Skip to document
Welcome to StudocuSign in to access the best study resources
Guest user
0followers
Upload
HomeMy LibraryAsk AI
  • You don't have any recent items yet.
My Library
  • You don't have any courses yet.
  • You don't have any books yet.
  • You don't have any Studylists yet.

Shadow Health – Chest Pain (Brian Foster) with SOAP 2 (F)

N/A
Course

Advanced Pathophysiology (NUR 7610900)

4 Documents
Students shared 4 documents in this course
Academic year: 2022/2023
Uploaded by:
Anonymous Student
This document has been uploaded by a student, just like you, who decided to remain anonymous.
University of St. Augustine for Health Sciences

Comments

Please sign in or register to post comments.

Students also viewed

Related documents

Related Studylists

SOAPIES

Preview text

SOAP Note: Chest Pain SUBJECTIVE: Chief Complaint: The patient complains of chest pain. History of present illness: The patient BF is a 66-year-old female with a history of diabetes and hypertension, both of which are well controlled. The patient has been experiencing chest pains for months. She feels states that she first began by feeling squeezing in her chest followed by pressure below her sternum when going up the stairs in her house and therefore often taken to sleeping downstairs in the guest bedroom. BF states that the pressure in her chest usually resolves itself after roughly 5 to 10 minutes of rest. The patient also states that she occasionally feels the stated sensations during stressful periods at work as she runs her own consultancy. In such instances, the feeling is accompanied by pain in her jaw and mild nausea. She takes aspirin, metformin, and enalapril. BF, being an elderly individual has nonpleuritic, chronic chest pain accompanied by risk factors for coronary heart disease. The patient’s symptoms can be seen to be consistent with stable angina. In this particular case, the pivotal points are the exertional nature, the chronicity, and the location of the pain. Because of the seriousness of coronary heart disease and its prevalence, it is important to generate a differential diagnosis. Chest pain may also be a function of musculoskeletal disorders and Gastroesophageal reflux disease (GERD). Both diseases result in chest pain that could mimic angina including sensations of pressure and exacerbation by physical activity and should therefore be considered as well. The fact that the symptoms are chronic argues

against other diseases that are similarly serious including aortic dissection, pericarditis and pneumothorax. The pain could also be from a mediastinal abnormality. PMH: Past Medical History: BF reports hypertension, which was diagnosed at the age of 57. She also suffers from diabetes. Past Surgical History: The patient reports having had a caesarian section at the age of 28. She also had a cholecystectomy at 45. BF has not had any complications resulting from surgery. Accidents/Injuries: The patient reports that she has not had any accidents nor injuries prior to her visit. Hospitalizations: BF did not provide any account of recent. FH: The patient’s mother died at the age of 91 having had a history of Type II diabetes and hypertension as well. BF’s father is also deceased. He died at the age of 85 and a history of hypertension and hypercholesterolemia. The patient’s maternal grandparents are also deceased and had a history of coronary heart disease and Type II diabetes. Her paternal grandparents are deceased with a history of obesity, CVA, and also hypertension. Both of the patient’s sisters are alive with the oldest being 73-years-old and with a history of hypertension. The younger sister is 69-years-old and has a history of hypercholesterolemia and hypertension. BF has two sons both of whom have not been diagnosed with any medical conditions. Social History (detailed):

Gyn: The patient states she was experiencing no change in menses, no dysmenorrheal, no vaginal discharge, no pelvic pain, and no amenorrhea/menopause. Musculoskeletal: She has no pain in muscles or joints, and no paresthesias or numbness. Neurologic: BF experiences no weakness and no changes in sensation. Psychiatric: She has no depressive symptoms and no changes in sleep habits. The patient denies the thought of hurting himself or others. Skin: Patient is with no complaints of rashes or lesions. OBJECTIVE: Vitals: Blood pressure 113/78, O² sat 99%, pulse 91, respirations 18, temperature 36 C. General: BF was an edgy and flushed, appearing older woman. She appeared a bit distressed and was smirking at times. Patient was obese. She experienced no distress during the assessment. HEENT: Cardiovascular: S1, S2, no murmurs, gallops, or rubs. No S3 and S4. Skin: Moist, mucous membranes, normal skin turgor, no tenting. No lower extremity edema. Respiratory: The client’s breathing was quiet and unlabored. She could construct full sentences and her respiration was clear to auscultation. Abdominal: 6 cm scar in RUQ and 10 cm scar at the midline in the suprapubic region. An abdominal assessment revealed no discoloration and bowel sounds were normoactive in all quadrants; no bruits; no friction sounds over spleen or liver; tympany presides with scattered dullness over LLQ; abdomen soft in all quadrants. No masses were noted in the LLQ; no organomegaly; no CVA tenderness; the liver span of 7 cm at MCL and no hernias. Rectal: no hemorrhoids, fissures, or ulceration; strong sphincter tone, fecal mass in the rectal vault. Pelvic: no inflammation or irritation of the vulva, abnormal discharge, bleeding, masses or growth, or tenderness upon palpation. Urinalysis: Urine was clear, dark yellow with a normal odor. No nitrites, WBCs, RBCs, or ketones detected; pH 6, SG 1. LABS:

No labs available to review at this time TEST: None to review at this time Differential Diagnoses: Stable angina Musculoskeletal disorders Gastro esophageal reflux disease (GERD). ASSESSMENT: The diagnosis of stable angina is often determined through:  ECG: Normal when the patient was at rest or when she was pain-free. T wave inversions or depressions of the ST segment signifies ischemia. No Dysthymias or heart block was present.  24-hour ECG monitoring (Holter): Showed that the pain episodes correlate with activity.  Exercise or pharmacological stress electrocardiography: The test will provide more diagnostic information for example the level and duration of activity that is attained before the onset of angina.  Cardiac enzymes (AST, CPK, CK, and CK-MB; LDH and isoenzymes LD1, LD2): Within normal limits. Elevation would reveal myocardial damage  Chest X-ray: Usually normal but may show infiltrates that reflect pulmonary complications or decompensating.  Pco2, potassium, and myocardial lactate: Levels may be elevated during an anginal attack

 The patient was recently diagnosed with Type II diabetes which she has been controlling with sliding scale insulin.  We will obtain a hemoglobin A1C so as to understand how the patient’s blood sugar has behaved over the previous 3 months.

References Balla, C., Pavasini, R., & Ferrari, R. (2018). Treatment of angina: where are we?. Cardiology, 140(1), 52-67. Stone, G. W., Ellis, S. G., Gori, T., Metzger, D. C., Stein, B., Erickson, M., ... & ABSORB IV Investigators. (2018). Blinded outcomes and angina assessment of coronary bioresorbable scaffolds: 30-day and 1-year results from the ABSORB IV randomized trial. The Lancet, 392(10157), 1530-1540.

Was this document helpful?

Shadow Health – Chest Pain (Brian Foster) with SOAP 2 (F)

Course: Advanced Pathophysiology (NUR 7610900)

4 Documents
Students shared 4 documents in this course

University: University of St. Augustine for Health Sciences

Was this document helpful?
1
SOAP Note: Chest Pain
SUBJECTIVE:
Chief Complaint: The patient complains of chest pain.
History of present illness:
The patient BF is a 66-year-old female with a history of diabetes and hypertension, both of which
are well controlled. The patient has been experiencing chest pains for months. She feels states
that she first began by feeling squeezing in her chest followed by pressure below her sternum
when going up the stairs in her house and therefore often taken to sleeping downstairs in the
guest bedroom. BF states that the pressure in her chest usually resolves itself after roughly 5 to 10
minutes of rest. The patient also states that she occasionally feels the stated sensations during
stressful periods at work as she runs her own consultancy. In such instances, the feeling is
accompanied by pain in her jaw and mild nausea. She takes aspirin, metformin, and enalapril.
BF, being an elderly individual has nonpleuritic, chronic chest pain accompanied by risk factors
for coronary heart disease. The patient’s symptoms can be seen to be consistent with stable
angina. In this particular case, the pivotal points are the exertional nature, the chronicity, and the
location of the pain. Because of the seriousness of coronary heart disease and its prevalence, it is
important to generate a differential diagnosis. Chest pain may also be a function of
musculoskeletal disorders and Gastroesophageal reflux disease (GERD). Both diseases result in
chest pain that could mimic angina including sensations of pressure and exacerbation by physical
activity and should therefore be considered as well. The fact that the symptoms are chronic argues
1

Students also viewed

Related documents