Soap Note Assignment | Buy assignments online
SOAP Note: Arterial Insufficiency
|Name: JH||Patient Encounter No: N/A|
|Date: 7/15/2018||Age: 69 yrs||Sex: Female|
|CC: “I feel pain when I walk, and there is a tingling sensation in my feet.”|
|HPI: JH was well until last week when she started to feel some tingling sensation in her feet. She ignored it, but it persisted until seven days ago when she experienced pain upon walking for 100 meters. The pain could relieve at rest. She never sought for any medical intervention thinking the problem would resolve, but it persisted until now three days ago when she felt pain and noticed slight swelling of her lower extremities. Currently, she experiences difficulties walking thus in need of treatment.|
|Medications: Propranolol, Benazepril, Lovastatin, and Metformin.|
Medication Intolerances: None.
Chronic diseases: Hypertension, Hyperlipidemia, and diabetes mellitus.
Major Trauma: None.
Surgical operations: Minor open and drainage three years ago.
Admissions: One time during the birth of her last born twenty years ago.
|Family History: Both parents died, the father due to a stroke and the mother due to breast cancer. All her siblings are alive and well.|
|Social History: She is a social drinker, and she smokes five cigarettes per day. She stays alone. Her three children rarely visit her as they are out of the state.|
|Review of Systems|
|General: Positive for weight gain, but she denies fever and chills.||Cardiovascular: Positive for edema and palpitations but denies orthopnea.|
|Skin: Positive for rashes and warmth on the lower extremities.||Respiratory: Denies wheezing and TB Hx.|
|Eyes: Positive for slight blurry in vision.||Gastrointestinal: Denies ulcers or constipation.|
|Ears: Denies hearing loss.||Genitourinary: Gravida 0 para IV. Denies nocturia. Positive for polyuria. At menopause. Last pap was done seven months ago. Denies vaginal discharge or other vaginal changes.|
|Nose/Mouth/Throat: Denies nosebleeds or sinusitis.||Musculoskeletal: Positive for warmth and slight swelling of edema of both knee joints. Positive for cramping, stiffness, and pain when walking.|
|Breast: Denies nodules.||Neurological: Denies seizures, faintness, or blackout spells.|
|Heme/Lymph/Endo: Positive for polyphagia.||Psychiatric: Positive for depression but denies anxiety.|
|Weight: 160 BMI: 26.6
Height: 5’ 5’’
|Pulse: 82||Temp: 98.7 F
|Resp: 18||BP: 135/85mmHg|
|Appearance: Alert and answers questions appropriately.|
|Skin: Bruised and warm on the right lower extremity.|
|Head: Atraumatic. Normocephalic. Ears: Gray TM and. Eyes: Adequate vision. Neck: No masses or lymphadenopathy. Mouth: No sores. Throat: No lesions. Nose: Pink. No bleeding.|
|Cardiovascular: Capillary refill of 4 seconds. Irregular heart rhythm. Pallor of the left foot and the redness of the left lower extremity noticed.|
|Respiratory: Slight wheeze. No Ronchi.|
|Gastrointestinal: Active BS and non-tender.|
|Breast: No dimpling.|
|Genitourinary: No lesions on vulvar, clear to cloudy drainage present, Well estrogenized.|
|Musculoskeletal: Knee swelling has been noticed. Limited ROM has been identified.|
|Neurological: She has a waddling gait but her balance is stable.|
|Psychiatric: Fully oriented.|
|Special Tests: None.|
1. Deep Venous Thrombosis (I82.401). There is pain in the right lower limb. A physical exam reveals its pallor, and it is warm. According to Endig, Michalski, and Beyer-Westendorf (2016), discoloration of the skin accompanied by pain and warmth may indicate DVT.
2. Superficial Thrombophlebitis (180.01). This patient may have this diagnosis given that she complains of pain in the right lower extremity. Physical examination reveals redness. These two symptoms are significant indicators of the diagnosis (Evans, & Ratchford, 2018).
3. Arthritis (M19.90). The patient complains of pain in the knees of both extremities. She experiences stiffness, and there is slight swelling of the knees upon physical examination. These symptoms are significant indicators of arthritis (Souza, Neta, Gazzola, & Souza, 2017).
Arterial Insufficiency (I73.9). The primary diagnosis, as per the provided information, is arterial insufficiency. Although the patient has other diagnoses such as obesity and diabetes mellitus, the main problem that brought her to the hospital is knee pain and leg swelling. When she walks for more than 100 meters; pain in her lower extremities increases. She also has intermittent occurrences of cramping in legs, especially in the right lower extremity. However, when she rests, the pain disappears. According to Aboyans et al. (2017), muscle pain that is triggered by activity in the extremities is an indicator of arterial insufficiency. Physical exam reveals weak to absent dorsalis pedis pulse in the right lower extremity. Blood tests show a cholesterol level of 270mg/dL. Arterial insufficiency occurs due to reduced blood flow, which occurs as a result of fat deposition in the arteries (Aboyans et al., 2017). In this case, the patient has a high cholesterol level that confirms fat deposition in the arteries. Thus, although she has other diagnoses, the primary focus of treatment is to manage arterial insufficiency.
Further testing: Doppler Ultrasound to evaluate blood flow
Medications: Medication administration has focused on managing symptoms and stopping the progression of the illness. Regarding the management of the symptoms, Aboyans et al. (2017) recommend pain relief. I this case, cilostazol has been given, and the patient will take 100mg twice a day by mouth for seven days. This drug will dilate blood vessels and reduce pain thus facilitating walking. According to Gerhard-Herman et al. (2017), reduced blood flow can cause clotting and exacerbate arterial insufficiency. For this reason, Plavix has been given, and the patient will take 75mg orally once a day for seven days to prevent blood clot thus facilitating recovery. The patient will combine these medications with metformin, propranolol, and benazepril that she is currently taking to manage diabetes and blood pressure.
Education: The patient has been told that diet contributes immensely to the development and progression of arterial insufficiency. Available evidence shows that physical activity and a balanced diet can improve the outcomes of patients with this diagnosis (Gerhard-Herman et al., 2017; Aboyans et al., 2017). Thus, she has been told to find time after pain relief to walk or jog so that she can achieve and maintain a healthy weight. She has also been advised to avoid eating foods with a high amount of salt to manage her blood pressure effectively. Much emphasis has been put on reduced alcohol intake, smoking cessation, and consumption of more fruits and vegetables to facilitate recovery.
Non-medication Treatments: She has been told to consume fiber and magnesium to accompany the food she consumes to facilitate a reduction of blood pressure.
Follow-up: The medications she has been given will be over by the seventh day. Therefore, she will come back seven days from now to get additional drugs. Additionally, she will be helped to make a regular exercise schedule, which will be significant in helping her to manage her weight.
Aboyans, V., Ricco, J. B., Bartelink, M. L. E., Björck, M., Brodmann, M., Cohnert, T., … & Espinola-Klein, C. (2017). 2017 ESC guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the European Society for Vascular Surgery (ESVS) Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries Endorsed by: The European Stroke Organization (ESO) The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular …. European Heart Journal, 39(9), 763-816. https://doi.org/10.1093/eurheartj/ehx095
Endig, H., Michalski, F., & Beyer-Westendorf, J. (2016). Deep vein thrombosis–Current management strategies. Clinical Medicine Insights: Therapeutics, 8, 1-10. doi: 10.4137/CMT.S18890
Evans, N. S., & Ratchford, E. V. (2018). Superficial vein thrombosis. Vascular Medicine, 23(2), 187-189. doi: 10.1177/1358863X18755928
Gerhard-Herman, M. D., Gornik, H. L., Barrett, C., Barshes, N. R., Corriere, M. A., Drachman, D. E., … & Misra, S. (2017). 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease: Executive summary: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology, 69(11), 1465-1508. doi: 10.1161/CIR.0000000000000471
Souza, I. F. D. S., Neta, O. R. S. D., Gazzola, J. M., & Souza, M. C. D. (2017). Elderly with knee osteoarthritis should perform nutritional assessment: Integrative literature review. Einstein (São Paulo), 15(2), 226-232. doi: 10.1590/S1679-45082017RW3834