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SOAP Evaluation

In this SOAP evaluation, the student strives to find out the following.
-The signs and symptoms of the disease
-The patient’s physical outlook and its relation with the disease
-The patient’s medical history and its relation to the current illness
-How to diagnose the disease
-The methods and tests used to diagnose the disease
-Pharmacological treatment and medication of the illness
-Non-pharmacological treatment of the illness
-Management and follow up of the illness as well as the patient
Test Questions
-What is the current physical condition of the patient?
-What is the patient’s medical history
-How is the patient’s medical history important?
-What are the aspects of the patient’s social life?
-Which are the most appropriate methods of diagnosing the illness?
-What are the most suitable tests to be carried out?
-Which is the best mode of treatment, and which medicines and therapy should be administered to the patient?
-How should the patient manage his treatment procedure and what follow up measures should be taken so as to monitor the patient’s treatment process?
Sign and symptoms/Clinical presentation of disease process

This is a 66-year-old black male patient with a history of gout, osteoarthritis, hypertension, and extremity edema. Patient complains of sudden onset of chest pain relieved when sitting in upright position. He is married and was encouraged by his family to call his primary doctor to discuss conditions. He was instructed to come into the clinic for further evaluation. He presented in the clinic with increasing chest pain and dyspnea. Patient reports these symptoms are persistent and have increased over the past week. Vital signs obtained, elevated temperature observed. Patient verbalized recent upper respiratory infection. The patient consented to obtain labs. Echocardiogram and EKG performed, changes identified, and hospitalization recommended.

The patient has a history of chronic illnesses as well as major traumas. These include gout, osteoarthritis, hypertension, and extremity edema. Besides that there are no known instances of allergies and no recorded medical intolerances. Regarding surgeries and hospitalization history, B.C has undergone appendectomy as well as cholecystectomy. Looking into the patient’s family history, it can be seen that his father died when he was 69 years of age due to colon cancer. B.C’s mother is alive but suffers from depression. Additionally, he has a detailed history of diabetes as well as high blood pressure. B.C has one sister, who has a history of uncontrolled diabetes. Finally, he has two brothers, each one of them with a history of hypertension. Looking at the social history, the patient is a college graduate currently working at a manufacturing plant as a manager. He is married and resides at a private home in a private safe and gated community with his wife. B.C and his wife attend church regularly, that is, every Sunday, and participate actively in Bible study. His wife is also an active member of the church choir. For other activities, B.C enjoys fishing as well as cooking on the weekends. Besides that he enjoys preparing daily meals for his wife. B.C. has two adult children who live in Atlanta, Georgia. He denies any use of drugs and alcohol.

Diagnostic workup

Before B.C is taken to hospital for an in depth interview and tests. Preliminary tests can be carried out in the clinic. A pericardial effusion, an echocardiography or the ECG may give initial hints for the examination. The chest X-ray scan might identify pericardial calcifications (Bickley, 2013). Doppler echocardiography as well as cardiac catheterization, especially during breathing maneuvers, is symptomatic. This is because they demonstrate the diastolic filling disturbance, the equal rise of left and right ventricular end-diastolic, as well as mean atrial pressures, and the strong dependency of ventricular filling from breathing. Computed tomography or magnetic resonance imaging might expose the thickened pericardial layer (Goolsby, Grubbs, 2011). The most significant differential diagnosis is restrictive cardiomyopathy, which has comparable clinical as well as hemodynamic findings.

In the review of systems, B.C. has reported a gain of weight with over 20 lbs. this year alone. He has also noticed a decline in his energy levels. He states that he is extremely tired and short of breath when engaging in physical activities. He complains of increased sweaty skin. However, he denies any bruises, bleeding, skin discolorations or any notable changes in lesions or moles. For his visual health, B.C wears corrective lenses and visits his ophthalmologist every year. For Cardiovascular health, B.C is experiencing orthopnea that is relieved only when he is sitting in an upright position. He also reports some bilateral lower extremity edema and pain, which is treated with prescribed diuretics. B.C also reports a recent upper respiratory infection that was addressed with ABT treatment. He also reports increased instances of coughing as well as dyspnea with activity over the past week. He, however, denies any history of TB. He also denies abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, and black, tarry stools. He denies any instances of ear pain, hearing deficits, tinnitus, or discharge. B.C. also denies any urgency, frequency, burning, or changes in the color of his urine. He states that he is only sexually active with his wife and proceeds to deny the use of any contraceptives. He also denies any history of STDs.

For the Nose, Mouth, and Throat, B.C denies any sinus problems, dysphagia, nose bleeds or discharge, hoarseness, and throat pain. He reports on his annual visit to the family dentist. B.C, however, has partial upper dentures but denies any dental diseases. B.C. reports chronic pain and swelling in the joints. He reports decreased movement in the upper as well as the lower extremities related to diagnosed gout. He reports no back pain, but some osteoporosis is present. B.C denies any history fractures. The patient also denies any lumps, bumps, or changes in the bilateral breast. And for his Neurological health, he denies vertigo, tingling, or any seizure episodes. He also reports No black-out spells or changes in equilibrium. B.C. states that he has never received any blood transfusions. He has no bruising to the skin. He reports sweaty skin over the last couple of days, and his HIV status is negative. Finally, the B.C expresses a feeling of anxiety as well as fatigue at times but denies depression. He also reports the inability to sleep due to difficulty in breathing as well as chest discomfort. B.C denies any suicidal thoughts or plans.

General Appearance

B.C. is an obese male independently ambulating, gait slow but steady. He is Alert and oriented, well groomed, and appropriately dressed for the weather. B.C. maintains direct eye contact and answer questions appropriately. No signs of distress observed. His Skin is brown, dry, clean, and intact. No bruising, rashes or lesions noted.
HEENT

B.C Head is normocephalic, atraumatic, and without lesions; the hair is coarse and evenly distributed. Eyes: PERRLA. EOMs are intact. No conjunctival or scleral injection. Ears: Canals are patent. Bilateral TMs are pearly gray with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa is pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. The oral mucosa, pink and moist. The pharynx is non-erythematous and without exudate. Upper partial dentures and lower teeth are intact with evidence of fair hygiene. Cardiovascular: S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs. Capillary refills two seconds. Pulses 3+ throughout (Hojs, January 01, 2005). B.C. has a bilateral trace of ankle edema. Respiratory: B.C. chest wall is symmetrical, respirations regular, lungs are clear to auscultation bilaterally. B.C is obese, his abdomen is round, soft, and non-tender. His bowel sounds are active in all quadrants. No hepatosplenomegaly.

His Breast examination was deferred. Genitourinary Tests were also deferred. B.C. is ambulatory independently, gait is slow but steady. Limit review on movements due to a sudden onset of pain in back, neck and shoulder. B.C speech is clear and appropriate. CN II-XII is grossly intact. B. C. is also Alert and Oriented. His clothing is cleaned and in good condition. B.C. sustained direct eye contact throughout the interview process, with all questions answered appropriately. His tone is low but clear.

Lab Tests

CBC, BMP, T4, TSH, Lipid, A1c-pending KUB, H- Pyloric, Troponin
Special Tests
EKG, Chest x-ray, Echocardiogram, Ultrasound abdomen
Differential Diagnosis

ECG can be diagnostic in acute pericarditis and typically reveals ST rise in all leads. The ratio of the amplitude of ST section to the amplitude of the T wave in leads I, V4, V5, and V6 on electrocardiogram can be used to separate acute pericarditis (AP) from early repolarization (ER) and early repolarization of left ventricular hypertrophy (ERLVH) (Lotrionte, Biondi, Imazio, et al, January 01, 2010). Echocardiography is particularly helpful if the pericardial flow is suspected on clinical or radiographic grounds, the illness persists longer than a week, or myocarditis or purulent pericarditis is assumed. A chest radiograph is only necessary for diagnosis in patients with effusions >250mL. Patients with scanty effusions (less than a few hundred milliliters) may present with a normal cardiac silhouette (Lotrionte, Biondi, Imazio, et al, January 01, 2010). Lab tests may involve CBC; serum electrolyte, blood urea nitrogen (BUN), and creatinine levels; erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels; and cardiac biomarker measurements, lactate dehydrogenase (LDH), and serum glutamic-oxaloacetic transaminase (SGOT; AST) levels.

Final Diagnosis

Three differential diagnoses included Acute Myocardial Infarction, Pericarditis and Infectious Cardiomyopathy. The factors of B.C chest pain, abnormal ECG findings, recent respiratory infection, patterns of dyspnea, and elevated temp of 100.8 assisted in the determination of the patient's diagnosis of Pericarditis. Myocardial Infarction and Infectious Cardiomyopathy was ruled out by ECG and prolonged complaint of chest pain over several days. The patient’s ability to lean forward for relief was also considered in this ruling. Troponin elevations are common in pericarditis (Sparano, & Ward, December 01, 2011). the combination of serial ECG and echocardiographic findings will generally allow diagnostic specificity. Final diagnosis is Acute Pericarditis 420.90
Further testing
B.C was sent to the emergency room for further elevation due to the elevation of ST segment with some old infarction and possible cardiac workup.Medication administered include Levaquin 750 mg daily for 14 days and Albuterol
B.C required hospitalization for further evaluation and management. The resulting pending of his echocardiography will help determine the degree of effusion and assisted developing and effective treatment intervention plan. According to (Buttaro,), symptoms of pericarditis include anterior chest pains that may radiate to shoulder area if the diaphragmatic surface of the pericardium is involved (Buttaro, Trybulski, Bailey, Sandberg, 2013). Buttaro also states sharp chest pain that increases with inspiration or supine positioning and lessens with forward positioning, which correlates with B.C current symptoms. Fever and viral etiology are also determining factors associated with the diagnosis of Pericarditis.

Management

Treatment and medication

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the pillar of the therapy. These agents have similar efficacy, with relief of chest pains in about 85-90% of patients within days of medication (Ekart, Hojs, January 01, 2012). A full-dose NSAID should be used, and medication should last 7-14 days. Colchicine, alone or mixed with an NSAID, can be considered in the event of recurrent or continued symptoms beyond 14 days. Corticosteroids should not be used for the introductory treatment of pericarditis except when it is indicated for the underlying illness, the patient's condition has no response to NSAIDs or colchicine, or both agents are contraindicated. Surgical treatment includes pericardiectomy, pericardiocentesis, pericardial window placement, and pericardiotomy. Pericardiectomy is the most effective surgical method for managing large effusions since it has the lowest correlated risk of intermittent effusions.

This procedure is employed in constrictive pericarditis, effusive pericarditis, or chronic pericarditis with multiple attacks, steroid dependence, and intolerance to other medical management. If B.C has effusions larger than 250 mL, effusions in which the size grows despite exhaustive dialysis for 10-14 days, or effusions with evidence of tamponade, then he is a candidate for pericardiocentesis (Rheuban, September 01, 2005). Pericardial window placement is used for effusive pericarditis therapy. Consider subxiphoid pericardiotomy for massive effusions that do not resolve. This procedure may be executed under local anesthesia and has a lower risk of complications than pericardiectomy.

Education

B.C. required extensive education relating to his disease process. He will need additional teaching after discharge from the hospital. This includes Reviewing and assuring that the patient verbalizes and understands when symptoms are worsening and knows when to seek urgent care. Introduce lifestyle modification for the management of gout, diet, and exercise. Provide verbal and written material on exposure smoking, including second-hand smoke. Discuss with patient signs and symptoms of diagnosis such as; elevated fever, increasing sob, and sudden onset of pain in jaw, neck, shoulder and back.

Conclusion

His clinic visit was overwhelming and prevented his ability to retain an understanding of his disease process and interventions. He will require assistance in developing lifestyle modifications, diet adjustment, and medication teaching (Jill, Cheryl, 2010). His teaching should also include his family to assist in identifying risk factors and implementing prevention measures.

The SOAP evaluation was successful as all the objectives were accomplished. The patient was aptly interviewed and his medical history obtained. Several diagnostic tests were also carried out to confirm the illness. The various procedures for treatment administered have also been discussed including management, treatment, medication, education and follow up. Lifestyle advice was also given to the patient to ensure that he leads a healthy lifestyle, one that will facilitate quick healing and a sustainable healthy life.

References

Goolsby, M. J., & Grubbs, L. (2011). Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 2nd Edition. [VitalSource Bookshelf version]. Retrieved from
Buttaro, T. M., Trybulski, J., Bailey, P. P., Sandberg-Cook, J. (2013). Primary care: A collaborative practice. (4th ed.)(pp. 399-401). St. Louis, MO: Elsevier.
Bickley, L. S. (2013). Bates’ pocket guide to physical examination and history taking (7th ed.). Philadelphia, Baltimore, New York, London, Buenos Aires, Hong Kong, Sidney, Tokyo: Wolters Kluwer Health | Lippincott Williams & Wilkins. Retrieved from
Jill C. Cash, Cheryl A. Glass. (2010). Family Practice Guidelines. Springer Publishing Company, Incorporated. ISBN: 9780826197825.
Hojs, R. (January 01, 2005). Cardiac troponin T in patients with kidney disease. Therapeutic Apheresis and Dialysis, 9, 205-207.
Lotrionte, M., Biondi-Zoccai, G., Imazio, M., Castagno, D., Moretti, C., Abbate, A., Agostoni, P., Gaita, F. (January 01, 2010). International collaborative systematic review of controlled clinical trials on pharmacologic treatments for acute pericarditis and its recurrences. American Heart Journal, 160, 4, 662-70.
Sparano, D. M., & Ward, R. P. (December 01, 2011). Pericarditis and Pericardial Effusion: Management Update. Current Treatment Options in Cardiovascular Medicine, 13, 6, 543-555.
Rheuban, K. S. (September 01, 2005). Pericarditis. Current Treatment Options in Cardiovascular Medicine, 7, 5, 419-427.
Ekart, R., & Hojs, R. (January 01, 2012). Hemodialysis: Indications, vascular access, different modalities and complications. Hemodialysis.