SOAP NOTE 3 MONTHS LATER:

S:  Patient is seen three months after last visit.  At her last visit her only problem was that of mild infrequent short lasting episodes of weakness.  EKG, and labs were all normal at the time except for a slight bradycardia.  Patient declined further work up and has reported no interim problems until three days ago.  She states three days ago that she notices swelling in her legs and problems sleeping.  She wakes with shortness of breath feeling a little panicked feeling.  She gets better when she sits up for a few minutes.  She states she is compliant with all of her medications.

      Atenolol 25 mg tab, one p.o. b.i.d.

• Isosorbide dinitrate 20mg tab, one p.o. q day.
• Lasix 20 mg tab, one p.o. q day.
• NTG .4 SL tabs prn.  (No use)
• ASA 325 mg tab, one p.o. q day.

Tylenol 325 mg tab, one or two p.o. q 8 hours prn.  (Uses about one or two per day for knee pains.)

O:  Temp:  35.0            Pulse: 46            Resp: 28            BP:  188/96            Weight: 195 pounds

Alert, in moderate distress, obviously short of breath, mildly anxious.

HEENT:  PERRL, EOMI, TMs negative, oral pharynx negative, neck supple, thyroid non palpable.

CV:  Heart regular.  S-3 present, no S-4, no murmur, +JVD

Lungs:  Crackles in the lower one half of the posterior fields.

Abdomen:  Soft with normal bowel sounds.

GU/Rectal: normal examination

Neuro:  CN II-XII intact, Motor intact, sensation intact, coordination intact, Babinski not present bilaterally, Negative Rhomberg, Gait normal but slow.

Extremeties:  pitting edema to mid tibia present bilaterally.

Labs and other tests:

EKG:  Third degree heart block

Electrolytes, glucose, and LFTs all normal

CBC normal

CXR:  cardiomegally, Kerly’s B lines present, small bilateral pleural effusions.

0xygen saturation 91% on room air.

A:             CHF – Acute secondary to bradycardia

            S/P MI

            DJD history           

• Admit, Rule out MI labs, serial EKGs, add ACE inhibitor, Loop diuretics, oxygen therapy, Evaluation for pacemaker, Monitor, ICU, see admit orders on hospital record.

POST HOSPITAL SOAP NOTE

S:  Patient is seen one week post hospitalization for CHF secondary to bradycardia.  MI was ruled out.  While hospitalized patient was diuresed, and a pacemaker was placed.  Patients response to the pacemaker was significant.  She was released after 5 hospital days in satisfactory condition with a weight of 183 pounds and no edema.  Her Oxygen saturation at discharge was 97% on room air.  Since being at home she has been compliant with medications and is feeling well.  No chest pain/PND/Orthopnea.  No edema.  No shortness of breath.  Her ability to exercise is back to her baseline.  No cough/hemoptysis.  GI review negative.

Patient notes that the addition of the new medication, Enalapril, is cost prohibitive and wonders what she might do about it.  She did purchase it, but would like to know if there is a less expensive alternative.

When asked how she’s doing with all of her medications she says it’s difficult because her husband is becoming quite a task to take care of.  She says that he used to be the “keeper of the medications” but with his prostate cancer treatments, and COPD problems he can’t help her much anymore, and in fact she has to help him with her medications.  Her daughter she says has always been very helpful, but notes that this is becoming a problem as well.  She says her daughter looks exhausted coming over to the house all of the time taking care of her and her husband.  She thinks this is because her daughter is such a good mother and has her own kids to take care of and on top of it works part time.  She believes she and her husband get most of their medications most of the time, but she says it’s exhausting getting through all of the chores of the day.  She’s thought about hiring someone to come and help, but when she looked into it the cost was more per hour than her husband used to make in a week when he was younger.  She is a bit tearful talking about all of this. 

Medications: 

Enalapril 5mg tab, one p.o. q day.

Atenolol 25 mg tab, one p.o. q day.

• Isosorbide dinitrate 40mg tab, one p.o. q day.
• Lasix 40 mg tab, one p.o. q day.
• KCL – 20 mEq, p.o. q day
• NTG .4 SL tabs prn.  (No use)
• ASA 325 mg tab, one p.o. q day.

Tylenol 325 mg tab, one or two p.o. q 8 hours prn.  (Uses about one or two per day for knee pains.)

O:  Afebrile, HR 72 and regular, BP 138/72, Respiratory rate 18, weight 186 pounds

Alert, in no acute distress

HRRR, no S-3, no S-4, No murmur, No gallup, No rub

Lungs – mild reduction in breath sounds.  No crackles, rales, rhonchi, wheeze.

NBS

No edema

Neuro exam non focal.

Mental status exam:  Dress in the past has been very fastidious.  She has a couple of small difficult to see food stains on her sweater today – this is a change for this patient.  

EKG – paced rhythm at rate of 72/min

Lytes, BUN, Creat, LFTs,  CBC all normal.

CXR – mild cardiomegally, otherwise clear.  Pacemaker and proper wire placement noted

A:              1.  S/P MI

            2.  Recent hospitalization for CHF – no signs of recurrent CHF-Pacemaker

• DJD
• Mental status changes.

5.   Family stressors of failing health, less available home helpers, and financial difficulties.