is non-radiating and is relieved on resting. There is a positive history of easy fatigability and shortness of breath Clinical Log One-SOAP Note Assignment Paper.
Current medications
PO Nifedipine 20mg 12 hourly
PO Lisinopril 10mg 24 hourly
PO Metformin 500mg 12 hourly
Allergies
No known food or drug allergies
Past medical history
He is a known hypertensive and diabetic patient on medications. His wife, however, reports that he is not compliant.
Surgical history
Had appendectomy done 15 years ago
Family history
He is the 3rd born in a family of five. All siblings are alive and well with no underlying medical conditions.
Maternal grandparents are deceased secondary to old age.
The paternal grandmother died from a stroke, whereas the grandfather suffered a heart attack.
His mother is alive and has dementia, while his father is alive and has hypertension.
Social History
He is married and has five living children.
He occasionally takes alcohol during the weekend with his friends. Currently smokes cigarettes about one pack per day. Denies illicit substance abuse.
Occupation
He is a businessman.
Immunization
Recently had the Johnson and Johnson covid 19 vaccine.
Health Maintenance
He regularly takes grilled meat about three times per week. Rarely does physical exercise, even taking walks. He only seeks medical attention whenever he feels it’s necessary.
Review of systems
General: denies chills, fever, or weight loss.
Neurologic: denies headache, dizziness, loss of consciousness, or convulsions.
HEENT: denies blurry vision or eye pain. Denies ear pain, discharge, or ringing in the ears. Denies sores or ulcerations in the cheeks, tongue, or gums. Denies pain or difficulty in swallowing or hoarseness of voice. Denies nasal discharge, pain, or congestion.
Neck: denies swelling or lump in the neck. Denies history of neck stiffness.
Cardiovascular: positive complaints of chest pain and easy fatigability. Denies orthopnea, palpitations and PND.
Respiratory: denies difficulty in breathing, cough, and hemoptysis.
Gastrointestinal: denies abdominal pain, nausea, diarrhea, or vomiting.
Genitourinary: denies dysuria, increased urinary frequency, and hematuria.
Psychiatric denies hallucinations, suicidal ideations, anxiety, or depression.
Endocrinology: denies weight loss or weight gain.
Musculoskeletal: denies joint muscle and joint pain. No history of swelling or stiffness.
Hematologic: denies spontaneous bruising or bleeding.
Allergies
No history of eczema, hay fever, or asthma.
Objective
General: Mr. G.N 54-year-old African American male, is in a fair general condition, oriented in time, place, and person, and has no respiratory distress.
Vital signs: BP-130/86mm/hg, PR 78b/min, RR 18breaths/min, spo2 98% RA, RBS 10mmol/l, temperature 27.20c, weight 204lbs, height 5’8, BMI 31.0kg/m2
HEENT: normocephalic, no bruising, lesions, or masses noted. There is equal distribution of hair. Eyes: no eye discharge, redness, cataract, periorbital edema, exophthalmos, or exophthalmos observed. Ears: hearing for high, medium, and low is intact bilaterally, no pain on moving the pinna, and no ear discharge or redness on the outer and inner ear. The tympanic membrane is gray, shiny, and intact bilaterally. Dark brown cerumen is noted bilaterally. Nose, mouth, and throat: mucous membranes are moist, pink, and intact, with no evidence of bruising, swelling, or bleeding in turbinates. The septum is centrally located. No sores or wounds on the gums, cheeks, tongue, or soft or hard palate. No halitosis or untreated dental carriers.
Neck: no lumps or swellings were observed, and the trachea is centrally located. The thyroid gland is symmetrical with no masses, lumps or goiter observed.
Neurological: he is oriented in time, place, and person. He follows both simple and complex commands. Cranial nerves are grossly intact. Pupils are bilaterally and equally reactive to light.
Respiratory System: no chest wall deformities, no scars, or obvious masses. There is a normal rate, rhythm, depth, and breathing effort. Normal chest expansion and tactile fremitus. No tenderness was elicited. There is a resonance note on percussion and equal and bilateral air entry with no added sounds Clinical Log One-SOAP Note Assignment Paper.
Cardiovascular: normoactive prechondium.no heaves or thrills, and the apex beat is not displaced. S1 and S2 were heard with no murmurs. S3 is pointed out at the mitral area with the PMI felt in this area. There was mild lower limb edema noted.
Gastrointestinal: the abdomen is moving with respiration; no scars or masses are noted. Bowel sounds are present, and no vascular bruits were heard. No tenderness on light palpation or organomegaly on deep palpation. Tympanic note heard on percussion.
Musculoskeletal: mild pitting lower limb edema to the level of the mid-leg. Normal muscle power and tone in all groups of muscles. No joint pain or stiffness was reported.
Diagnostic tests
- Lipid profile: check the cholesterol levels and help rule out hyperlipidemia.
- CBC: check the hemoglobin and white blood cell levels.
- BNP: essential in assessing cardiac function to help rule out cardiac failure.
- CMP: a panel of tests that measures the current status of the body’s metabolism. It consists of electrolytes fluids, blood glucose levels kidney and liver function tests.
- HBA1C: evaluate the blood glucose control over the last 90 days.
- Cardiac enzymes: a biomarker for evidence of heart muscle damage. They include; troponin T troponin I, myoglobin, and creatinine phosphokinase.
- Chest X-ray: assess the trachea, lungs, and heart, and look for surrounding pathology. Helps evaluate the size of the cardiac shadow.
- ECG: monitor the heart’s electrical activity and identify abnormal heart rhythms.
- Echocardiogram: assess the anatomy of the heart and its vessels and their function Clinical Log One-SOAP Note Assignment Paper.
Assessment
Coronary Artery Disease (I25.111): a disease that results from a reduced supply of oxygen and blood to the myocardium. It is caused by occlusion of the coronary arteries that leads to a demand-supply mismatch of oxygen levels. It primarily involves the formation of fatty plaques in the lumen of the coronary arteries, which then obstruct blood flow (Rai Dilawar Shahjehan & Bhutta, 2022). Common risk factors associated with the disease include; hypertension, diabetes, hyperlipidemia, and familial history. The clinical presentation includes; chest pain after a light physical exercise or even at rest and shortness of breath.
Congestive heart failure (428.0): a condition with impaired heart function to meet the body’s needs. Risk factors predispose patients to include; hypertension, diabetes, chronic lung diseases, coronary artery disease, pulmonary embolism, and others (Malik et al., 2022). Patients typically present with chest pain, shortness of breath, easy fatiguability, orthopnoea, edema, and PND
GERD (K21.9): occurs when the gastric contents reflux back into your esophagus, irritating the lining. Patients commonly present with acidity after ingestion of food, epigastric pain, chest pain, and a chronic cough (Clarrett & Hachem, 2018)Clinical Log One-SOAP Note Assignment Paper. Some risk factors associated with GERD include; obesity, intake of spicy food, cigarette smoking, and others.
Plan
It is advised that Atherosclerotic Cardiovascular diseases-related risk factors be controlled through a team-based approach by both pharmacological and non-pharmacological interventions. Pharmacological consist of anti-anginal and cardio protective medications. According to American Heart Association, every patient should be given guideline directed medical therapy that consist of; beta-blocker low dose aspirin nitroglycerin as needed, and a moderate to high intensity statin. If the symptoms are still not well controlled with this, titrate the beta blocker therapy, add a calcium channel blocker and consider use of long-acting nitrates. If the arteries are severely narrowed, surgical intervention is sought to widen the arteries, a process known as cardiac catheterization (Shah, 2021). Patient should be educated on medication compliance to ensure well controlled hypertension, diabetes and lipid levels. In addition encourage cessation of smoking, weight loss and physical exercises.
Research Article
The American college of cardiology emphasizes on lifestyle modification as the basis for ASCVD risk reduction efforts. They include; regular exercise, avoiding tobacco products, intake of heart-healthy diet and maintenance of a healthy weight. This is used together with cholesterol-lowering drug therapies (Grundy et al., 2019)Clinical Log One-SOAP Note Assignment Paper. Drug therapy for the lifestyle-related risk factors such as diabetes, hypertension and smoking cessation should also be encouraged. Statin therapy is recommended for people who are at increased risk of ASCVD as they help in reduction of LDL levels.
References
Clarrett, D. M., & Hachem, C. (2018). Gastroesophageal Reflux Disease (GERD). Missouri Medicine, 115(3), 214–218. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6140167/
Grundy, S. M., Stone, N. J., Bailey, A. L., Beam, C., Birtcher, K. K., Blumenthal, R. S., Braun, L. T., de Ferranti, S., Faiella-Tommasino, J., Forman, D. E., Goldberg, R., Heidenreich, P. A., Hlatky, M. A., Jones, D. W., Lloyd-Jones, D., Lopez-Pajares, N., Ndumele, C. E., Orringer, C. E., Peralta, C. A., & Saseen, J. J. (2019). 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation, 139(25). https://doi.org/10.1161/cir.0000000000000625
Malik, A., Brito, D., Sarosh Vaqar, & Chhabra, L. (2022, May 5). Congestive Heart Failure. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430873/
Rai Dilawar Shahjehan, & Bhutta, B. S. (2022, February 9). Coronary Artery Disease. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK564304/
Shah, S. N. (2021, October 17). Coronary Artery Atherosclerosis Guidelines: Guidelines Summary, 2020 ACC Guidelines on CV Disease Risk Reduction in T2D, 2018 ACC Expert Consensus Decision Pathway on Novel Therapies for CV Risk Reduction in TD2 and ASCVD. Medscape.com; Medscape. https://emedicine.medscape.com/article/153647-guidelines Clinical Log One-SOAP Note Assignment Paper
Clinical Log One-SOAP Note
Bio Data
Patient’s initials: G.N
Age: 54
Sex: male
Race: African American
Subjective Data
Chief complain: chest pain
History of presenting Illness: Mr. G.N 54-years-old African American male, is accompanied by his wife and has presented with chest pain for the last one month. It was sudden onset, on and off; he describes it as tight and sharp, lasting for a few minutes. The pain is aggravated by slight movement and exertion, especially when doing his farm work. It is non-radiating and is relieved on resting. There is a positive history of easy fatigability and shortness of breath. Clinical Log One-SOAP Note Assignment Paper
Current medications
PO Nifedipine 20mg 12 hourly
PO Lisinopril 10mg 24 hourly
PO Metformin 500mg 12 hourly
Allergies
No known food or drug allergies
Past medical history
He is a known hypertensive and diabetic patient on medications. His wife, however, reports that he is not compliant.
Surgical history
Had appendectomy done 15 years ago
Family history
He is the 3rd born in a family of five. All siblings are alive and well with no underlying medical conditions.
Maternal grandparents are deceased secondary to old age.
The paternal grandmother died from a stroke, whereas the grandfather suffered a heart attack.
His mother is alive and has dementia, while his father is alive and has hypertension.
Social History
He is married and has five living children.
He occasionally takes alcohol during the weekend with his friends. Currently smokes cigarettes about one pack per day. Denies illicit substance abuse. Clinical Log One-SOAP Note Assignment Paper
Occupation
He is a businessman.
Immunization
Recently had the Johnson and Johnson covid 19 vaccine.
Health Maintenance
He regularly takes grilled meat about three times per week. Rarely does physical exercise, even taking walks. He only seeks medical attention whenever he feels it’s necessary.
Review of systems
General: denies chills, fever, or weight loss.
Neurologic: denies headache, dizziness, loss of consciousness, or convulsions.
HEENT: denies blurry vision or eye pain. Denies ear pain, discharge, or ringing in the ears. Denies sores or ulcerations in the cheeks, tongue, or gums. Denies pain or difficulty in swallowing or hoarseness of voice. Denies nasal discharge, pain, or congestion.
Neck: denies swelling or lump in the neck. Denies history of neck stiffness.
Cardiovascular: positive complaints of chest pain and easy fatigability. Denies orthopnea, palpitations and PND.
Respiratory: denies difficulty in breathing, cough, and hemoptysis.
Gastrointestinal: denies abdominal pain, nausea, diarrhea, or vomiting.
Genitourinary: denies dysuria, increased urinary frequency, and hematuria.
Psychiatric denies hallucinations, suicidal ideations, anxiety, or depression.
Endocrinology: denies weight loss or weight gain.
Musculoskeletal: denies joint muscle and joint pain. No history of swelling or stiffness.
Hematologic: denies spontaneous bruising or bleeding.
Allergies
No history of eczema, hay fever, or asthma.
Objective
General: Mr. G.N 54-year-old African American male, is in a fair general condition, oriented in time, place, and person, and has no respiratory distress. Clinical Log One-SOAP Note Assignment Paper
Vital signs: BP-130/86mm/hg, PR 78b/min, RR 18breaths/min, spo2 98% RA, RBS 10mmol/l, temperature 27.20c, weight 204lbs, height 5’8, BMI 31.0kg/m2
HEENT: normocephalic, no bruising, lesions, or masses noted. There is equal distribution of hair. Eyes: no eye discharge, redness, cataract, periorbital edema, exophthalmos, or exophthalmos observed. Ears: hearing for high, medium, and low is intact bilaterally, no pain on moving the pinna, and no ear discharge or redness on the outer and inner ear. The tympanic membrane is gray, shiny, and intact bilaterally. Dark brown cerumen is noted bilaterally. Nose, mouth, and throat: mucous membranes are moist, pink, and intact, with no evidence of bruising, swelling, or bleeding in turbinates. The septum is centrally located. No sores or wounds on the gums, cheeks, tongue, or soft or hard palate. No halitosis or untreated dental carriers.
Neck: no lumps or swellings were observed, and the trachea is centrally located. The thyroid gland is symmetrical with no masses, lumps or goiter observed.
Neurological: he is oriented in time, place, and person. He follows both simple and complex commands. Cranial nerves are grossly intact. Pupils are bilaterally and equally reactive to light.
Respiratory System: no chest wall deformities, no scars, or obvious masses. There is a normal rate, rhythm, depth, and breathing effort. Normal chest expansion and tactile fremitus. No tenderness was elicited. There is a resonance note on percussion and equal and bilateral air entry with no added sounds.
Cardiovascular: normoactive prechondium.no heaves or thrills, and the apex beat is not displaced. S1 and S2 were heard with no murmurs. S3 is pointed out at the mitral area with the PMI felt in this area. There was mild lower limb edema noted.
Gastrointestinal: the abdomen is moving with respiration; no scars or masses are noted. Bowel sounds are present, and no vascular bruits were heard. No tenderness on light palpation or organomegaly on deep palpation. Tympanic note heard on percussion.
Musculoskeletal: mild pitting lower limb edema to the level of the mid-leg. Normal muscle power and tone in all groups of muscles. No joint pain or stiffness was reported. Clinical Log One-SOAP Note Assignment Paper
Diagnostic tests
- Lipid profile: check the cholesterol levels and help rule out hyperlipidemia.
- CBC: check the hemoglobin and white blood cell levels.
- BNP: essential in assessing cardiac function to help rule out cardiac failure.
- CMP: a panel of tests that measures the current status of the body’s metabolism. It consists of electrolytes fluids, blood glucose levels kidney and liver function tests.
- HBA1C: evaluate the blood glucose control over the last 90 days.
- Cardiac enzymes: a biomarker for evidence of heart muscle damage. They include; troponin T troponin I, myoglobin, and creatinine phosphokinase.
- Chest X-ray: assess the trachea, lungs, and heart, and look for surrounding pathology. Helps evaluate the size of the cardiac shadow.
- ECG: monitor the heart’s electrical activity and identify abnormal heart rhythms.
- Echocardiogram: assess the anatomy of the heart and its vessels and their function.
Assessment
Coronary Artery Disease (I25.111): a disease that results from a reduced supply of oxygen and blood to the myocardium. It is caused by occlusion of the coronary arteries that leads to a demand-supply mismatch of oxygen levels. It primarily involves the formation of fatty plaques in the lumen of the coronary arteries, which then obstruct blood flow (Rai Dilawar Shahjehan & Bhutta, 2022)Clinical Log One-SOAP Note Assignment Paper. Common risk factors associated with the disease include; hypertension, diabetes, hyperlipidemia, and familial history. The clinical presentation includes; chest pain after a light physical exercise or even at rest and shortness of breath.
Congestive heart failure (428.0): a condition with impaired heart function to meet the body’s needs. Risk factors predispose patients to include; hypertension, diabetes, chronic lung diseases, coronary artery disease, pulmonary embolism, and others (Malik et al., 2022). Patients typically present with chest pain, shortness of breath, easy fatiguability, orthopnoea, edema, and PND
GERD (K21.9): occurs when the gastric contents reflux back into your esophagus, irritating the lining. Patients commonly present with acidity after ingestion of food, epigastric pain, chest pain, and a chronic cough (Clarrett & Hachem, 2018). Some risk factors associated with GERD include; obesity, intake of spicy food, cigarette smoking, and others.
Plan
Stable ischemic heart disease presents as stable angina in an acute setting. Both pharmacological and non-pharmacological interventions manage it. Pharmacological consist of anti-anginal and cardioprotective medications. According to Rai Dilawar Shahjehan & Bhutta (2022)Clinical Log One-SOAP Note Assignment Paper, every patient should be given guideline-directed medical therapy that consists of; a beta-blocker, low dose aspirin nitroglycerin as needed, and a moderate to high-intensity statin. If the symptoms are still not well controlled with this, titrate the beta-blocker therapy, add a calcium channel blocker, and consider using long-acting nitrates.
If the arteries are severely narrowed, surgical intervention is sought to widen the arteries, a process known as cardiac catheterization. The patient should be educated on medication compliance to ensure well-controlled hypertension, diabetes, and lipid levels. In addition, encourage smoking cessation, weight loss, and physical exercises.
Research Article
Coronary artery disease is among the cardiovascular diseases that cause morbidity and mortality. The research article explains some of the risk factors associated with CAD. Understanding some of the risk factors is important in modern medicine to help develop effective treatment plans and preventive strategies in clinical practice. Risk factors are either modifiable or non-modifiable(Hajar, 2017)Clinical Log One-SOAP Note Assignment Paper. Modifiable risk factors include; poorly controlled hypertension, smoking, diabetes, hyperlipidemia, obesity or overweight, stress, unhealthy eating habits, and lack of physical activities. On the other hand, the non-modifiable risk factors comprise; advance in age (>45 years in men and >55 years in women), family history, race, and the male gender.
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References
Clarrett, D. M., & Hachem, C. (2018). Gastroesophageal Reflux Disease (GERD). Missouri Medicine, 115(3), 214–218. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6140167/
Hajar, R. (2017). Risk factors for coronary artery disease: Historical perspectives. Heart Views, 18(3), 109. https://doi.org/10.4103/heartviews.heartviews_106_17
Malik, A., Brito, D., Sarosh Vaqar, & Chhabra, L. (2022, May 5). Congestive Heart Failure. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430873/
Rai Dilawar Shahjehan, & Bhutta, B. S. (2022, February 9). Coronary Artery Disease. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK564304/ Clinical Log One-SOAP Note Assignment Paper