Description
Soap note and History and physical of Unstable Angina
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Main Diagnosis: Chronic Atrial Fibrillation
Name
Institution
Course
Instructor
Date
2
Main Diagnosis: Chronic Atrial Fibrillation
Patient Initials: J.P.
Age: 63 Years
Gender: Male
Allergies: No history of known allergies
Current Medications:
o Digoxin 0.125mg PO daily to enhance heart rate control
o Furosemide 40mg PO daily to improve fluid management
o Metoprolol 50mg PO BID to enhance heart rate control
o Warfarin 5mg PO daily to ensure anticoagulation
PMH:
o Chronic Atrial Fibrillation
o Stage-3 Chronic Kidney Disease
o Hyperlipidemia
o Type-2 diabetes
o Hypertension
Immunizations: Immunized with pneumonia and influenza vaccine up to date
Surgical History:
o Arthroscopic knee surgery in 2017
o Cholecystectomy in 2019
Family History:
o The mother was diagnosed with hypertension three years ago, and she is under treatment.
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o His father was diagnosed with myocardial infarction two years ago and is on medications.
o None within the family has an atrial fibrillation history.
Social History: J.P. lives in Maryland with her wife. He was a high school teacher but retired
three years ago. He does not smoke or drink alcohol. HE rarely engaged in physical exercise. He
eats any food he comes across, including healthy and unhealthy foods. His hobby involves
watching TV programs and reading newspapers. He has three grown-up children but lives away
from their parents for job purposes. He has never been exposed to a substance that might harm
his health. He is social and likes socializing with people. When watching or reading newspapers,
he takes the precaution of using glasses to protect his eyes from excessive light.
Subjective Data:
Chief Complaint: “I have been experiencing shortness of breath and palpitations for more than a
year.”
HPI: J.P., a 63-year-old Caucasian male patient, presented to a clinic complaining of shortness
of breath and palpitations for more than a year. He claims that the condition started gradually and
worsened with time. Although the condition mainly affects his chest, his entire body is also
affected since he sometimes develops fatigue. This condition mostly occurs when the patient
engages in any activity, especially during the day, and relieves at rest. He also reports to be
experiencing lightheadedness and chest pain in addition to palpitations and shortness of breath.
He claims that these symptoms are sometimes so severe to the extent that they interfere with his
normal way of daily functioning.
Review of Systems:
o General: He admits to fatigue but no weight loss or fever
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o HEENT: He denies headaches and dizziness, blurred vision and double vision, tinnitus
and ear pain, runny nose and nasal congestion, as well as voice hoarseness and sore
throat.
o Lungs: He denies wheezing, coughing, and sneezing.
o Cardiovascular: He admits to shortness of breath and palpitations.
o GI: He denies abdominal pain, vomiting, and nausea.
o GU: He admits to increased urinary frequency, urinary incontinence, and urinary
urgency.
o Neuro: He denies changes in coordination, numbness, and weakness.
o Psychosocial: He admits to being social with occasional stress but no changes in mood.
o Derm: He denies lesions and skin rashes.
Objective Data
Physical Exam:
o Vital signs: Blood pressure of 131/81mmHg, respiratory rate of 17 breaths/min, heart
rate of 110-130bpm, temperature of 98.8°F, height of 5’2”, and weight of 180lbs
o General: He appears to be well-nourished and well-developed
o HEENT: Head: His head is atraumatic. Eyes: Pupils are reactive to light and equal.
Ears: The auditory canal is clear with a translucent tympanic membrane. Nose: Septum is
midline with no signs of abrasions or nose bleeds. Throat: The throat is pink and moist
with no signs of abnormalities.
o Neck: Neck is supple with no enlarged thyroid or distention of the jugular vein
o Pulmonary: Breathing sounds are bilaterally clear.
o Cardiovascular: He has irregular heartbeats and rhythm.
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o Abdomen: His abdomen is soft and non-tender with no organomegaly signs.
o Auscultation: He has normal bowel sounds on auscultations.
o Musculoskeletal: He displays the full range of motion
o Derm: No evidence of lesions or rashes on the skin
Assessment
Differential Diagnoses
Chronic Atrial Fibrillation (ICD-10: I48.2): This refers to a persistent and long-term
period of rapid and irregular heartbeats. This occurs when there is no coordination of the heart’s
upper and lower chambers. This condition is considered to be chronic when it occurs persistently
for more than 12 months (Ding et al., 2021). This condition’s most common signs and symptoms
include fatigue, shortness of breath, lightheadedness, and palpitations. This is likely the possible
diagnosis for J.P. because he experiences all the mentioned signs and symptoms.
Heart Failure Exacerbations (ICD-10: I50.9): This refers to episodes of heart failure
flare-ups. Heart failure mostly develops when the heart fails to pump blood normally, leading to
various signs and symptoms, such as difficulty exercising, fatigue, shortness of breath, and fluid
retention (Halatchev et al., 2022). This condition is usually associated with several factors, such
as dietary issues, medication non-compliance, and uncontrolled hypertension. The only aspect
that makes this condition an unlikely diagnosis is that it occurs in episodes, but J.P. experiences
the symptoms persistently.
Anxiety-Related Palpitations (ICD-10: F41.0): This refers to a condition characterized
by irregular and rapid heartbeats associated with heightened stress and anxiety. An individual
with this condition experiences palpitations described as rapid, pounding, and fluttering
heartbeat. It is also characterized by shortness of breath and fatigue (Govender et al., 2022).
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Although J.P. experiences palpitations, fatigue, and shortness of breath, they are not associated
with heightened stress and anxiety, and therefore this is unlikely the primary diagnosis.
Main Diagnosis: Chronic Atrial Fibrillation as evidenced by the signs and symptoms.
Plan:
Pharmacological and Non-Pharmacological
o Reduce digoxin dosage to improve heart rate control
o Use cardioversion of antiarrhythmic medications as a strategy to control heart rhythm
o Ensure that the patient’s chronic kidney disease is well managed through monitoring
renal function
o Review and adjust anticoagulation therapy involving warfarin
o Schedule a follow-up appointment after two weeks for reassessment and medication
adjustments
Education:
o Educate the patient about the need for medication adherence
o Educate the patient on healthy lifestyle such as regular physical exercise and hearthealthy diet
o Inform the patient about severe symptoms that require immediate medical attention.
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References
Ding, W. Y., Gupta, D., Wong, C. F., & Lip, G. Y. (2021). Pathophysiology of atrial fibrillation
and chronic kidney disease. Cardiovascular Research, 117(4), 1046-1059.
https://doi.org/10.1093/cvr/cvaa258
Govender, I., Nashed, K. K., Rangiah, S., Okeke, S., & Maphasha, O. M. (2022). Palpitations:
Evaluation and management by primary care practitioners. South African Family
Practice, 64(1), 5449. 10.1001/jama.2022.22744
Halatchev, I. G., Wu, W. C., Heidenreich, P. A., Djukic, E., Balasubramanian, S., Ohlms, K. B.,
& McDonald, J. R. (2021). Inpatient versus outpatient intravenous diuresis for the acute
exacerbation of chronic heart failure. IJC Heart & Vasculature, 36, 100860.
https://doi.org/10.1016/j.ijcha.2021.100860
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History and Physical
Name
Institution
Course
Instructor
Date
2
History and Physical
Date of Encounter: 23/01/2024
Patient Initials: J.P.
Age: 63 Years
Gender: Male
Chief Complaint: “I have been experiencing shortness of breath and palpitations for more than a
year.”
HPI: J.P., a 63-year-old Caucasian male patient, presented to a clinic complaining of shortness
of breath and palpitations for more than a year. He claims that the condition started gradually and
worsened with time. Although the condition mainly affects his chest, his entire body is also
affected since he sometimes develops fatigue. This condition mostly occurs when the patient
engages in any activity, especially during the day, and relieves at rest. He also reports to be
experiencing lightheadedness and chest pain in addition to palpitations and shortness of breath.
He claims that these symptoms are sometimes so severe to the extent that they interfere with his
normal way of daily functioning.
Allergies: No history of known allergies
Current Perception of Health: Good
PMH:
o Chronic Atrial Fibrillation
o Stage-3 Chronic Kidney Disease
o Hyperlipidemia
o Type-2 diabetes
o Hypertension
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Hospitalization: The patient has never been hospitalized
Current Medications:
o Digoxin 0.125mg PO daily to enhance heart rate control
o Furosemide 40mg PO daily to improve fluid management
o Metoprolol 50mg PO BID to enhance heart rate control
o Warfarin 5mg PO daily to ensure anticoagulation
Family History:
o The mother was diagnosed with hypertension three years ago, and she is under treatment.
o His father was diagnosed with myocardial infarction two years ago and is on medications.
o None within the family has an atrial fibrillation history.
Social History: J.P. lives in Maryland with her wife. He was a high school teacher but retired
three years ago. He does not smoke or drink alcohol. HE rarely engaged in physical exercise. He
eats any food he comes across, including healthy and unhealthy foods. His hobby involves
watching TV programs and reading newspapers. He has three grown-up children but lives away
from their parents for job purposes. He has never been exposed to a substance that might harm
his health. He is social and likes socializing with people. When watching or reading newspapers,
he takes the precaution of using glasses to protect his eyes from excessive light.
Review of Systems:
o General: He admits to fatigue but no weight loss or fever
o HEENT: He denies headaches and dizziness, blurred vision and double vision, tinnitus
and ear pain, runny nose and nasal congestion, as well as voice hoarseness and sore
throat.
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o Lungs: He denies wheezing, coughing, and sneezing.
o Cardiovascular: He admits to shortness of breath and palpitations.
o GI: He denies abdominal pain, vomiting, and nausea.
o GU: He admits to increased urinary frequency, urinary incontinence, and urinary
urgency.
o Neuro: He denies changes in coordination, numbness, and weakness.
o Psychosocial: He admits to being social with occasional stress but no changes in mood.
o Derm: He denies lesions and skin rashes.
Physical Exam
o Vital signs: Blood pressure of 131/81mmHg, respiratory rate of 17 breaths/min, heart
rate of 110-130bpm, temperature of 98.8°F, height of 5’2”, and weight of 180lbs
o General: He appears to be well-nourished and well-developed
o HEENT: Head: His head is atraumatic. Eyes: Pupils are reactive to light and equal.
Ears: The auditory canal is clear with a translucent tympanic membrane. Nose: Septum is
midline with no signs of abrasions or nose bleeds. Throat: The throat is pink and moist
with no signs of abnormalities.
o Neck: Neck is supple with no enlarged thyroid or distention of the jugular vein
o Pulmonary: Breathing sounds are bilaterally clear.
o Cardiovascular: He has irregular heartbeats and rhythm.
o Abdomen: His abdomen is soft and non-tender with no organomegaly signs.
o Auscultation: He has normal bowel sounds on auscultations.
o Musculoskeletal: He displays the full range of motion
o Derm: No evidence of lesions or rashes on the skin
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Assessment (Differential Diagnoses)
o Chronic Atrial Fibrillation (ICD-10: I48.2)
o Heart Failure Exacerbations (ICD-10: I50.9)
o Anxiety-Related Palpitations (ICD-10: F41.0)
Plan
o Reduce digoxin dosage to improve heart rate control
o Use cardioversion of antiarrhythmic medications as a strategy to control heart rhythm
o Ensure that the patient’s chronic kidney disease is well managed through monitoring
renal function
o Review and adjust anticoagulation therapy involving warfarin
o Educate the patient about the need for medication adherence
o Educate the patient on healthy lifestyle such as regular physical exercise and hearthealthy diet
o Schedule a follow-up appointment after two weeks for reassessment and medication
adjustments
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