Posted: September 28th, 2023

Focused SOAP Note for a patient with chest pain

Focused SOAP Note for a patient with chest pain
S:
CC: “Chest pain”
HPI: The patient is a 65 year old AA male who developed sudden onset of crushing chest pain, which began early this morning. The pain is described as “crushing” and is rated nine out of 10 in terms of intensity. The pain is located in the middle of the chest and is accompanied by shortness of breath and nausea. The patient tried an antacid with minimal relief of his symptoms.
PMH: Positive history of GERD and hypertension is controlled
FH: Mother died at 78 of breast cancer; Father at 75 of CVA. No history of premature cardiovascular disease in first degree relatives.
SH: Negative for tobacco abuse, currently or previously; consumes moderate alcohol; married for 39 years
Allergies: PCN-rash; food-none; environmental- none
Immunizations: UTD on immunizations, covid vaccine #1 1/23/2021 Moderna; Covid vaccine #2 2/23/2021 Moderna
ROS

General–Negative for fevers, chills, fatigue
Cardiovascular–Negative for orthopnea, PND, positive for intermittent lower extremity edema
Gastrointestinal–Positive for nausea without vomiting; negative for diarrhea, abdominal pain
Pulmonary–Positive for intermittent dyspnea on exertion, negative for cough or hemoptysis
O:
VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70”
General–Pt appears diaphoretic and anxious
Cardiovascular–PMI is in the 5th inter-costal space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is heard best at the second right inter-costal space which radiates to the neck. A third heard sound is heard at the apex. No fourth heart sound or rub are heard. No cyanosis, clubbing, noted, positive for bilateral 2+ LE edema is noted.
Gastrointestinal–The abdomen is symmetrical without distention; bowel sounds are normal in quality and intensity in all areas; a bruit is heard in the right para-umbilical area. No masses or splenomegaly are noted. Positive for mid-epigastric tenderness with deep palpation.
Pulmonary– Lungs are clear to auscultation and percussion bilaterally
Diagnostic results: EKG showing ST elevation in leads II, III, aVF. CK-MB elevated to 45. CXR unremarkable.
A:
Differential Diagnosis:
Myocardial Infarction – supported by the 2020 ACC/AHA Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes and the 2019 ACC Expert Consensus Decision Pathway on Management of High-Risk Non-ST-Elevation Acute Coronary Syndromes which recommend evaluating for myocardial infarction in patients presenting with chest pain using cardiac biomarkers, ECG and symptoms (O’Gara et al., 2020; Amsterdam et al., 2019).
Angina – signs and symptoms as outlined in the 2020 ACC/AHA Guideline for the Diagnosis and Treatment of Patients With Stable Ischemic Heart Disease include chest pain, tightness, pressure or squeezing that may radiate to the neck, jaw, shoulder, back or arm and is provoked by physical or emotional stress (Fihn et al., 2020).
Costochondritis – typically presents as localized chest wall pain and tenderness over the costochondral junctions, as described in the American College of Rheumatology guideline for the management of fibromyalgia (Wolfe et al., 2010) and signs on exam include localized tenderness over the costochondral junctions without swelling or redness, according to UpToDate (Chang, 2022).
Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction
P: Admit patient for further evaluation and management of myocardial infarction. Initiate aspirin, nitroglycerin, beta blocker. Notify cardiology for possible catheterization.
Focused SOAP note:
Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2019;74(23):e139-e228. doi:10.1016/j.jacc.2019.03.009
Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;140(11):e596-e646. doi:10.1161/CIR.0000000000000678
Chang A. Costochondritis. In: Post TW, ed. UpToDate. UpToDate; 2022. Accessed May 20, 2022. https://www.uptodate.com/contents/costochondritis
Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2012;126(25):e354-e471. doi:10.1161/CIR.0b013e318277d6a0
O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127(4):e362-e425. doi:10.1161/CIR.0b013e3182742cf6
Wolfe F, Clauw DJ, Fitzcharles MA, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken). 2010;62(5):600-610. doi:10.1002/acr.20140

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