shortnessofbreathandlegswelingSOAP_Note.docx

Running head: SHORTNESS OF BREATH AND LEG SWELLING SOAP NOTE 1
SHORTNESS OF BREATH AND LEG SWELLING SOAP NOTE 2

Shortness of Breath and Leg Swelling SOAP Note
Student’s name
Instructor
Course
Date

Name: Mrs. J

Pt. Encounter Number: 759

Date: 15/10/20

Age: 67

Sex: Female

SUBJECTIVE

CC:
“shortness of breath and swollen leg”

HPI:
Mrs. J visited the facility with complaints of a chest that has persisted from the last 3 days. The pain intensity is 9/10. The pain is accompanied with shortness of breath and coughing up a bloody sputum. His right leg is swollen. The pain is coming from his right calf. The pain is under no medication to relieving his pain.

Medications: He has not taken any medicines to relieve his condition.

PMH

Allergies: NKDA

Medication Intolerances: Not any

Chronic Illnesses/Major traumas: Not any

Hospitalizations/Surgeries: Not any

Family History
Not disclosed by family

Social History
living with her husband and 3 children after going for the retirement. She smokes 3 packs of cigars every day.

ROS

General
She looks composed and cooperative. She is neat and alert.

Cardiovascular
Positive for edema and erythema to R. lower extremity; PND, orthopnea.

Skin
intact, cool and sweaty

Respiratory
Negative: difficulty in breathing, wheezing, and shortness of breath

Eyes
Parent reports no concern. Reports no drainage or issues with the eyes, states patient is able to follow objects.

Gastrointestinal
Negative for abdominal pain, diarrhea, vomiting and nausea.

Ears
Patient responds clearly to sound

Genitourinary/Gynecological
No burning sensation when urinating

Nose/Mouth/Throat
Parent denies any cough, runny nose, or any cold symptoms

Musculoskeletal
Negative: stiffness, joint pain, back pain, no muscle pain.

Breast
no nipple abnormality, axillary or supraclavicular adenopathy, tenderness to palpation, dominant masses.

Neurological
Negative: ataxia, paralysis, syncope, dizziness, numbness or tingling in the extremities, or headache. No change in bowel or bladder control.

Heme/Lymph/Endo
Stated absence of bruising, bleeding or anemia. Negative: splenectomy history or enlarged nodes.

Psychiatric
Negative: anxiety, depression.

OBJECTIVE

Weight 210lbs BMI 24.8

Temp 98.4

BP 148/88

Height 5’6’

Pulse

Resp 32

General Appearance
Pt is alert and oriented x4 and appears diaphoretic and anxious

Skin
Skin is clean and intact. Dry and wet. No lesions or rashes.

HEENT
Head: normocephalic, symmetric, and atraumatic. There is no presence of hernia around the neck and the trachea.
Eye: non-inflamed eyes. The covering of the eye is bilaterally aligned with the eyelids.
Ears: the absence of exudation. The ear is bilaterally aligned with side appearance. Both the skin and the ear look healthy.
Nose: no presence of lesions. The mucous membrane is moist and pink.
Throat: front sinus and maxillary are tender to palpation. The gap response is sensitive. Both tongue and uvula lie in the middle line—no exudating tonsils. Mucus is scant and thick.

Cardiovascular
Absence of murmurs, S3 and S4. Normal rhythm, S1 and S2.

Respiratory
Respirations even and unlabored. No wheezes, rhonchi or rales on auscultation. No cough. Normal contour of chest, good expansion and symmetry.

Gastrointestinal
All his 4 quadrants have positive bowel sound. It is soft with masses on palpation.

Breast
no nipple abnormality, axillary or supraclavicular adenopathy, tenderness to palpation, dominant masses.

Genitourinary
No CVA tenderness noted; bladder is palpable and non-distended.

Musculoskeletal
Her spine exam is normal. Hip exam normal with no clicks. All extremities moving equally.

Neurological
no abnormal reflexes, normal motor development and tone.

Psychiatric
She provides correct and desired answers to the questions. Very pleasant with any conversation, denies anxiety.

Lab Tests

EKG indicates tachycardia chest x-ray,

Special Tests
None

Diagnosis

Differential diagnosis

1. Chronic Obstructive Pulmonary Disease (COPD): Patients at risk for COPD have dyspnea with or without exertion, chronic cough with or without mucous production or wheezing; diagnosis based on history and physical, spirometry, those who are smokers (Anderson & Morrow, 2017). This diagnosis would be ruled out because the patient is not a smoker.
2. Deep Vein thrombosis (DVT)— DVT occurs when clotted blood hinders blood flow occurring deep in the calf or thigh (McCarthy et al., 2015). According to McCarthy et al. (2015), DVT usually occurs near venous valves and develops from clotting factor buildups such as thrombin, fibrin, and platelets. DVT manifests as swelling, pain, and redness to the leg’s back, and sometimes it may be asymptomatic (McCarthy et al., 2015). DVT can be identified by performing the Homan’s sign, where the calf discomfort is caused by ankle dorsiflexion with the knee extended (McCarthy et al., 2015). Diagnosis can also be made by performing a physical assessment, medical history, and venous Doppler and serum D-dimer lab testing (McCarthy et al., 2015). During the physical exam, Mr. H displayed unilateral right calf with 2+ edema, erythema, warmth, tenderness on palpation noted; left lower extremity without edema, erythema; 2+ dorsalis pedis pulses bilaterally which is concurrent which a diagnosis of DVT. His D-dimer was also positive, which further validates the diagnosis of DVT.
3. Myocardial Infarction– According to Waheed, Kudaravalli & Hotwagner (2020), a MI occurs when coronary blood flow to the heart is interrupted, which leads to tissue necrosis. The blockage is most often caused by fat, cholesterol, and other substances (Waheed, Kudaravalli & Hotwagner, 2020). An MI manifestation includes chest pain and tightness that may radiate to the neck, jaw, shoulder, shortness of breath, fatigue, cold sweat, and lightheadedness (Waheed, Kudaravalli & Hotwagner, 2020). The patient is experiencing shortness of breath, fatigue, and chest pain, which he doesn’t report radiate to any other body parts. The EKG does not reveal an ST-elevation, which is seen in patients suffering from MI. So, a MI diagnosis is possible but unlikely.

PLAN including:
· Further testing – none
· Medication – 1. “Albuterol 5mg NEB x 1 dose now (CPT 94640)”
2. Altace taken to manage renal artery stenosis or if hypovolemia is present with a daily dosage of 2.5mg PO; and/or1.25mg PO.
· Education – Complete entire medication as directed by the physician.
Mr. J was educated on the importance of adhering to prescribed medicines and that her symptoms will clear in the first week. She will follow-up with the primary care doctor and book an appointment in case the symptoms persist.
· Nonmedication treatments – avoid smoking as much as possible since it will trigger breathing difficulty problems. She should be getting her yearly influenza vaccination. Exercising your legs either after a long journey with a plane, care, or other means of transport. Avoid smoking.
· Follow-up – Doctor’s appointment should be conducted in the emergency department.

Evaluation of patient encounter

I had a productive and successful encounter with the patient. The patient’s CC was adequately addressed.

References
Anderson, J. L., & Morrow, D. A. (2017). Acute myocardial infarction. New England Journal of Medicine, 376(21), 2053-2064.
McCarthy, B., Casey, D., Devane, D., Murphy, K., Murphy, E., & Lacasse, Y. (2015). Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane database of systematic reviews, (2).
Waheed, S. M., Kudaravalli, P., & Hotwagner, D. T. (2020). Deep Vein Thrombosis (DVT). StatPearls [Internet].

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