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SOAP NOTE

Name:  R.G Date: 08/21/2019 Time: 10 AM   Age: 56 y/o Sex: Female SUBJECTIVE CC: 

“I have been experiencing increasing shortness of breath, fatigue and problems sleeping”

  HPI: 

R.G, a 56 y/o African American female presents to the office with complaints of increasing shortness of breath on exertion and mild fatigue for the past five days. The patient reports that he has been experiencing shortness of breath after climbing stairs or walking two to three blocks he also reports difficulty sleeping at night and states that he often need two pillows to feel comfortable. Patient reports that 2 years ago, she suddenly started experiencing shortness of breath after hurrying for an aeroplane. Following the incidence, she was admitted to hospital and treated for acute pulmonary edema. After the pulmonary edema episode, the patient reports that his blood pressure had been high consistently. Patient denies chills, cough, chest pain, palpitations, vomiting, diarrhea abdominal pain/distension

  Medications:

Diltiazem 180 mg/d for HTN

Hydrochlorothiazide 50 mg/d for HTN and heart failure

Lopressor 25mg orally BID HTN and heart failure

Glyburide 5 mg/d for diabetes

Indomethacin 25 mg TID for pain

  PMH

Allergies:  No known Drug allergies

Medication Intolerances: None

Chronic Illnesses/Major traumas: Diastolic dysfunction with diastolic congestive heart failure, Hypertension (diagnosed 5 years ago), type 2 diabetes mellitus (diagnosed 4 years ago), arthritis (diagnosed two years ago). Denies a history of asthma  

Hospitalizations/Surgeries: patient was admitted to hospital and treated for acute pulmonary edema. Patient has no history of surgeries

  Family History: Coronary heart disease, hypertension, arthritis ( father), Type 2 diabetes mellitus ( mother), Hypertension ( older brother), other siblings and her children alive and well. 

Social History: Patient lives with her husband and youngest son. She works as a teller at one of the local banks. Patient reports that she takes two glasses of wine after work, reports a 6-year history of tobacco smoking but states that she quit. Denies use of illicit drugs

  ROS General

Complains of mild fatigue and weakness. Denies fever chills, night sweats and any recent unexplained weight loss or gain

Cardiovascular

Patient reports dyspnea especially when trying to sleep, which is relieved with elevation of the head with two pillows. Patient also reports swelling in lower limbs and a history of HTN. Denies chest pain, palpitations, and PND

  Skin

Denies delayed healing, rashes, skin discolorations or changes in moles or lesions

Respiratory

Reports exertional dyspnea and wheezing by denies cough, sputum production and hemoptysis

  Eyes

Patient is short sighted, uses corrective lenses. Denies blurring 

Gastrointestinal

Patient reports nausea and bloating but denies abdominal pain or distension,

vomiting, diarrhea, and constipation.

   Nose/Mouth/Throat

Denies sinus problems, dysphagia or sore throat  

Genitourinary

Denies frequent urination at night, frequency burning, or changes in color of urine.  

Heme/Lymph/Endo

Denies bruising, blood transfusion, swollen glands, increase thirst, and increased hunger

Musculoskeletal

Patient reports a history of degenerative joint disease and muscle weakness.

Psychiatric

Reports sleeping problems due to shortness of breath. Denies depression, anxiety, or a history of mental disorders

Neurological

Denies syncope, seizures, paresthesias. Patient complains of weakness

OBJECTIVE Weight   190lbs       BMI 33.7 Temp 36.3 BP 110/50 Height 5’3” Pulse 78 Resp 24 General Appearance

Well-developed and well-nourished, dyspneic with moderate activity but in no distress following a few minutes of rest. AAOX3, good speech and eye contact. Responds to questions appropriately.

Skin

Skin is warm, dry and intact. No skin discolorations, lesions or rashes

HEENT

Head: Normocephalic, atraumatic. Eyes:  PERRLA. Conjunctiva and EOM normal. No scleral injection. Mouth: oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Neck: supple, No JVD and masses.

Cardiovascular

Prominent S3 and S4 gallops. No clicks, rubs or murmurs. Bipedal oedema

Respiratory

Chest wall symmetric. Respirations are tachypneic. No use of accessory muscles. Became more short of breath and tachypneic when in supine position. Audible expiratory wheeze with prolonged expiratory phase. Vesicular breath sounds with reduced breath sounds at bases, right greater than left with inspiratory rales bilaterally. No consolidation signs

Gastrointestinal

Normoactive bowel sounds in all quadrants. Moderately obese, soft, nontender abdomen. No hepatosplenomegaly. 

Musculoskeletal

Full ROM in all 4 quadrants

Neurological

Speech is clear with good tone. Posture erect with stable balance and normal gait

Psychiatric

Patient is awake and oriented X3

Lab Tests

Lab: Na 132, K 3.8, HCO3 21. BUN 17. Cr 1.1. Glucose 120 mg/dL. WBC 4.8, hemoglobin and hematocrit 11.1 and 32.6

  Special Tests

Transthoracic echocardiogram- LVEF normal but LVH and abnormal diastolic filling patterns

EKG- reveals atrial fibrillation at the rate of 75 beats/min, normal intraventricular

conduction. QRS duration of 350 ms

Chest X-ray- reveals cardiomegaly and pleural fluid reveals pulmonary edema

 Diagnosis  Differential Diagnoses

o 1-Acute on Chronic diastolic (congestive) heart failure. This is a complex condition that results from structural and functional cardiac disorders that impair the capability of the ventricle to eject or fill blood (Yusuf, 2019). The key signs and symptoms of the condition include dyspnea, and fatigue, which often limit the patients exercise tolerance and fluid retention, which is associated with pulmonary congestion along with peripheral edema (Yusuf, 2019). Dyspnea on exertion is most common associated with left-sided heart failure. Physical examination often reveals tachycardia, jugular venous pressure, S4 and S3 gallop and peripheral edema (Yusuf, 2019).

o 2-Chronic Pericarditis. This defines the inflammation of the pericardium which starts gradually and results into accumulation of the fluid in the pericardial space. According to Yusuf (2019), the condition is characterized by coughing, shortness of breath and fatigue. It can also be caused by TB, heart surgery and frequent radiation therapy to the chest. Other less causes for the condition include viral infections, bacterial infection and mesothelioma (form of cancer caused when exposed to asbestos).

o 2- Cardiac tamponade. A clinical syndrome caused by the accumulation of fluid in the pericardial space. This cause a reduction in ventricular filling which is followed by hemodynamic compromise. The condition also results into shock, pulmonary edema and eventually death of the patient. The patient with this condition experiences reduced arterial blood pressure, muffled heart sound and distended neck veins (Yusuf, 2019).

Diagnosis

o Acute on Chronic diastolic (congestive) heart failure (ICD code I50.33)

Plan/Therapeutics  

Further testing None Medication Initiate captopril 6.25 mg orally three times daily- Captopril is an ACE inhibitor, which are the first line treatment for patients with mild to moderate heart failure symptoms and left ventricular dysfunction (Yusuf, 2019). ACE inhibitors reduce heart failure symptoms including dyspnea, peripheral edema and fatigue and reduce the risk of heart attack. Captopril was started at a lower dose given that Ponikowski et al. (2018) recommends

that patients not taking ACE inhibitor to be started at a lower dose. Continue Lopressor 25mg orally BID- Lopressor is a beta1-adrenergic blocker at lower doses. Ponikowski et al. (2018) state that selective beta1-adrenergic blockers such as Lopressor are used in heart failure to reduce heart rate along with blood pressure. The medication has been shown to reduce mortality and morbidity in patients with heart failure. A meta-analysis by Bavishi, Chatterjee, Ather, Patel, and Messerli (2015) found that irrespective of pretreatment heart rate, beta-blockers decreased mortality in patients with heart failure with reduced ejection fraction in sinus rhythm Continue Hydrochlorothiazide 50 mg PO once daily- Hydrochlorothiazide is a diuretic which are used as an adjunct treatment in patients with fluid retention and should be combined with an ACE inhibitor and a beta-blocker. Yancy et al. (2017) state that all symptomatic patients with signs of congestion should receive a diuretic, irrespective of LVEF. Diuretics produce various symptomatic benefits than other heart failure drugs. These drugs have been shown to relieve pulmonary and peripheral edema (Rickers, et al., 2017). Education Educating the patient on heart failure including the conditions disease process, signs and symptoms, causes and possible complications. Patient was also instructed to restrict sodium intake to at least 3 g/day (Ponikowski et al., 2018). Patient was advised to keep a daily fluid intake/output at home and to restrict fluid intake when necessary. She was also advised to monitor her weight daily and to increase her engagement in exercise, which is critical in the control of blood pressure (Ponikowski et al., 2018). Additionally, she was informed on the importance of blood pressure control and diabetes management on the prevention of exacerbations of heart failure. Lastly, patient was educated on the importance of continuous and close monitoring of her health and was referred to a specialized heart failure clinic-based care (Ponikowski et al., 2018). Non-medication treatments Sodium restriction and fluid restriction-reducing sodium intake and fluid restriction when necessary reduces water retention, which is associated with peripheral edema (Ponikowski et al., 2018). Cardiac rehabilitation and exercise training- this improves exercise tolerance, and quality of life with reduced morbidity and mortality in patients with heart failure (Ponikowski et al., 2018).

 Evaluation of patient encounter- The patient encounter was well, and the patient was cooperative throughout the session. The education given to the patient was well received as she was attentive to all the guidelines and other procedures. She admitted complying with all the guidelines. The encounter provided me with increased insight on the evaluation and treatment of patients presenting with signs and symptoms of acute on chronic diastolic (congestive) heart failure.

Reference:

Bavishi, C., Chatterjee, S., Ather, S., Patel, D., & Messerli, F. H. (2015). Beta-blockers in heart failure with preserved ejection fraction: a meta-analysis. Heart failure reviews, 20(2), 193-201.

Ponikowski, P., Voors, A. A., Anker, S. D., Bueno, H., Cleland, J. G., Coats, A. J., … & Jessup, M. (2016). 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. European journal of heart failure, 18(8), 891-975.

Rickers, C., Läer, S., Diller, G. P., Janousek, J., Hoppe, U., Mir, T. S., & Weil, J. (2017). Chronic Heart Failure. Cardiology in the Young, 27.

Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Colvin, M. M., … & Hollenberg, S. M. (2017). 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Journal of the American College of Cardiology, 70(6), 776-803.

Yusuf, S. (2019). Chronic congestive heart failure – Symptoms, diagnosis and treatment | BMJ Best Practice. Retrieved 22 August 2019, from http://newbp.bmj.com/topics/en-us/61

SOAP NOTE Name:  S.S Date: 10/10/2019 Time: 12:30 p.m   Age: 70 Sex: Female SUBJECTIVE CC:  “My skin is turning pale and my feet and hands feel cold”   HPI:  S.S comes to the clinic with complaints of her skin turning pale and feeling cold in the feet as well as the hands. The patient explains that she started having these symptoms three weeks ago. She mentions that the cold feeling in her feet and hands is accompanied by headache, chest pain, and dizziness, which go away after taking ibuprofen. She also mentions that she cannot walk for long distances because she feels short of breath and weak besides feeling exceedingly tired. She often rests to catch a breath. She also notes that even though she is vegetarian, she has been having an urge to consume dirt. The patient claims that she had been skipping meals recently since she was diagnosed with positive H. Pylori. She denies blood in stool, states that the last colonoscopy was in 2005 with normal results.

Medications: Ibuprofen PRN for headache and chest pain  Levothyroxine 0.50 mcg/daily for hypothyroidism PMH: Hypothyroidism diagnosed in 2013 Allergies:  NKD Medication Intolerances: None Hospitalizations/Surgeries: She mentions that in 2009, she underwent a breast biopsy for suspected breast cancer, but the results were negative. Colonoscopy 2005 negative results. Family History Father died 20 years ago from coronary artery disease. Mother died 15 years ago from diabetes. Brother was diagnosed with colon cancer 2 years ago. Other siblings are healthy. Social History Patient holds a Bachelor’s degree in commerce. Patient worked as a bank manager before retiring. Patient is married and lives with her husband (74 years of age) and two grandchildren (19 years and 15 years of age). Patient does not consume alcohol, smoke or abuse drugs. Patient mentions putting on her seatbelt on always.  ROS General Patient reports feeling extremely fatigued, dizzy, and feeling weak. Denies, night sweats, fever, chills, weight change

Cardiovascular Patient reports dyspnea and chest pain. Denies edema 

Skin Patient reports pale skin. Denies bruising,

Respiratory Patient reports dyspnea and wheezing. Denies

rashes, or lesions  cough, hemoptysis, hx of pneumonia or TB  Eyes Patient wears corrective lenses, reports blurring vision  

Gastrointestinal Denies abdominal pain, diarrhea, vomiting, nausea, or changes in stool color or bowel movement 

Ears Denies discharge, hearing loss, ear pain, ringing in ears

Genitourinary/Gynecological Denies burning, changes in color of urine, urgency, or frequency or vaginal discharge

Nose/Mouth/Throat Denies nose bleeds or discharge, dental disease, sinus problems, dysphagia, throat pain, hoarseness,  

Musculoskeletal Denies joint swelling, back pain, fracture hx, pain or stiffness, osteoporosis

Breast Denies SBE, bumps, tumors, or changes

Neurological Reports feeling weak. Denies paresthesias, syncope, black out spells, transient paralysis, seizures

Heme/Lymph/Endo Denies hx of blood transfusion, bruising, swollen glands, cold or heat intolerance, night sweats, increase hunger or thirst

Psychiatric Patient reports being anxious. Denies sleeping difficulties, depression, suicidal attempts/ideation

OBJECTIVE Weight    130 lbs       BMI 21.0 Temp 98.0 BP 123/62 Height 5’6 Pulse 105 Resp 17 General Appearance Well-nourished and well-developed, normal asthenic. Excellent attention to grooming Skin Skin is pale. Clear to lesion, rashes or ulcers HEENT Head is normocephalic/atraumatic without lesions; hair consistently dispersed. Eyes:  PERRLA. Scleral injection or Conjunctival absent. EOMs intact. Ears: Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Canals patent. Nose: Normal turbinates; nasal mucosa pink. Septal deviation absent. Neck: Supple. Full ROM; cervical lymphadenopathy and occipital nodes absent. Nodules or thyromegaly absent. Oral mucosa moist and pink. Non erythematous pharynx without exudate. Teeth are in excellent repair. Cardiovascular Regular RR. Gallops and rubs absent. JVD absent. 2+ peripheral pulses in both dorsalis and both radialis bilaterally Respiratory Lungs clear to auscultation and percussion bilaterally. Wheezes, rhonchi and crackles absent Gastrointestinal

Abdomen soft, non-tender, non-distended; BS active X4 quadrants. No hepatosplenomegaly Breast N/A Genitourinary N/A Musculoskeletal Unstable gait. Cyanosis, clubbing, pitting edema absent. Full motion range. Joint deformities absent Neurological Cranial nerves II-XII within normal limits. Deep tendon reflexes 2+ in both biceps and both knees. Psychiatric Excellent insight and judgment. Oriented X4. Excellent recent and remote memory. Appropriate affect and mood. Lab Tests Hemoglobin 9.8 g/dL (Low) Hematocrit 30.0 % (Low) Mean Corpuscular Volume (MCV): 65 fL (decreased) RDW 16.0% (increased) Platelet, Neutrophils, Mono, Eosinophils, basophils: WNL Serum ferritin levels: pending Serum iron- pending Reticulocyte count-pending Total iron binding capacity- pending

Special Tests None    Diagnosis Further test: Serum ferritin levels Serum iron Total iron binding capacity

Differential Diagnoses o 1-Iron Deficiency Anemia D50.9: o 2- Cold Autoimmune Hemolytic Anemia (AIHA) D59.1 o 3- Thalassemia D56.1 Diagnosis o Iron Deficiency Anemia (IDA) D50.9

Plan/Therapeutics Medication

 Ferrous sulfate 325 mg 1 tablet orally TID for 3 months  Vitamin C (500 units) q.d for 3 months

Education  Patient was educated on the significance of amplifying daily intake

of iron-rich foods  Patient was educated to increase vitamin C intake  Patient was advised to avoid drinking black tea.  Increase dietary fiber to prevent constipation, which is a side effects

of ferrous sulfate Follow-up

 Patient scheduled for a follow-up appointment in 4 weeks, to repeat blood work after therapy. Patient was advised to contact the clinic if symptoms exacerbate or do not improve

Referral  GI for colonoscopy

Discussion of Assessment and Plan S.S is a 70 y/o Caucasian female with complaints of pale skin and cold in the feet

and hands. Based on the patient's symptoms, physical exam, and diagnostic findings, the primary diagnosis is iron deficiency anemia (IDA) D50.9. IDA is the most prevalent type anemia, where there is an inadequate number of healthy blood cells (Camaschella, 2015). As the name suggests, the condition occurs because of insufficient iron. Without sufficient iron, the body is not able to produce adequate hemoglobin (Camaschella, 2015). The disease is characterized by symptoms including fatigue, shortness of breath, cold feet and hands, chest pain, fast heartbeat, and strange cravings for non-nutritive substances, including starch, dirt, or ice (Alzaheb & Al-Amer, 2017). Risk factors include being female and being vegetarian (Alzaheb & Al-Amer, 2017). The condition was confirmed by a low level of hemoglobin and a low RBC volume as established by the CBC test. According to Hennek et al. (2016), patients with IDA exhibit low levels of hemoglobin than average (12.0-15.5 g/dL in females) and a volume of RBC lower than average (80- 96 fL/red cell in adults).

Other conditions that may present with similar symptoms include Cold Autoimmune Hemolytic Anemia (AIHA) D59.1 and Thalassemia D56.1. Cold AIHA was ruled out due to the absence of critical symptoms such as pain in the back of the legs, diarrhea, and pain and blue coloring in the feet and hands, which are common in individuals with the condition (Barcellini, 2015). Additionally, the patient does not present with key risk factors associated with cold AIHA. Such include infections, certain cancers, collagen-vascular diseases such as systemic lupus erythematosus, and family history of the hemolytic disease (Barcellini, 2015). Nevertheless, confirmation of the absence of cold AIHA will be possible once the Coombs test results are established, which should be negative for antibodies, which may affect RBCs (Khan et al., 2017). Thalassemia was ruled out because the patient does not present with crucial features associated with the condition, including dark urine, facial bone deformities, abdominal swelling, and yellowish skin (Origa, 2017). Furthermore, the condition is common in individuals of Italian, Greek, Asian, African, or Middle Eastern descent (Origa, 2017). The patient is Caucasian.

The patient's treatment included iron supplements, and vitamin C. Evidence has demonstrated that a dosage of 120 mg of elemental iron once daily can replenish iron in the body in three months (Okam, Koch, & Tran, 2016). Moreover, vitamin C is excellent

in promoting the absorption of iron when taken with iron pills once each day (Fei, 2015). Patient education included increasing iron and vitamin C intake and avoiding the

consumption of black tea. Notably, the patient is vegetarian, which puts her at risk of iron deficiency. Increasing the intake of foods rich in iron such as beans, cashews, fortified breakfast cereals, baked potatoes, and whole-grain and enriched breads can assist in raising her iron levels (Schrier et al., 2016). Moreover, the patient was also educated on the significance of increasing her vitamin C intake. Citrus fruits, papaya, strawberries, and cantaloupe are rich sources of vitamin C, which can promote the absorption of iron in the body (Fei, 2015). However, the patient was also educated to avoid the consumption of black tea as it lessens the absorption of iron (Ahmad Fuzi et al., 2017). Follow-up was scheduled in four weeks, and the patient was advised to contact the clinic if symptoms exacerbate or fail to improve with therapy.

EVALUATION OF THE ENCOUNTER: The encounter with the patient went exceedingly well. Specifically, assessment, diagnosis, as well as treatment went as needed. The patient cooperated all through and was ready to adhere to the treatment plan. We had a serious discussion concerning increasing iron and vitamin C intake and she was given a list of food products, which are rich in the nutrients. I believe that all the required history together with assessment data was gathered and nothing was left out.

Reference: Ahmad Fuzi, S. F., Koller, D., Bruggraber, S., Pereira, D. I., Dainty, J. R., & Mushtaq, S. (2017).

A 1-h time interval between a meal containing iron and consumption of tea attenuates the inhibitory effects on iron absorption: a controlled trial in a cohort of healthy UK women using a stable iron isotope. The American journal of clinical nutrition, 106(6), 1413- 1421.

Alzaheb, R. A., & Al-Amer, O. (2017). The prevalence of iron deficiency anemia and its associated risk factors among a sample of female university students in Tabuk, Saudi Arabia. Clinical Medicine Insights: Women's Health, 10, 1179562X17745088.

Barcellini, W. (2015). New insights in the pathogenesis of autoimmune hemolytic anemia. Transfusion medicine and hemotherapy, 42(5), 287-293.

Camaschella, C. (2015). Iron-deficiency anemia. New England journal of medicine, 372(19), 1832-1843.

Fei, C. (2015). Iron Deficiency Anemia: A Guide to Oral Iron Supplements. Clinical Corelation The nyu langone online journal of medicine https://www clinicalcorrelations org.

Hennek, J. W., Kumar, A. A., Wiltschko, A. B., Patton, M. R., Lee, S. Y. R., Brugnara, C., … & Whitesides, G. M. (2016). Diagnosis of iron deficiency anemia using density-based fractionation of red blood cells. Lab on a Chip, 16(20), 3929-3939.

Khan, U., Ali, F., Khurram, M. S., Zaka, A., & Hadid, T. (2017). Immunotherapy-associated autoimmune hemolytic anemia. Journal for immunotherapy of cancer, 5(1), 15.

Liebman, H. A., & Weitz, I. C. (2017). Autoimmune hemolytic anemia. The Medical clinics of North America, 101(2), 351-359.

Okam, M. M., Koch, T. A., & Tran, M. H. (2016). Iron deficiency anemia treatment response to oral iron therapy: a pooled analysis of five randomized controlled trials. Haematologica, 101(1), e6.

Origa, R. (2017). β-Thalassemia. Genetics in Medicine, 19(6), 609.

Schrier, S. L., Auerbach, M., Mentzer, W. C., & Tirnauer, J. S. (2016). Treatment of iron deficiency anemia in adults. UpToDate. Waltham (MA): Wolters Kluwer.