Soap notes help to identify the tests, diagnosis and the interview with the patient. These notes help to analyze a patient's case based on history or family.
Below is an Ihuman case study Soap Note on Robert Rose
Patient: Robert Rose
Clinical Site: Ihuman
Pts Initials: RR Age:17 y/o Sex: M
Subjective
CC: “Chest pain”
HPI: Robert Rose is 17-year-old athletic Caucasian male who presents to the ED with a 6-hour hx of chest pain, accompanied by palpitations, SOB, and fever. Patient has no significant PHM. Chest pain is described as deep dull achy 7/10 pain locatedmidsternal w/o radiation. Pain started while resting on his couch 6 hrs ago. Does not have alleviating or aggravating factors. Patient also with c/o recent URI 1 week ago that preceded his current symptoms. On exam patient with tachycardia, tachypnea, and febrile to 102.2.
Allergies: NKNA Meds: none PMH: none
Surg Hx: none
FH: no significant family hx
SH: No tobacco use, 1 sexual partner - uses condoms, active life style
Review of Systems:
Cons: patient companies of fever, chills, fatigue CV: denies: edema, dizziness, syncope Complains of: chest pain, palpitations
Lungs: denies cough, phlem, wheezing Complains of: SOB, DOE
Skin: denies pruritus, masses, rashes or bruises
Objective:
Vitals: BP: 100/70mmHg , Pulse-140, RR-24,Temp- 102.2degrees F, SPO2: 95%
Cons: WNWD. Appears to be in moderate distress.
CV: Tachycardic (140s),S1S2, no murmur noted. No JVP distention. No edema.
Lungs: CTAB, labored, tachypnea
Neuro: AAOx4
Skin: CDI, no rash, cyanosis or clubbing
PSYCH: Appropriate mood and affect, answering questions appropriately
Significant test results:
Troponin I- 6.5- elevated
TTE-Large areas of LV wall hypokinesis, Ventricle assumes a more “spheroid” shape from its normal and septal wall appears thickened.
CBC WBC12,419 mm3, hgb 16 g/dl,plts 348 k/dl- elevated WBC
Blood culture and sensitivity- pending12 lead ECG- Sinus Tachycardia, rate 140 Assessment/Plan
Primary Diagnosis: Dx: Myocarditis: icd10: Myocarditis I51.4
Myocarditis is most with respiratory symptoms of chest pain, palps/tachycardia, dyspnea and fever following a recent viralURI. This patient was found to be tachycardic (HR 140’s) with a regular rhythm, verified by EKG. He has elevated troponin that can be caused by cardiac distress, not only myocardial infarctions cause elevated troponins. His TTE was significant for hypokinesis which is a common finding in myocarditis.
Treatment
- Given the treatment needed for your cardiac conduction, further management will be needed in the emergency department
- In the ER you van expect IV’s, supplemental oxygen, and cardiac monitoring.
- You will be given Tylenol for management of your fever above temperatures of 100.4
- A cardiology consult and CT surgery consult will be fulfilled during your hospital admission for further management
- Please follow up in office within 1 week of discharge
Differential Diagnosis:
PE: This is an appropriate differential diagnosis given the complaint of chest pain, SOB, and age of the patient. PE is a blood clot that travels to the lung. D-dimers have high sensitivity as well as high false positives. D-dimers were found in a study to be higher falsely positive in the elderly community rather than the younger community. D-dimers should only be used as a definitive negative in those with low suspension (Crawford, Andras, Welch K, Sheares, Keeling,Chappell, 2009). In this instance a CT scan was needed, and a negative chest CT scan was the result.
Sepsis: This is an appropriate differential given the fevers and elevation in WBCs and blood cultures are still pending. This diagnosis is lower on the list given the normal lab value in lactic acid. According to the new definition of this issue, septic shock can be diagnosed under two conditions: The first condition is persistent hypotension after fluid resuscitation and requiring vasopressors to maintain MAP >65 mmHg and the second condition is serum lactate level >2 mmol/L (Lee and An 2016).
Rhiannon Whyte,FNPS
References:
https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-myocarditis-in- adults#H13
Crawford F,Andras A,Welch K,Sheares K, Keeling D, Chappell FM. D-dimer test for excludingthe diagnosis of pulmonary embolism. Cochrane Database Syst Rev. 2016 Aug5;2016(8):CD010864. doi: 10.1002/14651858.CD010864.pub2. PMID: 27494075; PMCID: PMC6457638.
Lee, S. M., & An, W. S. (2016). New clinical criteria for septic shock: serum lactate level as new emerging vital sign. Journal of thoracic disease, 8(7), 1388–1390. https://doi.org/10.21037/jtd.2016.05.55
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