Arunateja Chennareddy SOAP Note 2

Name: ___E.L___________________________________________ SOAP NOTE-2

Subjective:

Chief Complaint – complaints of chest pain, located in the left chest.

History of Present Illness: E. L is a 82 y.o. male with PMH of CAD (s/p MI ~9 years ago, no PCI

done), CVA (~6 years ago, residual right-sided vision deficits), DMII, HTN, HLD, CKD,

hypothyroid, former smoker and recent hospitalization for AKI on CKD (c/b pneumonia) who

presents from subacute rehab facility with acute onset chest pain. Patient states that this morning

at 5:00AM he suddenly developed sharp, 8/10, substernal chest pain. The pain is non-radiating.

He also reported nausea (no vomiting), a headache, and mild dyspnea at the time. He says the pain

is like that of his prior MI. He also describes a history of right leg weakness x2 weeks and

now right-hand weakness x1 week. Regarding his recent hospitalization, he was at RWJ-Rahway

(11/31/2018 through mid-December). He had a negative lexiscan this admission and an echo

showing normal EF with severe MR, moderate TR. Per his daughter, his creatinine was in the 2's

at time of discharge. Pt with recent admit to hamilton rwj 12/31-1/15 then went to rehab, wasn't

walking upon discharge- admitted to renal failure, left leg weakness, daughter states pneumonia

during hospitalization, did see cardiology , cannot remember doctors name- saw nephrology. In er

pt was evaluated by dr shanahan, cards on call, will have pt seen by hamilton cardiology due to

they have seen him during his last admission

Daughter states last cath 8-9 yrs ago, st francis- cannot remember cardiologist but states no stent

or intervention she is aware of.

o Onset- 1 hr ago, similar episodes before

o Location- left chest

o Duration- for 1 hr

o Character- pressure like pain

o Aggravating factors- none

o Alleviated – none

o Radiation- no

o Severity- moderate

 PMH:

 CVA

 Acute kidney injury

 Acute myocardial infarction

 Chronic kidney disease

 Diabetes type II

 Diaphragmatic hernia

 Essential hypertension

 GERD (gastroesophageal reflux disease)

 Gout

 Hyperlipidemia

 Hypertensive heart disease without heart failure

 Hypothyroidism

 PNA

 Polyneuropathy

 UTI
Arunateja Chennareddy SOAP Note 2

 Past Surgical History: None

 Social History: lives with wife, retired,

Smoking status: former smoker quit 12 yrs ago

Types: cigarettes

Packs/day: 1.00

Years:30.00

Smokeless tobacco: No

Alcohol use: quit 10 yrs ago

Drug use: Denied

 Family History:

 Maternal:

Mom- expired (2000) CKD

 Paternal

Dad- Expired (1998)- Stroke

 Siblings:

Brother- 88 yr. old HTN, CAD for last 30 yrs.stroke.

Medications: outpatient

 Tylenol 650 mg Q4 hrs for pain fever PRN

 Albuterol 5mg/ml 0.5% nebs- 2.5 mg nebulizer Q8H

 Aluminuim- magnesium hydroxide-Simethicone 200-200-20 mg in 5 ml oral suspension -

take 30 ml POQ6Hrs as needed.

 ASA Enteric coated 81mg PO OD

 Calciumarbonate-VitaminD(Caltrate 600+D) PO 1 tab BID

 Carvdilol 25mg 1 tab PO BID

 Gabapentin 300 mg 1 cap PO OD at bedtime

 Synthroid 75MCG tab 1 tab PO OD before breakfast

 Linagliptin 5mg tablet PO 1 tab OD

 Omeprazole 20 mg DR tab PO OD

 Allergies:

 Levemir( insulin Detimir)- rash

 Plavix (clopidogrel)-rash

 Immunizations:

09/08/1965 DTAP/TDAP/TD (1 - Tdap)

11/08/2016 PNEUMOCOCCAL (1 of 2 - PCV13)

10/30/2018 INFLUENZA (1)

 Preventive Screenings:

09/08/1946 HEPATITIS C SCREENING

09/08/1996 COLONOSCOPY

 Review of Systems:

 Subjective:

 General: (-) Fever, (-) chills, (-) malaise, (-) fatigue, (-) night sweats, (-) weight loss, (-)

change in appetite,

 Constitutional: Negative for activity change, chills.

 Skin, hair, nails: (-) rashes, (-) itching, (-) redness and (-) color changes in extremities, (-

) swollen foot, (-) lesion, (-) eruptions, (-) texture changes, (-) unusual nail/hair growth,
Arunateja Chennareddy SOAP Note 2

 HEENT: (-) headache, (-) dizziness, (-) loss of consciousness, (-) head injuries, (-) visual

changes, (-) blurring, (-) double vision, (+) glasses, (-) eye pain, (-) crusts, (-) purulent

discharge, (-) scleral injection, (-) conjunctiva erythema, (-) corneal abrasion, (-) eye

trauma, (-) hearing loss, (-) ear pain, (-) fullness, (-) ear discharge, (-) vertigo, (-) tinnitus,

(-) nasal congestion, (-) nasal discharge, (-) sneezing, (-) post nasal drip (-) nosebleeds, (-

) diminished smell, (-) sinus pain (-) sinus fullness, (-) sore throat, (-) hoarseness, (-)

bleeding gums, (-) ulcers, (-) tooth pain, (-) diminished taste, (-) Trouble Swallowing, (-)

drooling.

 Respiratory: (-) cough, (-) sputum- mild clear, (+) shortness of breath, (-) wheezing, (-)

pain during respiration, (-) dyspnea, (-) orthopnea, (-) night sweats, (-) exposure to TB, (-)

seasonal allergies, (-) apnea, (+) chest tightness

 Cardio/vascular: (+) chest pain, (-) palpitations, (+) edema bil legs, (-) decreased exercise

tolerance, (-) pain or cramping during ambulation

 GI: (-) abdominal pain, (-) abdominal distention (+) nausea, (-) vomiting, (-) heart burn, (-

) diarrhea, (-) constipation, (-) change in bowel pattern, (-) decreased appetite, Regular diet

 GU: (-) frequency, (-) urgency, (-) burning, (-) flank pain, (-) suprapubic pain (-) hematuria,

(-) incontinence, (-) penile discharge, (-) sexual difficulties, (-) STIs.

 Musculoskeletal: (-) joint pain, (-) joint swelling, (-) joint heat, (-) limitation in motion, (-

) myalgia, (-) weakness, (-) bony deformities, (-) neck stiffness

 Hematopoietic: (-) weakness, (-) easy bruising, (-) fatigue, (-) easy bleeding.

 Endocrine: (-) thyroid enlargement/tenderness, (-) heat/cold intolerance, (-) weight

change, (-) hair changes, (-) changes in skin texture, (-) polydipsia, (-) polyuria, (-) changes

in shoe, glove, hat size

 Neurological: (-) headache, (-) fainting, (-) seizures, (-) speech difficulty (-) loss of

consciousness, (-) weakness, (-) tremors, (-) numbness, (-) changes in sensation, (-)

confusion, (-) tremors

 Psych: (-) depression, (-) anxiety, (-) sleep disturbance, (-) confusion, (-) Lethargy.

Objective:

Physical assessment: BP- 147/91, Pulse - 78, Temp – 97.6 °F (36.4°C) (Oral), Resp-20, Ht 5' 8"

(1.727 m), Wt -225 lb (102.1 kg), SpO2 98%, 34.21 BMI kg/m²

General appearance: He is oriented to person, place, and time. He appears well-developed and

well-nourished. He is active and cooperative. Non-toxic appearance. No distress.

Skin: fair, generally dry, warm, smooth, (-) pallor, (-) moisture, (-) exanthemas, (-) ulcerations, (-

) pruritis, (-) rash, (-) tenting; (-) Edema/ discoloration (-) erythema,

Hair: white hair color, wavy, normal distribution (-) thinning of scalp hair; (-) decreased hair

distribution of arms and lower extremities; (-) unusual facial growth; Nails: opaque, groomed, (-)

ridging, (-) splitting, nail beds pink, (-) redness, swelling, tenderness, deformity; (+) capillary refill,

(-) clubbing,

Head: normocephalic, symmetrical features, (-) edema, (-) tenderness over frontal and maxillary

sinuses

Lymphatics: (-) pre/post auricular, (-) anterior cervical tenderness, non-palpable lymph nodes. No

cervical adenopathy noted.

Eyes: PERRLA, EOMs intact, conjunctiva normal, (-) exophthalmos, (-) purulent discharge, (-)

ptosis

Ears: Tympanic membrane pearly gray, (-) cerumen, bony landmarks visualized
Arunateja Chennareddy SOAP Note 2

Mouth/Throat: tongue/uvula midline, mucosa pink, (-) dry lips, (-) erythema, (-) exudate,

Neck: Normal range-of-motion, trachea midline, (-) JVD, (-) thyroid enlargement (-) nodules, (-)

carotid bruits

Chest: appearance appropriate to age, (-) tenderness

Heart: S1/S2 heard on auscultation, (-) murmurs, (-) thrills, heaves, lifts, (-)s3, s4 sounds, (-)

murmurs.

Lungs: Respiratory rate regular, breath sounds, (-) cough, (-) adventitious sounds, (-) use of

accessories, (-) Rhonchi, (-) expiratory wheezes. (-) CVA tenderness

Abdomen- (+) normoactive bowel sounds in all 4 quadrants, (-) tenderness, (-) guarding, (-)

palpable mass, (-) organomegaly (-) flank tenderness. (+) Obese and soft.

Extremities: warm to touch; (-) erythema, (-) edema, (-) tenderness of calfs; (-) edema in lower

extremities; (-) ulcers; (+) bilateral posterior tibia and dorsalis pedis pulses (+) ROM intact

Musculoskeletal: (-) kyphosis; extremities symmetrical in size; muscle strength varied – review

Neuro Exam; (-) limited ROM

Neurological: CN I-XII grossly intact; (-) involuntary movements; (-) focal weakness/paresis, (-)

tremor, Neuro exam with clear weakness on the right arm 3-5 strength poor grip ; he is right-hand

dominant and right leg mild weakness 4/5 strength. Due to recent h/o CVA NIH Stroke scale is

administered.

1a Level of consciousness: 0=alert; keenly responsive

1b. LOC questions: 0=Performs both tasks correctly

1c. LOC commands: 0=Performs both tasks correctly

2. Best Gaze: 0=normal

3. Visual: 0=No visual loss

4. Facial Palsy: 0=Normal symmetric movement

5a. Motor left arm: 0=No drift, limb holds 90 (or 45) degrees for full 10 seconds

5b. Motor right arm: 1=Drift, limb holds 90 (or 45) degrees but drifts down before full 10 seconds:

does not hit bed

6a. motor left leg: 0=No drift, limb holds 90 (or 45) degrees for full 10 seconds

6b Motor right leg: 0=No drift, limb holds 90 (or 45) degrees for full 10 seconds

7. Limb Ataxia: 1=Present in one limb

8. Sensory: 0=Normal; no sensory loss

9. Best Language: 0=No aphasia, normal

10. Dysarthria: 0=Normal

11. Extinction and Inattention: 0=No abnormality

Total Score:2

Psychiatric: He has a normal mood and affect. His speech is normal, and behavior is normal.

Judgment and thought content normal. Cognition and memory are normal.

Labs Reviewed

COMPREHENSIVE METABOLIC PANEL - Abnormal; Notable for the following:

Glucose 176 (*)

Na 142

K 3.7(*)

Ca 7.8(*)

Cl 104

BUN 106 (*)

Creatinine 4.4 (*)

GFR NA-A 14 (*) A-A 17(*)

All other components within normal limits

HEME PROFILE + ELECT DIFF - Abnormal; Notable for the following:

WBC 6.2

Hemoglobin 10.6

Hematocrit 32.2(*)

All other components within normal limits.

Troponins 1st 0.25 (*),

PT 15.3(*) INR 1.2(*)

AUTOMATED DIFF - Abnormal; Notable for the following:

% Lymphocytes 5.2 (*)

% Monocytes 13.3 (*)

IMMATURE GRANULOCYTE 1.9 (*)

# Lymphocytes 0.48 (*)

# Monocytes 1.22 (*)

IMMATURE GRANULOCYTE ABSOLUTE 0.17 (*)

All other components within normal limits

EKG: NSR, ST depression in lateral leads, unchanged from previous tracings. Old EKGs reviewed

for identifying baseline.

Radiology: EXAM: XR Chest 1 View CLINICAL INDICATION: Chest Pain PROCEDURE:

A single digital radiograph of the chest was obtained. 01/24/2019, 6:14 AM COMPARISON:

None. FINDINGS: There are no tubes or lines present. Ill-defined airspace opacity is noted right
Arunateja Chennareddy SOAP Note 2

upper lobe. Interstitial pattern is noted bilateral lower lung zones. The costophrenic angles are

clear bilaterally. There is no pneumothorax. The cardiac silhouette is within normal limits. Hilar

and mediastinal contours are grossly normal There are degenerative changes in the spine.

Nonspecific airspace opacity right upper lobe. This could represent an infectious infiltrate.

Malignancy cannot be excluded. Nonspecific bilateral lower lung zone interstitial pattern.

Unenhanced CT recommended. Electronically signed by: Mark Tenenzapf, M.D.

EXAM: CT Chest wo IV Contrast CLINICAL INDICATION: RUL opacity-Chest pain,

unspecified-Unspecified kidney failure PROCEDURE: A helical dataset of the chest was

acquired. Interpretation is based on review of axial, coronal, and sagittal reformat images.

Automated exposure control was utilized for this exam. Dosimetry information: CTDIvol per

series = 0.1 mGy,0.1 mGy,12.9 mGy, Total DLP = 561.9 mGy.cm. COMPARISON: Plain films

performed earlier on this date. FINDINGS: Heart: There are coronary arterial atherosclerotic

calcifications (moderate calcific burden). There is no pericardial effusion. There are atherosclerotic

changes of the aorta without evidence of aneurysm. The vascular structures within the

mediastinum are normal in diameter. Mediastinum/hila: Evaluation is limited without IV contrast.

Right hilar masses/lymphadenopathy are, however, present. There are also enlarged right

paratracheal lymph nodes and a few mildly enlarged lymph nodes anterior to the arch. Largest

individual nodal structure is noted in the right paratracheal area measuring 2 x 1.4 cm. Lungs:

There is a spiculated soft tissue mass within the right upper lobe posterior segment measuring 3 x

2.5 cm axial image 28. There are mild compressive atelectatic changes near the lung bases. There

are a few scattered small groundglass opacities within the left lung which are nonspecific. There

are small bilateral pleural effusions. There is a small focus of pleural-based soft tissue thickening
Arunateja Chennareddy SOAP Note 2

within the right lower thorax posterolaterally measuring 1.3 cm. Chest wall/axilla: There is no

axillary adenopathy. Right supraclavicular lymphadenopathy is suspected measuring on the order

of 2.6 x 1.1 cm. The thyroid gland is normal in appearance. Bones: There are degenerative

changes of of the spine. There are old right-sided rib fractures. The visualized portions of the

upper abdomen are unremarkable.

3 x 2.5 cm right upper lobe mass. Right hilar and superior mediastinal lymphadenopathy. Right

supraclavicular adenopathy suspected. Small bilateral pleural effusions with small pleural-based

lesion on the right. Metastatic malignancy is strongly suspected. Electronically signed by: Mark

Tenenzapf, M.D.

EXAM: CT Head wo IV Contrast CLINICAL INDICATION: Stroke COMPARISON: None.

PROCEDURE: A helical dataset of the brain was acquired. Interpretation is based on review of

axial, coronal and sagittal reformat images. Automated exposure control was utilized for this exam.

Dosimetry information: CTDIvol = 0.1 mGy,0.1 mGy,36.7 mGy, DLP = 890.6 mGy.cm.

FINDINGS: There is no intracranial hemorrhage demonstrated. There is no mass, mass-effect, or

midline shift. There is no abnormal intra or extra-axial fluid collection. There is no evidence of

acute territorial/transcortical infarct. CT may be insensitive in the first 24 hours, and MRI may be

more sensitive if there is a high degree of clinical concern. The ventricles and sulci are mildly

prominent, consistent with mild atrophy. There is decreased attenuation in the periventricular and

subcortical white matter, consistent with small vessel disease. The cerebellum and brainstem

appear within normal limits, allowing for artifact. The sella and parasellar regions appear normal.

The orbital regions are unremarkable. The visualized portions of the paranasal sinuses and mastoid
Arunateja Chennareddy SOAP Note 2

air cells are unremarkable. The calvarium is intact. There is no evidence of fracture. The

visualized portions of the upper cervical spine appear normal.

No acute intracranial abnormality. Electronically signed by: Theresa Aquino, MD

Assessment:

Per daughter Pt has been having some weakness of the right upper ex and is scheduled to have CT

head today. CT ordered in the ER. To get more details, RN Call out to Marianna at the Elms of

Cranbury. RN asked if patient is on any blood thinners. Per Marianna, patient hasnt been receiving

any blood thinners. Patient was discharged from RWJ December 15th and is in acute rehab for

AKI and Chronic Kidney Disease.

Pt observed and reevaluated in the ER. Pt still with pain. Pt ekg with mild st depressions laterally.

Pt with + trop, however, pt in renal failure with creat 4.1. Pt is DNR/DNI.

Nitro drip ordered. Pt case discused with Dr. Shanahan, came to the ER to see pt, Pt in CT. Plan

to obtain CT head and if neg heparin and admit to the IMCU. Pt case d/w DR. Koganti will notify

oncomiing intensivist, Dr. Youseff for likely IMCU admit.

Primary working Diagnosis:

NSTEMI

(Papadakis.S.J., et.al., 2018).

Differential Diagnosis:

(Papadakis.S.J., et.al., 2018).

(Papadakis.S.J., et.al., 2018).

Active Co-Morbid Diagnosis:

Plan:

Further diagnostics: Follow up Labs:

CBC with manual leukocyte differential- to get clear picture of the wbc differentials

BMP- to trend the potassium levels and for further management

TSH- to identify any underlying hormonal issues considering the history of pheochromocytoma

BNP- to identify any underlying CHF and also to get clearence before starting an alpha blocker.

HbA1C- to further evaluate hyperglycemia for DM as patient BMI >30

Troponins 3 hr &6 hr- to rule out or evaluate in further for cardiac etiology

EKG- follow up in AM for identifying abnormal rhythms.

D- Dimers- as patient at low risk for PE, to further evaluate the need of CT Scan / VQ Scan

Treatment plan: E.L is a 82 y.o. male with PMH of CAD (s/p MI ~9 years ago, no PCI done),

CVA (~6 years ago, residual right-sided vision deficits), DMII, HTN, HLD, CKD, former smoker

and recent hospitalization for AKI on CKD (c/b pneumonia) who presents from subacute rehab

facility with acute onset chest pain.

#NSTEMI: substernal chest pain, troponin elevated to 0.25 (although in the setting of acute on

chronic renal failure), and borderline lateral ST depression in V3-V4. He had a normal lexiscan

(1/14/2018) and an echo which showed EF 55% (and severe MR, moderate TR). Hamilton

cardiology following.

- Notably the patient does not wish to pursue cardiac catheterization at this time (DNR/DNI status)

- Continue heparin gtt

- Nitroglycerine gtt discontinued, continue nitro paste q6 PRN for chest pain
Arunateja Chennareddy SOAP Note 2

- Continue DAPT with aspirin/Brilinta (reported plavix allergy)

- Continue metoprolol succinate 25mg PO QD

- Troponin now downtrending 0.25 -> 0.23

- Repeat echo ordered

#Acute on chronic kidney disease: unclear baseline, although renal function significantly worsened

~1 month ago. Reportedly improved by discharge to ~2's, although per records was 4.0 two days

prior to admission. Nephrologist Dr. Hannani (Mercer Renal Associates).

- Trend BMP's

- Strict I/O's, daily weights

- Will try to obtain records from last hospitalization and primary nephrologist.

#RUL lung mass: CT chest showed a 3.0x2.5cm RUL mass with associated right hilar and

mediastinal (possibly supraclavicular) LAD, concerning for metastatic malignancy per radiology.

- Given solitary pulmonary mass and pt's smoking history, more suspicious of lung primary. Will

need close follow up and possible biopsy when cardiac and renal issues controlled

#Right-sided weakness: RUE weakness x1 week, RLE weakness x2 weeks. CT head negative on

admission.

- Considering MRI to better evaluate for ischemic process

#DMII:

- LDSSI, glucose checks qAC/qHS. Uptitrate regimen as appropriate

#HTN:

- Metoprolol succinate 25mg PO QD as above

#HLD: Not on a statin (reported allergy to simvastatin, reaction unclear)

- Will try to determine if a true allergy and if a statin can be started this admission

#Mitral regurgitation: severe per TTE 1/14/2019. Patient seems asympatomic at present

- Repeat echo as above

#GERD:

- Lansoprazole 15mg PO QD

#Hypothyroid

- Continue home synthroid 75mcg PO QD

FENP: No IVF, replete PRN, NPO, SCD's

Code Status: DNR/DNI

Pharmacological:
Arunateja Chennareddy SOAP Note 2

1. Acetaminophen 650 mg oral Q6H PRN

2. aspirin EC 81 mg oral Daily

3. gabapentin 300 mg oral Daily at bedtime

4. heparin 100 units/mL 0-60 Units/kg (Order-Specific) intraVENOUS Q6H PRN

heparin0-32 Units/kg/hr (Order-Specific) intraVENOUS Continuous

5. lansoprazole 15 mg oral Daily pre breakfast

6. levothyroxine 75 mcg oral Daily pre breakfast

7. magnesium sulfate 2g intraVENOUS Once

8. metoprolol SUCCINATE ER 25 mg oral Daily

9. nitroGLYCERIN 1 inch topical Q6H PRN

10. Insulin Aspart injection Subcutaneous Sliding scale (BS201-250- give 2 units, BS 251-300

– give 4 units, BS 301-350- Give 6 units, BS>351 – Call MD/NP/PA)

11. Dextrose 50% injection 25grams IV for hypoglycemia (BS<60), patient unresponsive.

12. Glucose 15Grams Tab PO for hypoglycemia (BS <60), patient alert.

13. Call MD/NP/PA if BS< 60/ BS>351

14. Oxygen 2 lit/hr via nasal cannula continuously to keep oxygen saturation at 90-95%

Nonpharmacological:

Continuous pulse oximetry monitoring,

Spirometry test in AM

Apply Sequential compression devices to Bilateral Lower extremities – Non-pharmacological

VTE prophylaxis.
Arunateja Chennareddy SOAP Note 2

Referral and Follow up:

Patient Education:

Explained about treatment plan for the management of the current problems and the plan.

Patient
Arunateja Chennareddy SOAP Note 2

References

Kasper, D. L., Fauci, A. S., Hauser, S. L., Longo, D. L. 1., Jameson, J. L., & Loscalzo, J. (2015).

Harrison's principles of internal medicine (19th edition.) (pg1703). New York: McGraw

Hill Education.

Papadakis, M. A., McPhee, S. J., & Rabow, M. W. (2018). 2018 current medical diagnosis &

treatment. New York: McGraw-Hill Education.