603 part 2 week 3 SOAP FEINBERG1

S: SUBJECTIVE DATA

Chief Complaint (CC): “my wife made me come, I feel fine”. Reports short of breath, heavy feeling in his chest, nausea, and sweaty

History of present illness (HPI): 60-year-old African American male reports chest heaviness, 3 days ago lasting approximately 3 minutes with no future episodes. Current pain 0/10. Aggravated by working out, relieved by resting. Associated symptoms SOB, nausea and diaphoresis. Reports feeling a little more tired and thinks this is because he has not worked out since this happened.

Past Medical History (PMH): Hypertension and elevated cholesterol managed by lifestyle changes. Reports general health good, recently started working out and lost weight. Reports feeling great until this episode 3 days ago. He reports feeling concerned because he feels more tired when he works out and has reduced strenuous running or working out since. Childhood illnesses: chicken pox. No current medications. Allergies: NKDA. Immunizations: up to date, does not take flu vaccine. Surgeries: T and A, Cholecystectomy, Vasectomy. Hospitalizations: None outside from the surgeries listed.

Denies prior blood transfusions.

Family History (FH): Parents are deceased. Mother died from complications of a stroke and father had lung cancer. Brother died at age 44 from malignant melanoma. Other brother and sister healthy.

Social History: Married for 20 years, works as an architect. Drinks a beer or glass of whiskey when playing poker and occasionally smokes a cigar.

ROS:

CONSTITUTIONAL: +Fatigue after chest pain episode 3 days ago, + recent intentional weight loss. Denies fever, chills, or weakness.

HEENT:  Eyes:  Denies pain, redness, dryness, visual changes or loss, blurred vision, double vision or yellow sclerae, denies corrective eye wear.

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Ears, Nose, Mouth, Throat:  No hearing loss, ringing in ears, epistaxis, sneezing, loss of smell, dry mucus membranes, post nasal drip, runny nose, bleeding gums, hoarseness, sore or pain in throat or jaw, or dysphasia.

CARDIOVASCULAR: + chest pain 3 days prior described as “heaviness”. Denies palpitations, irregular heart rate, orthopnea, murmurs, cramping in legs while walking, or edema.

RESPIRATORY: + shortness of breath during chest pain episode. Denies cough or sputum, nighttime waking with cough, wheezing or night sweats.

GASTROINTESTINTINAL: + Nausea, Denies decreased appetite, anorexia, vomiting, diarrhea. Denies change in bowel habits or blood noted in stool. Denies heartburn, indigestion, belching, abdominal pain, constipation.

GENITOURINARY: Denies dysuria or pain with urination blood in urine, cloudy urine, frequency, urgency, nocturia, genital ulcers, discharge, rashes, erectile dysfunction, sexual dysfunction, sexually transmitted dis

MUSCULOSKELETAL: Denies arm pain, muscle pain, joint pain or stiffness, or cramps. Denies difficulty with ROM, neck or back pain.

SKIN:  No rashes, lesions, bruising, redness, hives, pallor, sensitivity to sun exposure, nodules, itching, color changes in hands or feet, breast lumps, pain or gynecomastia.

NEUROLOGIC: Denies headache, dizziness, memory loss, syncope, muscle spasm, LOC, paralysis, ataxia, numbness or tingling in the extremities. Denies change in bowel or bladder control.

PSYCHIATRIC: Denies depression, mood disorders, anxiety or thoughts of suicide.

ENDOCRINE: + Diaphoresis with episode chest pain. Denies intolerance to hot or cold temperature, flushing, fingernail changes, polydipsia, polyuria, increased salt intake or decreased sexual desire.

HEMATOLOGIC/LYMPHATIC: Denies anemia, excessive bruising, bleeding tendency or clotting tendency. Denies enlarged nodes, history splenectomy.

ALLERGIC/IMMUNOLOGIC: Denies rhinitis, asthma, skin sensitivity, eczema, latex allergies or sensitivity.

0: OBJECTIVE DATA

Constitutional: African American male in NAD. Alert, oriented, and cooperative. Pain: 0/10 at present. Ht. 68″, Wt. 220 lbs. (100 kgs), BMI 33.5, BP 146/90, P 70, Sao2 97%

HEENT: Head normo-cephalic. Hair thick and distribution even throughout scalp. Eyes: Sclera clear. Conjunctiva: white, PERRLA, EOMs intact. No AV nicking noted. Ears: Tympanic membranes gray and intact with light reflex noted. Pinna and tragus non-tender. Nose: Nares patent without exudate. Sinuses non-tender to palpation, right-sided deviation. Throat: Oropharynx moist, no lesions or exudate. Teeth in poor repair, gums reddened and receding, filled cavities noted. Tongue smooth, pink, no lesions, protrudes in midline. Neck: supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses. Mild JVD in recumbent position.

CARDIOVASCULAR: Heart S1 and S2 noted, RRR, no murmurs noted. No parasternal lifts, heaves, and thrills. Peripheral pulses equally bilaterally. PMI 5th ICS displaced 4cm laterally. No edema in lower extremities.

RESPIRATORY: Lungs clear to auscultation bilaterally. Respirations unlabored. No rashes or vesicles noted on chest.

GASTROINTESTINTINAL: Abdomen round, soft, with bowel sounds noted in all four quadrants. No organomegaly noted.

GENITOURINARY: No abnormalities

MUSCULOSKELETAL:  No abnormalities

SKIN:  No rashes, lesions, bruising, redness, hives, pallor, sensitivity to sun exposure, nodules, itching, color changes in hands or feet, breast lumps, pain or gynecomastia.

NEUROLOGIC:  No abnormalities

PSYCHIATRIC:  No abnormalities

ENDOCRINE:  No abnormalities

HEMATOLOGIC/LYMPHATIC: No abnormalities

ALLERGIC/IMMUNOLOGIC: No abnormalities

Diagnostic testing: Lipid Panel from 3 months ago; TC 230, LDL 180, HDL 38. EKG in office shows ST depression in leads I, II, AVF, V5, and V6.

A: ASSESSMENT:

ACS – Ischemia heart disease (I24.9)- Larry’s presenting subjective findings of chest pain described as heaviness associated with shortness of breath, nausea, and diaphoresis that lasted about 3 mins with no further episodes. This is likely caused by partial or complete occlusion of a major or minor coronary artery, in this case, most likely related to atherosclerosis or cholesterol deposits within the artery wall (Smith, Negrelli, Manek, Hawes & Viera, 2015). With a history of hypertension, high cholesterol, obesity, and smoking which are modifiable risk factors that increase his risk of cardiovascular disease; as well as nonmodifiable risk factors including gender, and a family history of stroke in a first-degree relative (Cayla, Silvain, Collet, & Montalescot, 2015). Objective findings reveal JVD, hypertension at 146/90, PMI 5th ICS displaced 4cm laterally likely related to uncontrolled HTN, and diffuse ST depression in leads I, II, AVF, V2-V6 with ST-segment elevation in AVR to support the primary diagnosis of ACS – ischemic heart disease.  

Hyperlipidemia (E78.5)- Given Larry’s objective finding from his lipid panel three months ago showing HDL 38, LDL 180, Total Cholesterol of 230, he has hyperlipidemia. His calculated 10-year risk assessment score is 19.2%, he should be started on medication and implement lifestyle changes. High LDL levels greater than 130 in combination with total cholesterol levels of greater than 200 increases the risk of stroke and heart attack (Grundy et al., 2018).

Hypertension, essential (I10)- Larry is hypertensive based upon the JNC 8 guidelines as a 60-year-old male with an objective BP of 146/90. JNC 8’s treatment is guided by age, ethnicity, and comorbidities. Larry’s BP reading is 146/90 an according to JNC8, the goal for Larry is to maintain a BP of less than 150/90. Hypertension causes increased pressure in the arterial walls which can lead to stroke and heart attack (Carey & Whelton, 2018).

Obesity (E66.9)-Obesity is an excess of body fat manifested by body mass index (BMI) of 30 or higher in adults. Risk factors associated with obesity include sedentary lifestyle, excessive caloric intake, high fat diet, and environment. Based on the patient’s BMI of 33.5 he would be classified as obese (Garvey, 2018). Larry will need extensive lifestyle modifications to include diet and adequate exercise once cleared by cardiology, and through guidance of cardiac rehabilitation.

Periodontal disease, unspecified (K05.6)- Periodontitis is an infection that results in inflammation of the gums and surrounding tissue that can lead to progressive bone loss. Increased levels of inflammation have been noted in those with periodontitis and cardiovascular disease especially during acute phases. Periodontal disease and dental infections have been shown to contribute to factors associated with cardiovascular disease (Stephens, Wiedemer, & Kushner, 2018).

P: PLAN

Rx:

Aspirin 325mg non-enteric coated ASA chewable tablet. Sig: take 1 tab by mouth (PO) now. Dispense #1 Refills: 0 (Amsterdam et al., 2014)

Medications beneficial to treat Larry include the treatment of ACS, hypertension, and dyslipidemia at the time of discharge:

Metoprolol 50mg tablet, SIG: take 1 tab by mouth (PO) twice daily, dispense #60, Refills: 0. (Amsterdam et al., 2014)

Lisinopril 10mg, SIG: 1 tab by mouth (PO) once daily, Dispense #30, Refills: 0

(Amsterdam et al., 2014)

Atorvastatin 10mg tablet, SIG: take 1 tab by mouth (PO) daily at hour of sleep, dispense #30, Refills: 0. (Amsterdam et al., 2014)

Aspirin 81mg tablet, SIG: 1 tablet by mouth (PO) daily, dispense #30, Refills: 0. (Amsterdam et al., 2014)

Nitroglycerin 0.3mg tablet, Sig: 1 tab SL as needed for chest pain that does not stop within 5 minutes. May use 1 every 5 minutes up to 3 tabs. Call 9-1-1 or go to ED if use more than 1 tab. Dispense 6, Refills: 0

(Amsterdam et al., 2014)

Additional diagnostic tests (to be done in Emergency Department):

Repeat EKG

Serial cardiac troponin enzymes q3-6h x 2

BNP

Lipid profile

Additional tests (CBC, HgbA1C, CMP, EKG, CXR, echocardiogram) that may be ordered at discretion of Cardiologist

(Amsterdam et al., 2014)

Education:

Patient informed of his diagnosis and urgent need to go to emergency department immediately for further evaluation and monitoring. Brief explanation of diagnostic tests, possible treatments and anticipated discharge medications, along with potential side effects provided (Amsterdam et al., 2014).

Instructed to call 9-1-1 for CP, SOB, nausea, vomiting, syncope, sweating, irregular heartbeats, if they occur after discharge from ED (Amsterdam et al., 2014).

May take 1 tab nitroglycerin SL q 5mins x 3 for CP that does not resolve after 1 minute. Call 9-1-1 if two or more doses are needed (Amsterdam et al., 2014).

Patient will follow-up with cardiology. Informed patient that the cardiologist will order cardiac rehabilitation and might adjust medications (Amsterdam et al., 2014). Informed patient that I will be in touch with cardiologist to coordinate care.

Follow-up with primary care after cardiology appointment to recheck blood pressure, review response to medications and coordinate care (Amsterdam et al., 2014).

Pneumococcal and influenza vaccine administration planned at follow-up visit if no contraindications at that time (Amsterdam et al., 2014).

Dietary, physical activity, and smoking lifestyle modifications to reduce cardiac risk factors will be reviewed at follow-up visit (Amsterdam et al., 2014).

Dental health hygiene education

Referrals:

ED now (Amsterdam et al., 2014).

Cardiology consultation now and ongoing for continued management (Amsterdam et al., 2014).

Dental referral for periodontal disease care (Stephens, Wiedemer, & Kushner, 2018)

Follow-Up:

Cardiology within 1 week of discharge from ED or hospital (Amsterdam et al., 2014).

Primary care provider in 2 weeks to assess BP, response to medications, healthcare maintenance such as immunizations, screenings, and any adverse medication effects (Carey & Whelton, 2018).

References

Amsterdam, E. A., Wenger, N. K., Brindis, R. G., Casey, D. E., Ganiats, T. G., Holmes, D. R. . . . Zieman, S. J. (2014. AHA/ACC guidelines for the management of patients with non-ST-elevation acute coronary syndromes: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 64(24), 2645-2687. doi: 10.1016/j.jacc.2014.09.016

Carey, R. M., & Whelton, P. K. (2018). Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Synopsis of the 2017 American College of Cardiology/American Heart Association Hypertension Guideline. Annals of Internal Medicine, 168(5), 351–358. doi: 10.7326/M17-3203

Garvey, W. T. (2018). The diagnosis and evaluation of patients with obesity. Current Opinion in Endocrine and Metabolic Research,1-8. doi:10.1016/j.coemr.2018.10.001

Grundy, S. M., Stone, N. J., Bailey, A. L., Beam, C., Birtcher, K. K., Bumenthal, R. S., Braun, L. T. . . . Yeboah, J. (2018). AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: A report of the Aermcian College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. DOI: 10.1161/CIR.0000000000000624.

Smith, J. N., Negrelli, J. M., Manek, M. B., Hawes, E. M. & Viera, A. J. (2015). Diagnosis and management of acute coronary syndrome: An evidence-based update. Journal of the American Board of Family Medicine, 28(2), 283-293. doi: 10.3122/jabfm.2015.02.140189

Stephens, M. B., Wiedemer, J. P., & Kushner, G. M. (2018.). Dental Problems in Primary Care. AMERICAN FAMILY PHYSICIAN, 98(11), 654–660. Retrieved from

Dental health has been shown to contribute to factors associated with cardiovascular disease. The link is thought to be infection; in those with poor dental hygiene and cavities; as the infection/inflammation progresses it results in inflammation of the gums and surrounding tissue that can lead to a progressive bone loss. Increased levels of inflammation have been noted in those with periodontitis and cardiovascular disease especially during acute phases (Ghobadi, 2018). There is also an increased risk of developing infective endocarditis from oral bacteria. Larry is a smoker and has reddened receding gums with multiple dental caries noted. Larry should make an appointment as soon as possible to see a dentist. He should also be educated on good oral hygiene, smoking cessation, and the need for routine dental check-ups (Ghobadi, 2018).  

Medication education should include how and when to taking medications, side effects, proper storage, and importance of adhering to dosing schedule. Low blood pressure can occur with these medications he should know that dizziness, drowsiness, GI disturbances, dry mouth, and decreased heart rate can occur. He should report these symptoms immediately or seek emergency treatment. Also, he should report muscle cramps or pain as this can be related to electrolyte imbalances.

Referrals Larry should be seen by a cardiologist and a dentist.

Follow up. I plan to see him back in 2-4 weeks following cardiology visit or sooner if symptoms worsen. We will go over his treatment plan and evaluate medication compliance and effects. At that time, follow up blood work to include fasting blood glucose level, Hgb A1c, CBC, CMP, LFT, and UA to check for the efficacy of the prescribed medications. Management should be individualized to each patient to ensure compliance with treatment plan. Noncompliance leads to morbidity, unnecessary hospital admissions, and can reduce life expectancy. This is a problem as practitioners we should be aware of and educate and assist patients in removing these barriers to compliance (i.e., cost, side effects, or complex regimens). By using educational programs and support groups this can help patients that may be struggling with their diagnosis.

Reference

ACC/AHA ASCVD Risk Calculator. (2018.). Retrieved March 7, 2018, from  to an external site.)Links to an external site.Amakali, K. (2015).  Clinical care for the patient with heart failure: A nursing care perspective. Cardiovascular Pharmacology, 4 (142). DOI: 10.4172/2329-6607.1000142

Amsterdam, E. A., Wenger, N. K., Brindis, R. G., Casey, D. E., Ganiats, T. G., Holmes, D. R., . . . Zieman, S. J. (2014). 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: Executive summary. Journal of the American College of Cardiology, 64(24), 2645-2687. doi:

Arcangelo, V. P., & Peterson, A. M. (2013). Pharmacotherapeutics for advanced practice: a practical approach (3rd ed.). Philadelphia: Wolters Kluwer.

Armstrong, C. (2018). High Blood Pressure: ACC/AHA Releases Updated Guideline. American Family Physician, 97(6), 413-415.

Armstrong, C. (2014). JNC8 guidelines for the management of hypertension in adults. American Family Physician, 90(7), 503-504.

Cayla, G., Silvain, J., Collet, J., & Montalescot, G. (2015). Updates and current recommendations for the management of patients with non-ST-elevation acute coronary syndromes: What it means for clinical practice. The American Journal of Cardiology, 115(5), 10A-22A. doi:

Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., Thomas, D. J. (02/2015). Primary Care The Art and Science of Advanced Practice Nursing, 4th Edition. [Bookshelf Online]. Retrieved from  to an external site.)Links to an external site.Edmunds, M. W., & Mayhew, M. S. (2014). Pharmacology for the primary care provider (4th ed.). Retrieved from

Gander, J., Sui, X., Hazlett, L. J., Cai, B., H?bert, J. R., & Blair, S. N. (2014). Factors related to coronary heart disease risk among men: Validation of the Framingham Risk Score. Preventing Chronic Disease, 11 (140). Retrieved from:  to an external site.)Links to an external site.Ghobadi, N. (2018). Investigation of periodontal infections and its relation with cardiovascular diseases. Middle East Journal Of Family Medicine, 16(2), 341. doi:10.5742/MEWFM.2018.93282

Karr, S. (2017). Epidemiology and management of hyperlipidemia. American Journal of Managed Care, 23(9), S139-S148.

Kotecha, T., & Rakhit, R. D. (2016). Acute coronary syndromes. Clinical Medicine, 16s43-s48.

Trentman, T. L., Avey, S. G., & Ramakrishna, H. (2016). Current and emerging treatments for hypercholesterolemia: A focus on statins and proprotein convertase subtilisin/kexin Type 9 inhibitors for perioperative clinicians. Journal of Anesthesiology, Clinical Pharmacology, 32(4), 440-445. doi:10.4103/0970-9185.194773

Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Himmelfarb, C. D., . . . Wright, J. T. (2017). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Hypertension. doi:10.1161/hyp.0000000000000065

Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Colvin, M. M., . . . Westlake, C. (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. doi:10.1016/j.jacc.2017.04.025

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