A 60 year old woman with angina is prescribed 135mg VerapamilA 60 year old woman with angina is pres

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A 60 year old woman with angina is prescribed 135mg Verapamil

A 60 year old woman with angina is prescribed 135mg Verapamil

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Soap Note on Patient with Angina

  Houston Baptist University   (Acct #3170)  Case ID #: 1735-20231030-001   (Status: Pending)Date of Encounter: 10/30/2023 Student Information Semester:Fall SemesterCourse:Advanced Health AssessmentPreceptor: Clinical Site:Setting Type:Underserved area/population

Patient Demographics

Age:65 yearsBiological Sex:FemaleRace:CaucasianInsurance:MedicareReferral:Referred by her primary care physicianClinical InformationTime with Patient:45 minutesConsult with Preceptor:NoType of Decision-Making:Moderate complexityStudent Participation:Shared (50-50)Reason for Visit:Follow-upChief Complaint:The patient has multiple ongoing health issuesEncounter #:2Type of HP:ComprehensiveSocial Problems Addressed:NoneICD-10 Diagnosis Codes#1 –I20.9 – Unstable Angina#2 –E78.0 – Pure Hypercholesterolemia#3 –J44.9 – Chronic Obstructive Pulmonary Disease, UnspecifiedCPT Billing Codes#1 –99214 – Office or other outpatient visit for the evaluation and management of an established patient, moderate complexity, 25 minutesMedications# OTC Drugs taken regularly:0# Prescriptions currently prescribed:3# New/Refilled Prescriptions This Visit:2Types of New/Refilled Prescriptions This Visit:
Cardiovascular – Aspirin 81mg daily

Pulmonology – Albuterol inhaler PRN

Atorvastatin 20 mg OD

Adherence Issues with Medications:
The patient reports difficulty remembering to take medications as prescribed.Other Questions About This CasePeds Age Range:Age Range:Adults (19 or older)Clinical NotesDate: 10/16/2023

Time: 9:30 am

Vital Signs: Height: 5’5?, Weight: 160 lbs, Temp: 98.1°F, B/P: 148/80 mm Hg, Pulse: 75 bpm, Respiratory rate: 19 breaths per minute

Subjective  

History of Present Illness symptoms: Ms. Smith, a 65-year-old Caucasian female, presented for a follow-up appointment with a history of unstable angina, characterized by recurring chest pain, shortness of breath, and fatigue, and concerns about its increased frequency. She also has a diagnosis of pure hypercholesterolemia, managing it with occasional concerns about statin-related muscle aches. Additionally, she reported ongoing respiratory difficulties due to her chronic obstructive pulmonary disease (COPD), including nighttime shortness of breath and occasional forgetfulness in using her prescribed albuterol inhaler. These comorbidities have significantly impacted her daily life, and she is motivated to improve her management strategies for better symptom control and quality of life.

Current Medications:  Aspirin 81mg daily, orally; Albuterol inhaler PRN; Atorvastatin 20 mg OD orally

Medication allergies: NKDA

Social History: She is married, has a family, and is currently not working, likely retired, as there is no mention of occupation. She is an immigrant from Mexico, which may have cultural and language implications for her healthcare. She reports no alcohol consumption, smoking, or illegal drug use, and her hobbies and exercise routines are not detailed, possibly suggesting limited leisure activities. Her social history highlights her familial and cultural background, as well as her lack of engagement in certain health-risk behaviors.

Family History: Ms. Smith’s family history reveals a significant cardiovascular risk on her paternal side, with her father experiencing a heart attack and her paternal grandfather suffering from a stroke. On her maternal side, there’s a history of type 2 diabetes, as her mother and maternal grandmother both had the condition. Additionally, there is a family history of cancer, with her paternal aunt having breast cancer and her mother’s sister being diagnosed with ovarian cancer.

Review of systems:

General: The client is obese and presents with difficulties in breathing and abnormal heart sounds.

Eyes:  She is myopic and uses eye aids

Ears:  Reports tinnitus in her right ear

Nose:  Denies any nose conditions

Mouth/Throat: She cannot remember the last time she visited a dentist. She has lost two of her teeth in the upper jaw.

Cardiovascular: Reports chest pain and palpitations. There is easy fatiguability with minimal exertion or activity

Respiratory:  Reports difficulties in breathing, shortness of breath, cough, and wheezing

Gastrointestinal: Denies stomach pain. No recent stomach upsets.

Genitourinary: Reports frequent urination, with no pain on urination

Musculoskeletal:  Reports pain in the right leg joints

Skin:  Denies skin rashes or any skin conditions

Breasts: Denies breast pain or discharge

Neurological: Reports intermittent mild headaches

Psychiatric:  Denies depression anxiety, reports trouble sleeping

Endocrine:  Denies thyroid disease and heat intolerance.

Objective

General: The client is cooperative and talkative

Skin:  Dry skin, warm, no scars visible

Hair: Dry, well-groomed

Nails:  Nails are cut short and well-kempt

HEENT:

Head: Normocephalic and atraumatic noted

Eyes: No discharge, redness, or abnormalities observed

Ears: shape bilateral equal, no inflammation, tympanic membranes pearly grey, poor external hygiene

Teeth/Gums: Two missing teeth visualized in the upper jaw

Pharynx: Mucosa non-inflamed, posterior pharynx is normal

Neck:  No lesions observed. No distended veins were noted.

Heart: There is an apparent murmur heard.

Lungs: Wheezing, rhonchi, and decreased lung sounds auscultated.

Abdomen:  Regular bowel movements are heard on all the four quadrants

Back: The patient has kyphosis

Rectal:  Not examined

Extremities:  Edema noted on the right lower limb

Musculoskeletal:  Normal range of motion, no misalignment

Neurologic:  Alert and oriented x 3, normoreflexia

Psychiatric: The patient is in a euthymic mood

Pelvic:  Not examined

Breast: No masses, discharge, or abnormalities noted

Assessment:

Recurring chest pain

Shortness of breath

Fatigue

ICD-10 Codes

I20.9 – UNSTABLE ANGINA

E78.0 – PURE HYPERCHOLESTEROLEMIA

J44.9 – CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED

CPT Codes:

99203 – OFFICE/OP VISIT, NEW PT, MEDICALLY APPROPRIATE HX/EXAM; MODERATE LEVEL MED DECISION; 30-44 MIN

Plan:

Regularly monitor vital signs, including blood pressure, heart rate, and oxygen saturation, to assess the patient’s cardiovascular and respiratory status.

Conduct lipid profile tests and adjust statin therapy as necessary to achieve target cholesterol levels.

Assess respiratory function with pulmonary function tests (spirometry) to guide COPD treatment decisions.

Ensure patient adherence to prescribed medications, including antiplatelet agents, bronchodilators, and statins.

Educate the patient on recognizing angina and COPD exacerbation symptoms and encourage lifestyle modifications.

Periodically conduct blood tests to assess liver function, creatinine levels, and inflammatory markers to monitor the patient’s overall health and treatment safety.

Follow-up:

Follow up in two weeks to discuss lab results and review medications in case adjustments are needed.

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Solution: