Discussion answer post A_B
critique the Soap note. Your critique should identify at least one positive and one area for future growth.
CC: I like to know about my recent EKG, had some chest pain last week, I have been ok since then.
HPI:
Mrs. W is a 60 y/o female Asian, who comes in for a follow-up of her EKG and hypertension (HTN). During her previous checkup, she had intermittent episodes of chest pain for the last three weeks and was prescribed an EKG. The pain is associated with physical exertion and not with shortness of breath or nausea/vomiting.
ROS: Mrs. W describes no fever, shudders, cough, stomach pain, urinary or bowel complaints. She describes no orthopnea. Denies any problem in neck, head, breast, Neuro, skin, or musculoskeletal.
Medical HX: Prediabetes, HTN, Headache,
Family HX: Mrs. W does not have any family history of major cardiac events.
Meds list: Her medication for hypertension includes atenolol 50 mg daily. Atorvastatin 10 mg po qd, Tylenol 500 mg po q 6 hrs PRN for mild pain.
Social HX: nonsmoker, no drug use.
Allergy: none
She and her husband has been sticking to a low-fat Mediterranean diet.
Assessment: Mrs. W is a 60 yrs old female, seeming younger than her declared age, well-nourished, well-kempt, AAO X4, negative JVD, Weight — 162lbs; height — 66 inches; BMI — ~ 27; pulse, O2 sat 97 on room air, lungs CTA Bilateral, anterior-posterior, symmetrical chest expand —HR 81; BP — 139/85. Temp 97.7, pain 0/10.
The EKG shows an asymptomatic trend of skip beats with Arterial flutter rhythm, has been seen for follow-up after an asymptomatic EKG stress test. A more specific cardiac enzyme test will be done and ordered by specialist.
Differential Dx:
#1. Possibility of coronary artery disease (CAD) and intermediate probability of ischemia, due to the aflutter rhythm.
#2. Hypertension, under control on atenolol since BP under 140/90.
#3. Cardiomyopathy: Needs more study to diagnose. Will f/U with echo ultrasound of heart, Pt has HTN, which is one of the causes of cardiomyopathy, uncontrolled irregular heartbeat. Cardiovascular diagnostic and screening tests such as an electrocardiogram (ECG or EKG) or echocardiogram (echo) yield a lot of essential information about various functions of the heart, including the electrical movement of the heart, heartbeat pace, the efficiency of blood pumping through the heart’s compartments and valves. The blood flow through the coronary arteries to the heart muscle, and the abnormalities in the structure of the cardiovascular system. If a patient is having symptoms of potential coronary disease, and the preliminary cardiac diagnostic tests reveal even slight abnormalities, the patient must take advanced diagnostic tests such as computed tomography angiography (CTA) or magnetic resonance angiography (MRA). From these scans, the problems of a blocked blood vessel, aneurysm, or other structural heart problems can be diagnosed, and the appropriate treatment procedure can be followed to cure the disease (Canty et al., 2012).
Treatment plan:
1. Metoprolol 50 mg po BID (betta blocker)
2. ASA 81 mg PO QD for prevention of blood clot forming, due to arrhythmia.
3. F/ U appointment in a month for routine labs, lipid profile, TSH, reevaluation for arrhythmia, effect of medications, the report from the cardiologist.
4. Referral to cardiology
5. Continue current medications
6. continue on a healthy diet, and life balance.
7. Exercise, daily, reduce stress levels.
8. Lipid profile lab today. evaluation of cholesterol level.
Based on the results of the cardiac diagnosis, treatment is recommended based on the type of heart disease. The low-risk heart issues, such as unbalanced rhythm, can be treated with home remedies and some medications. By following a strict diet plan and exercising for at least 30 minutes daily, the risk of heart disease can be reduced. However, more chronic issues such as continuous heart pain and contractions blocked blood artery, or heart’s valve blockage require medical procedures or surgery such as bypass graft surgery (Goel et al., 2021). Computed tomography angiography (CCTA) is recommended for additional risk stratification, in chronic cases of arrhythmia, if a conduction problem is the cause, cardiac ablation, or cardioversion might be advised by a cardiologist.
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