Comprehensive Heart Failure SOAP Note

Comprehensive Heart Failure
Comprehensive Heart Failure

Want help to write your Essay or Assignments? Click here

Comprehensive Heart Failure SOAP Note

Patient Initials: ______Mrs S. H._             Age: _57 Years______                               Gender: __ Female_____


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

Want help to write your Essay or Assignments? Click here

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:


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


t 98.9, HR 87, RR15, BP 114/69 Height 5’3 , weight  270ibs BMI  47.8

Gen: A&O X 3


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

Want help to write your Essay or Assignments? Click here


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.

Want help to write your Essay or Assignments? Click here


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


Cervical screening test

Health prevention

 Healthy dietary is recommended to boost the immune system

Maintain hygiene to protect themselves from communicable diseases.


  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.

Want help to write your Essay or Assignments? Click here

Acute Tonsilitis SOAP Note

Acute Tonsilitis
Acute Tonsilitis

Want help to write your Essay or Assignments? Click here

Acute Tonsilitis

Subjective Data:

Name: J.W. Date: 2/27/2016 Time: 
Case ID #: 8008-20164545-015 Age: 35 years old Sex: Female

CC: Patient feels sick, with multiple symptoms including skin rash, fever, headache, pain in swallowing, sore throat, abdominal pain, nausea and vomiting.


The patient is a 35 year old female who presented to the clinic on Saturday, complaining that she has been feeling sharp pain in her abdomen and severe headache. She also notes that she has been experiencing the following symptoms sore throat, pain when swallowing food and nausea plus vomiting.

Patient is accompanied by her 15 year old daughter and 42 year old husband, who bring her to the clinic. J.W. further notes that she has fever and the symptoms began about three days ago, with the sore throat setting in suddenly. This is the first incident that the patient reports to the clinic. The patient notes that she took acetaminophen to relieve the fever and headache, but she decided to consult further treatment once she developed a skin rash.

Medications Currently in Use: Acetaminophen

Past Medical History

Allergies: Allergic to sulfa containing compounds. Had complications after using sulfonamides

Medication Intolerances: Intolerant to sulfonamides and generally sulfa containing drugs

Chronic Illnesses/Major traumas: no major illness/traumas
Hospitalizations/Surgeries: No surgical history recorded; hospitalized once due to pneumonia infection
Family History: No family history recorded on major illnesses; patient’s mum in good health

Want help to write your Essay or Assignments? Click here

Social History

Patient is a casual laborer living with her daughter and husband, plus her 54 year old mum. She takes her lunch from a local cafeteria, but cooks breakfast and supper at her home when she arrives from job in the evening. Her mum helps her cook food, but rarely when she is not present, ill or too tired to cook.

The patient states that she started to suspect food from the cafeteria after a change in management about a month ago. However, she continued to take lunch at the same place, but notes quality had significantly dropped. Also, she had heard a complaint from a regular customer, John, that the food was making him bloat his stomach two weeks ago though the condition disappeared without him attending to hospital.

Review of Systems

Positive for fever: No Cardiovascular symptoms. This time she was using acetaminophen
Denies chest pain, palpitations, PND, orthopnea, edema

Has a history of hx pneumonia but negative at the time of admission

Only reports for pain in her abdomen

Denies bruising, delayed healing, bleeding or skin discolorations. Has no lesion changes or moles but presents with a skin rash

Patient denies cough, breathing regular and symmetrical.

Denies eye discharge, no blurred vision, sees clearly without any aid

Reports pain in the abdomen

Denies pain in ears has no ear discharge, hearing loss, or ringing in ears.


 Denies concerns

Positive for sore throat

Denies concerns

Negative history

Denies syncope, seizures, transient paralysis, weakness, paresthesia, black out spells

Psychological: Denies depression, suicidal thoughts, irritability,
sleep disturbances, and anxiety

HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance Psychiatric
Denies concerns 

Want help to write your Essay or Assignments? Click here

Objective Data

Physical exam is done in the clinic, after which the patient is sent for a lab test out of the clinic. Case is suspected to be upper respiratory bacterial infection particularly streptococcal infection. The following data is recorded from the physical exam;

Vital Signs

Weight 125 BMI 20.7 Temp 101 BP 120/80
Height 170 Pulse 80 Resp 24

General Appearance
Constitutional marked as unremarkable: well developed: well nourished; no acute distress. Vital signs also noted as within acceptable limits. Patient dehydrated. General impression: A&Ox3, nicely dressed, appear appropriate, restless but cooperative, complains of chronic pain in the abdomen and headache

Skin is black, warm, dry, clean and intact. No lesions noted upon examination. Scarlatiniform rashes noted
Head is normocephalic, atraumatic and without lesions; hair evenly distributed. 

Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection.

Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. 

Nose: Nasal mucosa pink; normal turbinates. No septal deviation. 

Neck: Supple. Full ROM. 

Pharynx redness or exudates over the tonsils noted plus erythema. Beefy red swollen uvula: Anterior cervical Adenitis and Soft Palate Petechiae noted. Teeth and gums are however unremarkable

Want help to write your Essay or Assignments? Click here

S1, S2 with regular rate and rhythm. Heart location and apex is normal. No murmurs; no rubs, gallops, or click; femoral pulses normal.

Respiratory unremarkable; respiratory rate and pattern normal; lungs clear to auscultation bilaterally.

Abdomen is soft, non tender and non-distended. No palpable masses. Liver and spleen normal; no hernias; normal bowel sounds, no bloating, only pain in the abdomen noted 

Chest/breast unremarkable, no masses palpitated, no redness

Bladder is non-distended, no UTI present

Full ROM seen in all 4 extremities as patient moved about the exam room.

Speech is clear, Good tone plus Posture erect. Balance is stable; gait normal.

Want help to write your Essay or Assignments? Click here


Diagnostics & Lab Tests

Throat smear culture and blood specimen used

Incubation of the culture done for 48 hours before test

The suspected case is streptococcal infection by S. pyogenes or GAS

Positive rapid streptococcal test

Positive results for Antistreptolysin O test

Special Tests

Latex agglutination immunoassay test positive

Want help to write your Essay or Assignments? Click here

Assessment Findings and Plan


Patient confirmed to be having Group A Beta hemolytic Streptococcal infection, related acute pharyngitis and acute tonsilitis


Penicillin V 500 mg tid for daily 10 days or Amoxicillin 500 mg tid for 10 days

Continue with Acetaminophen till fever completely subsidizes

Amoxicillin is a substitute in the event the patient reports to be allergic to Penicillin

Drugs to be taken orally and in full dosage given by a pharmacist

There are no generic substitutes available


 Advice patient to take the following measures:

Use OTC acetaminophen only for fever if relapsing occurs

Wash hands well with soap and water after using bathroom or before eating

Rinse food well and cook properly before eating

Drink water that has been purified or filtered only

Not to smoke or drink alcohol before medication is over and tests negative for GAS

If possible carry packed lunch or change the place she takes lunch from

Want help to write your Essay or Assignments? Click here

Further Notes:

The likely cause of the GAS infection is food from the cafeteria that the patient takes lunch. This, she should refrain from consuming food from the place to avoid a recurrence of the infection. High hygiene standards must be maintained to ensure zero infections to the members of her household, who include her daughter, husband and mum. Also, if convenient to her report the matter concerning the low quality food being sold at the cafeteria to public health offices, for further investigation.

Follow up Schedule

The patient is advised to report to the clinic after a week, for assessment of dosage coverage and progression of the illness. This is to ensure she completes the dosages of all medications in order to eliminate all GAS in her system and avoid development of antibiotic resistance to the Penicillin V given, which results from an incomplete dosage. In this regard, the patient should be advised strongly on the importance of completing her medications, with two follow up meetings being scheduled after a week each.

Want help to write your Essay or Assignments? Click here

Evaluation and Revisions:

The subjective and objective data was collected accordingly but the diagnostics did not cover all possible infections. Since the above are confirmatory of GAS infection, as the cause of the acute pharyngitis and acute tonsillitis, there was deemed no need to conduct tests for other upper respiratory bacteria on the cultures.

This is not only to eliminate the chances of it being a multiple infection case, but also to dictate the medicine given. This revision is necessary alongside a confirmation from the patient concerning her status in connection penicillin allergy, which should dictate the type of antibiotic given. This should be handled accordingly by the pharmacist addressing the prescription.

Metronidazole, Trimethoprim, Tetracyclines and flouroquinolones should not be used for the following reasons. Metronidazole is not effective against S. pyogenes while the patient is allergic to sulfa compounds hence Trimethoprim is contraindicated.

On the other hand, Tetracyclines pose a very high susceptibility to resistance by the bacterial species, that is GAS. Finally, Flouroquinolones are very expensive and have an unnecessary broad spectrum of activity, hence a more specific antibiotic is necessary including the above named plus Azithromycin, Clarithromycin, Clindamycin and various Cephalosporins.  


Anjos, L. M. M., Marcondes, M. B., Lima, M. F., Mondelli, A. L., & Okoshi, M. P. (2014). Streptococcal acute pharyngitis. Revista da Sociedade Brasileira de Medicina Tropical, 47(4), 409-413.

Camara, M., Dieng, A., & Boye, C. S. B. (2013). Antibiotic susceptibility of streptococcus pyogenes isolated from respiratory tract infections in dakar, senegal. Microbiology insights, 6, 71.

John, L. J., Cherian, M., Sreedharan, J., & Cherian, T. (2014). Patterns of Antimicrobial therapy in acute tonsillitis: A cross-sectional Hospital-based study from UAE. Anais da Academia Brasileira de Ciências, 86(1), 451-457.

Spinks, A., Glasziou, P. P., & Del Mar, C. B. (2013). Antibiotics for sore throat. Cochrane Database Syst Rev, 11.

Want help to write your Essay or Assignments? Click here

SOAP Note for a Patient with; Ectopic Pregnancy

Ectopic Pregnancy
Ectopic Pregnancy

Want help to write your Essay or Assignments? Click here

SOAP Note for a Patient with; Ectopic Pregnancy


A 30-year-old female, gravid 1, para1+0.The patient complained of abdominal pain in the right adnexal area which was generalized. She complained of dizziness, light headedness, and syncope. She experienced abnormal uterine bleeding for three days. She had not undergone and gynecological operation and had been on folic and iron supplements. Her menarche was at the age of 14years. Her menses were regular and used to last for 5days and occurred every 28days.The patient had used hormonal implant for three years and had been removed three months ago. She had not received her menses for two months. She was sexually active and had post-coital bleeding. She used to take alcohol on a regular basis.


The patient was sick looking and was groaning in pain.On palpation, there was generalised abdominal tenderness, and unilateral adnexal mass was present on the right hypochondria. Her vital signs were; Temperature -36.7degrees Celsius, blood pressure-98/56 mm/Hg, pulse-50beats/min. On bimanual examination, there was cervical motion tenderness. Her Serum HCG levels were 4500 IU/l; a trans-vaginal Ultrasound revealed a tubal mass in absence of intrauterine gestational sac.


  • Ectopic pregnancy which leads to acute abdominal pain and bleeding (Marion & Meeks, 2012).
  • Ovarian torsion resulting in localized lower abdominal pain radiating to the back or thigh  and nausea and vomiting

A  Urinary tract infection leading to lower abdominal pain and dysuria and increased micturition

  • Appendicitis presenting with guarding abdominal pain and nausea and vomiting. Diagnosis of ectopic pregnancy was made due to the acute abdominal pain, associated bleeding, and increased βhCG levels


The overall goal of management was to preserve the life of the mother, and this was managed through termination of pregnancy and reconstruction of the implantation site. The patient was given a bed rest ensure that she had reduced activity (Marion & Meeks, 2012). The patient was cannulated and started on intravenous fluids to restore the fluid volume deficit. Blood samples for the laboratory were obtained. Relaxation techniques were used to relieve pain.

Want help to write your Essay or Assignments? Click here

Medical management

The patient was put on intramuscular methotrexate. Methotrexate is a folic acid antagonist which deters cell division. The products of conception degenerates and detaches from the uterus leading to death (Epee-Bekima & Overton, 2013). Viability of the cytotrobhoblast is prevented together with β-hCG secretion (Wright, Busbridge & Gard, 2013).

Surgical management

Laparoscopic salpingectomy was considered to be the primary treatment of the ectopic pregnancy. Salpingectomy was conducted so as to repair the ruptured fallopian tube (Marion & Meeks, 2012).

Alternative management

Expectant management, the ectopic pregnancy could be waited to resolve on its own. However, this would be followed by β-hCG measurement and trans-vaginal ultrasound to confirm whether the disorder has resolved (Epee-Bekima & Overton, 2013).


The patient was advised to visit the clinic after 3-4 weeks for b-hCG measurement and ultrasonography. The patient was also advised on early pregnancy clinic visits.

Reflection notes

Patient involvement: I would carefully advise my patient of the advantage associated with any of the treatment approaches and ensure she fully participates in the selection of the mode of therapy. The use of laparoscopy could be used so as to come up with the diagnosis so as to minimize use of Surgery is the primary form of treatment. In addition to that, a less surgical procedure such as laparoscopic approach would have been used since it is associated with minimal intra-operative blood loss and hospital stay.


Epee-Bekima, M., & Overton, C. (2013). Diagnosis and treatment of ectopic pregnancy. The Practitioner, 257(1759), 15-18.

Marion, L. L., & Meeks, G. R. (2012). Ectopic pregnancy: history, incidence, epidemiology, and risk factors. Clinical obstetrics and gynecology, 55(2), 376-386.

Mergenthal, M. C., Senapati, S., Zee, J., Allen-Taylor, L., Whittaker, P. G., Takacs, P., … & Barnhart, K. T. (2016). Medical management of ectopic pregnancy with single-dose and 2-dose methotrexate protocols human chorionic gonadotropin trends and patient outcomes. American Journal of Obstetrics and Gynecology.

Practice Committee of the American Society for Reproductive Medicine. (2013). Medical treatment of ectopic pregnancy: a committee opinion. Fertility and Sterility, 100(3), 638-644.

Wright, S. D., Busbridge, R. C., & Gard, G. B. (2013). A conservative and fertility-preserving treatment for interstitial ectopic pregnancy. Australian and New Zealand Journal of Obstetrics and Gynaecology, 53(2), 211-213.

Want help to write your Essay or Assignments? Click here