Case 4
Work on a two SOAP notes. One SOAP note per day.
Day 1:
Patient Details:
·
Age: 79 years and 65 kg
·
Gender: Male
·
Medical History:
· Hypertension (well-controlled)
· History of smoking (20 pack-years)
·
Home medications:
· Lisinopril 40 mg PO QD
Presenting Symptoms:
The patient presented to the emergency department with severe chest pain (rated 9/10 on the pain scale), radiating to the left arm, associated with shortness of breath and nausea. He appeared anxious and diaphoretic.
Initial Examination:
·
BP: 85/50 mmHg
·
HR: 112 bpm
·
RR: 28 breaths/min
·
Oxygen saturation: 92% on room air
·
Temperature: 37.2°C
·
Heart Sounds: S1, S2 normal; no murmurs
·
Lung Sounds: clear
·
Extremities: Cool, clammy, and edematous with peripheral cyanosis
ECG Findings:
·
ST Elevation in leads II, III, aVF, and V1-V4, consistent with
Inferior + Anterior STEMI.
Significant Labs:
·
Troponin I: > 1000 ng/L
·
Creatinine: 1.8 mg/dL
Day 4:
The patient became progressively hypotensive. ECG showed rapid atrial fibrillation with a ventricular rate of 140 bpm. Patient has been having orthopnea and difficulty breathing since day 2. Increased jugular venous distension (JVD) was noted.
Vital signs:
·
BP: 124/90 mmHg
·
HR: 135 bpm
·
RR: 26 breaths/min
Significant Labs:
·
Creatinine: 2.4 mg/dL
·
BNP: 1324 pg/mL (elevated, suggestive of heart failure)
Chest X-Ray:
· Lungs: Bilateral rales at the bases
CT pulmonary angiogram:
· was performed after the patient developed sudden hypoxemia, and it revealed a pulmonary embolism (PE) affecting the right lung
