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Comprehensive Heart Failure SOAP Note
Patient Initials: ______Mrs S. H._ Age: _57 Years______ Gender: __ Female_____
SUBJECTIVE DATA: \
Chief Complaint (CC): “I have been experiencing shortness of breath and fatigue in the last two weeks.”
History of Present Illness (HPI): Patient complains of shortness of breath, and general fatigue. Patient has been experiencing swelling of the feet and has been having difficulty in completing tasks that she would normally.
Medications: Synthroid 100mcg daily, Lisinopril 10 mg daily and Metoprolol 25 mg daily
Allergies: None
Past Medical History (PMH): measles at age 3, mumps at age 4
Past Surgical History (PSH): None
Family history;
Father died at age 65 y/o due to CAD.
Mother 70 y/o, alive diagnosed with hypertension
Brother (35) alive and healthy
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Personal and Social History:
She is born and raised in this community. She is a college graduate with a diploma in business management. She works as an assistant in one of healthcare facilities within the community. She lives with her daughter. She interacts with the community members. Pt denies smoking, but takes a lot of salt. The pt takes two cups of caffeine. Pt states that she is physically inactive.
Review of Systems:
HEENT: EOMI, PERRL,
CV: RRR, S3 present, m/r/g absent
RESP: breathing symmetrical, SOB, CTAB x mild crackles
ABD- NABS, Palpable masses absent, s/nt/nd, HSMeg absent
MS: 5/5 strength
NEURO: Normal sensation to stimuli, normal gait, DTRs 2/4, Patellar and brachiorad
PSYCH: Congruent mood and appropriate
OBJECTIVE DATA:
t 98.9, HR 87, RR15, BP 114/69 Height 5’3 , weight 270ibs BMI 47.8
Gen: A&O X 3
HEENT: EOMI, PERRL,
CV: RRR, S3 present, m/r/g absent
RESP: breathing symmetrical, SOB, CTAB x mild crackles
ABD- NABS, Palpable masses absent, s/nt/nd, HSMeg absent
MS: 5/5 strength
NEURO: Normal sensation to stimuli, normal gait, DTRs 2/4, Patellar and brachiorad
PSYCH: Congruent mood and appropriate
Labs: CBC, BMP
Imaging: CT
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ASSESSMENT:
Differential diagnosis (Dains, Bauman, and Scheibel, 2012):
a) Congestive heart failure
Due to elevated blood pressure, swelling of the extremities and shortness of
b) Asthma
Due to shortness of breathe, but not likely because patient denies history of asthma.
c) COPD exacerbation
Due to shortness of breath and general body weakness, but not likely because patient does not complain of productive cough.
d) Pneumonia
Due to shortness of breath and general body weakness, but not likely because patient denies chills, fever or coughs.
Final diagnoses: Congestive heart failure
This is because the patient experiences edema, and dyspnea and shortness of breath.
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Plan:
Therapeutic intervention
Simvastatin 20 mg once a day
Lisinopril 25 mg once daily -continue
Metformin 1000 mg two times a day
Metoprolol 25 mg once a day
Loratadine 10mg one times daily
Glimepiride 4 mg one times daily
Follow up in two weeks
Non therapeutic interventions
Lifestyle modification – reduced sodium chloride intake, caffeinated drinks, alcohol, clean eating, and physical activeness
Health promotion
Mammogram
Cervical screening test
Health prevention
Healthy dietary is recommended to boost the immune system
Maintain hygiene to protect themselves from communicable diseases.
Reflections
Congestive heart failure (CHF) is the leading cause for hospitalization in this community. There is no cure of the disease, but can effectively be managed through therapeutic and non-pharmacological measures (Esposito, Bagchi, and Verdier, 2009). My preceptor and I were on the same page in during care delivery and treatment of this pt. From the comprehensive assessment, I learnt that the patient was non-compliant to medication.I was assigned to research on the strategic ways that would be used to educate the patient and to ensure that she adhered to the recommended medication (Bickley, 2013
References ‘
Bickley, I.S. (2013). Bates Guide to physical examination and history taking .Wolters Kluwer/Lippincott Williams&Wilkins.
Esposito, D., Bagchi, A., Verdier, J.M. (2009). Medicaid beneficiaries with congestive heart failure: Association of medication adherence with healthcare use and costs. The American journal of managed care 15(7); 437-445
Dains, J.E., Bauman, L.C., Scheibel, P. (2012). Advanced Health Assessment and Clinical Diagnosis in Primary Care.
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