Comprehensive Heart Failure SOAP Note

Comprehensive Heart Failure
Comprehensive Heart Failure

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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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