SOAP note for a patient with cardiovascular Disorders

SOAPnote for a patient with cardiovascular Disorders

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SoapNote

Studentinitials-___Clinical Site initial-__Clinical hours perday___ ___

Clientinformation day _

Accordingto the Roy Adaptation Model, the primary requirements for a person’sphysiologic adaptation are the electrolyte and fluid, and theacid-base balance (Buttaro,Trybulski, Polgar &amp Sandberg-Cook, 2013).

Subjectivedata:

Age:57 years

Ethnicity:Asian

Keyissue and complains: Occasional chest discomfort

HPI:The patient is an Asian man who was admitted to this facility a yearago with a CABG and a coronary artery disease.

Cholesterol:160

HDL:68

LDL:78

ALT:Normal value

Triglycerides:74

Pastmedical history: Atrial fibrillation and mitral regurgitation,diabetes, and recurrent chest discomfort.

Socialhistory: He denied using drugs and alcohol.

HEENT:denies any dizziness, blurry vision, headaches, ear pain, nasaldrainage, dental complaints a sore throat, neck pain, or difficultywith the smell.

Lymphatic:denies any painful or swollen lymph nodes

Chest/Lungs/Respiration:denies any shortness of breath, wheezing, sputum, cough and does notremember the last time for a chest x-ray.

Heart:denies any palpitations, cardiac stents, and edema, and the heartshows regular rhythm and rate, where S1 and S2 are normal.

Abdomen/Gastrointestinal:denies vomiting, reflux, abdominal pain, constipation, nausea,diarrhea, or blood in the stool. There is a distended abdomen, butthe benign is non-tender. He has never experienced colonoscopy.

Genitourinary:denies changes in urine color or flow, changes in urinary habits,kidney stones, or UTIs.

Neurological:denies any numbness, dizziness, tremors, tingling or paresthesias.

Muscoskeleton:denies any stiffness, swelling of the joints or bones, pain or heat.

Objectivedata:

PhysicalExamination: Signs of distress noted, the patient looks healthy andoriented though.

Vitalsigns: The blood pressure is 117/75, the pulse rate is 79, the weightis 190 pounds.

HEENT:the head is symmetrical and normocephalic. Features of the face aresymmetrical. There is no eye examination because the patient has nocomplaints. Clear tymphanic membrane, minimal buildup of cerumen andthere is no pineal pain. There is no rhinne or Weber test because thepatient has no hearing problems. No internal or external nasalswelling, no polyps or crusting. Did not test the sense of smell, asthe patient had no nasal trouble. Oropharynx has no exudates orerythema. Detention has no gingival swelling. When the patient says‘aah,` the soft palate rises. The gag reflex is positive. Thetastewas not examined as the patient has no problems with taste ororal complaints.

Lymphatic:there is no lymphadenopathy

Chest/Lungs/Respiration:symmetrical chest, even respirations and with ease. Lungs areresonant to the percussion posteriorly. They are clear toauscultation with no rales, rhonchi or wheezes.

Heart:regular rhythm and rate, S1 and S2 are normal, no gallops, abdominalbruits or carotid, heaves, clicks or thrills. PMI palpitation is at5ICS. Bilateral pulse of dorsalis pedal, carotid, and 2+ radial. Noswelling noted coolness or varicosities. EKG from last year depicts1stdegree AV block of sinus bradycardia at a rate of 45.

Abdomen:flat, non-tender, soft, no palsations, masses, or hepatomegaly. Thepatient had no history of urinary, kidneys or liver complaints hence,no CTA and liver span tests were performed.

Gastrointestinal/Genitourinary, Rectum, Anus, and male genitalia: these were notexamined because the patient had no complaints about them. He says hedoes self-testicular tests and has no changes in the stream of urine,changes in stool, or changes in bowel habits.

Neurological:the gait of the patient seems symmetrical with no hardships. Noassessment of the sensory function, DTRs, cranial balance and nervesas the patient has no known history regarding the neurologicaldeficits.

Musculoskeletal:the spine has no curving, and the parts of the body appearsymmetrical. No pain, spasms or fasciculations in the ROM of lowerand upper extremities.

DiagnosticTest: the electrocardiogram showed that the sinus rate is normal with76 beats every minute.

Toolsfor screening: The Beck Depression Inventory was used to check forthe level of depression. C-reactive Protein Screening tool to measurethe levels of C-reactive proteins

Assessmentdifferential diagnoses:

  1. Stage 1 Hypertension.

  2. Pulmonary Edema

  3. Protein Overloading

  4. White coat syndrome

Stage1 hypertension was my primary diagnosis because it was the one thatrequired medical treatment (Heart.org, n.d)

Nursingdiagnosis: knowledge deficit relatedto nutrition and diet.

  1. Sinus bradycardia with the 1st degree AV block

Planof care diagnostic Plan

  1. CMP, CBC, level of uric acid, UA, lipid panel and EKG

  2. Check for TSH before the next visit

  3. Chest x-ray before the next visit

  4. Get the initial cardiology visit records prior to coming back to the clinic

Referraland Treatment Plan

  1. Continue with the current OTC MVI and fish oil

  2. Refer to the cardiology to monitor for the sinus bradycardia with the 1st degree AVB

IfBP continues to go up, start medical management like ACE-inhibitor

ManagementPlan and therapies

Teachabout moderation of the diet to reduce intake of sodium and caffeine,and teach about DASH diet (Buttaro etal.,2013).

Encouragethe patient to come back with the log of blood pressure of thereadings at home, after three months (NationalHeart Lung and Blood Institute, 2002).Patient advised getting enough rest and sleep.

Nutritionaltherapy: moderate the diet of the patient to include reduced intakeof sodium

PreventativeCare/ the Anticipatory Guidance for the Health Maintenance: Controlconsumption of phosphorus and food sodium of high proteins to meetthe needs of the patient.

ReflectionNotes-What I would do Differently: Depressioncheck: Refer to psychologist concerning depression to assist thepatient in managing his depression

Spinalstenosis: I would evaluate him for this and maybe recommend surgeryin future.

Syncope:Assess him to find out if there are signs of arrhythmias and anyepisodes of syncope.

Exercisesafety: Discuss the exercise safety with the patient to make surethat he is always safe.

References

Buttaro,T., Trybulski, J., Polgar, B., &amp Sandberg-Cook, J. (2013).Primarycare: The collaborative practice(4th ed., pp. 487-611). St. Louis, Mo.: Elsevier/Mosby.

Heart.org,AmericanHeart Association –Th Building healthier lives, free ofcardiovascular diseases and stroke.Retrieved 3 January 2016, from http://www.heart.org/HEARTORG/

NationalHeart Lung and Blood Institute, (2002). Primaryprevention of hypertension: The Clinical and the public healthadvisory from National High Blood Pressure Education Program.NationalHeart Lung and Blood Institute.Retrieved 3 January 2016, fromhttp://www.nhlbi.nih.gov/files/docs/resources/heart/pphbp.pdf

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