Soap Note For Chest Pain Discussion

HPI

Darius Davis is a 62-year old African American who arrives at the clinic complaining of chest pain that he believes may be caused by indigestion. The middle of the chest is where the pain is felt. It was approximately two months ago, while he was raking leaves, that he experienced chest pain for the very first time. However, once he took a rest for approximately ten minutes, the pain in his chest disappeared. He claims that chest pain occurs around three to four times each week. The patient characterizes the pain as pressure, and it has the sensation of a lot of weight being placed on his chest. On a scale from 1 to 10, he gives the pain a 5 or 6 rating.

ORDER HERE A PLAGIARISM-FREE PAPER 

Plan

Additional labs or diagnostic tests: Soap Note For Chest Pain Discussion

• Stress echocardiography. This will assist in determining how effectively the patient’s heart functions while it is under pressure (Gulati et al., 2022).
• Basic metabolic panel- check electrolyte levels
• Lipase- rule out pancreatitis B

Consults: Referral to cardiology

Therapeutic modalities:

• Pharmacological: Prescribe Nitroglycerin-sublingual 0.3mg as needed for chest pain. Continue HCTZ 25mg daily. Prescribe Lisinopril 5mg daily, Lipitor 40mg bedtime, and Aspirin 81mg daily.
• Non-pharmacological: Encourage patient to make dietary changes, exercise, and quit smoking (Balla et al., 2018).

Health promotion:  Encourage the patient to monitor blood sugar, obtain Covid 19 vaccine, and annual influenza vaccine.

Modifiable risk factors: hyperlipidemia, high blood pressure, smoking.

Non-modifiable risk factors: family history, race, age.

Patient education: Educate the patient on the importance of checking and recording blood pressure every morning.  Educate the patient on the benefits of smoking cessation on overall health. Educate the patient to adopt the Mediterranean Diet and to avoid adding salt to food (Martínez-González et al., 2019)Soap Note For Chest Pain Discussion.

Disposition/follow up instructions: RTC in 4 weeks. Consult with a cardiologist. To stop what he is doing and get some rest if he starts to feel chest pain. To take a nitroglycerin pill and dissolve it under your tongue if getting some rest does not relieve the chest pain. To report to the ER if the pain persists. Soap Note For Chest Pain Discussion

References

Balla, C., Pavasini, R., & Ferrari, R. (2018). Treatment of angina: Where are we? Cardiology, 140(1), 52-67. https://doi.org/10.1159/000487936

Gulati, M., Levy, P. D., Mukherjee, D., Amsterdam, E., Bhatt, D. L., Birtcher, K. K., Blankstein, R., Boyd, J., Bullock-Palmer, R. P., Conejo, T., Diercks, D. B., Gentile, F., Greenwood, J. P., Hess, E. P., Hollenberg, S. M., Jaber, W. A., Jneid, H., Joglar, J. A., Morrow, D. A., … Shaw, L. J. (2022). 2021 AHA/ACC/ASE/Chest/Saem/Scct/Scmr guideline for the evaluation and diagnosis of chest pain. Journal of Cardiovascular Computed Tomography, 16(1), 54-122. https://doi.org/10.1016/j.jcct.2021.11.009

ORDER NOW

Martínez-González, M., Gea, A., & Ruiz-Canela, M. (2019). The Mediterranean Diet and Cardiovascular Health. Circulation Research, 124(5), 779-798. https://doi.org/10.1161/circresaha.118.313348

I have an ihuman assignment where i have to write the plan and an HPI i have attached the requirements as well as an example of. what a completed assignment should look like, I have also attached some info from the assignment Soap Note For Chest Pain Discussion