Soap Notes on the John Smith Case

Soap Notes on the John Smith Case

SUBJECTIVE

CC: “There is a burning pain in my chest.”

HPI:

John Smith (J.S) is a 50-year-old Native American male who reported to the clinic complaining of chest pains. He stated that the pain was more like a burning sensation under his sternum. The patient also said that he has never had a similar experience, and the pain started three days ago. He said that he first felt a burning feeling after he woke up from his afternoon nap on Sunday. The patient also has a sore on the right lower extremity that drains purulent exudate. The pain has persisted. The patient has tried drinking water to ease the pain to no avail. He had not taken any medication to relieve the pain. He last visited the clinic a year ago.

Medications:

The patient has run out of his medication. He was prescribed:

• Cholestyramine (Rx):4 g PO q12-24hr; that was increased gradually over ≥ 1-month intervals for hyperlipidemia
• SYNTHROID:125 mcg per day for hypothyroidism
• Metformin 500 mg orally twice for Type II Diabetes
• Losartan 50mg, oral, for HTN

PMH

Allergies: NKDA

Medication Intolerances: None

Chronic Illnesses/Major traumas:

• Type II Diabetes
• Hypothyroidism
• Hyperlipidemia
• HTN

Hospitalizations/Surgeries: Total left knee replacement-2017

Family History

Mother deceased 68- Diabetes, HTN. Father- Deceased 56- prostate cancer, COPD, obese.

Social History

J.S. is a high school teacher who also doubled up as a gym teacher before the total knee replacement surgery three years ago. He likes to keep fit by taking walks every morning, but since the surgery, he has slowed down on this activity, and the weight has piled up. The patient is obese following the sedentary life he adopted after the surgery. J.S. lives with his wife, while his two grown-up sons live in different states. His second wife is 20 years his junior. He married her after the death of his first wife from a road accident. J.S. spends most of his time at home during the weekends. He stated that he stopped much of his socializing because of the immobility that came with the surgery.

ROS

General: No fever, fatigue, chills, energy level, and night sweats. The patient has gained 36 pounds in the last three years.

Skin: No moles and changes in lesions. No rashes, delayed healing, bruising, bleeding, or skin discolorations.

Eyes: No blurring or changes in his visual ability. The patient uses corrective lenses.

Ears: Slight hearing loss in the right ear. No ringing in ears, ear pain, and discharge

Nose/Mouth/Throat: No nose bleeds or discharge, Sinus problems. No  dysphagia, dental disease, throat pain, and hoarseness

Breast: Deferred

Heme/Lymph/Endo: Negative for COVID-19. Negative HIV status. The patient has a blood transfusion hx. No bruising, swollen glands, or night sweats. Increased cold or heat intolerance. Increased thirst and patient has increased hunger.

Cardiovascular: Chest pains below the sternum. No orthopnea, PND, palpitations, and edema

Respiratory: No dry cough. No wheezing, dyspnea, pneumonia history, TB, and hemoptysis.

Gastrointestinal: The patient says he has an increased appetite. The patient reported no diarrhea but has frequent bouts of constipation. No Abdominal pain, N/V/D, hepatitis, ulcers, hemorrhoids, and black, tarry stools.

Genitourinary/Gynecological: No urgency, frequency burning, or change in color of urine.

Musculoskeletal: Joint pain and stiffness. Muscle weakness. No back pain or joint swelling. The patient has a history of right total knee replacement.

Neurological: No transient paralysis, seizures, Syncope, weakness, back-out spells, and paresthesias.

Psychiatric: The patient has no sleep difficulty. The patient appears depressed. However, no anxiety or suicidal ideation/attempts

OBJECTIVE

Vitals: Weight: 189. BMI 32.4 Temp: 96.5 BP 139/90 Height: 5,4 Pulse: 63 Resp 18

General Appearance: The patient is obese class 1. He is oriented and alert *4. He answers questions appropriately. He also appears slightly distressed and believes he has a heart attack.

Skin: Skin is brown, clean, warm, dry, and intact. No rashes or lesions were noted.

HEENT

Head: The head is atraumatic, normocephalic, and without lesions. Hair is long hair but thinning.

Eyes: EOMs intact. PERRLA. No scleral or conjunctival injection.

Ears: Bilateral TMs pearly gray with positive light reflex; landmarks easily visualized. Canals are patent.

Nose: Normal turbinates; with a pink nasal mucosa. No septal deviation.

Neck: Enlarged thyroid. Full ROM; no occipital nodes; no cervical lymphadenopathy. The neck is supple. The oral mucosa is moist and pink.

The pharynx is without exudate and non-erythematous.

The left lower molar and the right upper premolar are missing.

Cardiovascular: S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs. No edema. Pulses 3+ throughout. Capillary refills two seconds.

Respiratory: Lungs clear to auscultation bilaterally. Symmetric chest wall. However, the patient experiences pain when taking a deep breath or when he coughs.

Gastrointestinal: No hepatosplenomegaly. Abdomen obese; Abdomen soft, non-tender.

BS active in all four quadrants.

Genitourinary: No CVA tenderness. Bladder is non-distended

Musculoskeletal: No pain. Slight gait from previous surgery. Full ROM on other extremities

Neurological: Speech clear. Posture erect. Slight gait from previous surgery. Balance stable. Good tone.

Psychiatric: The patient appears depressed. He, however, maintains eye contact. Alert and oriented. Dressed in clean blue pants and a grey shirt. His speech is clear, answers questions appropriately. Speech is of normal rate and cadence.

ASSESSMENT

Lab Tests

1. Kidney and liver function test
2. A comprehensive metabolic panel to measures blood sugar level, electrolyte, and fluid balance
3. CBC to evaluate RBCs, CBCs, and Platelets.

Diagnosis

Primary diagnosis:

1. Costochondritis

Differential diagnoses

1. Coronary Artery Disease
2. Heartburn
3. Collapsed lung
4. Gallbladder or pancreas problems
5. Panic attack

Primary Diagnosis:

Costochondritis

According to Flowers (2020), costochondritis is an infection of the rib cartilage that connects it to the sternum. The pain that is caused by the condition mimics a heart attack or similar heart conditions. The pain often occurs on the left side of the breastbone. It is also sharp, aches, or feels like immense pressure and affects multiple ribs. The aching is exacerbated when a patient coughs or takes a deep breath. There is often no cause of costochondritis. However, possible causes include an injury such as a blow to the chest; physical strain such as heavy lifting, severe coughing, and strenuous exercise; rheumatoid arthritis, ankylosing spondylitis, and osteoarthritis; joint infection; and tumors. Additionally, a chest infection, such as a respiratory tract infection and wound infection, can also cause costochondritis. The wear and tear of the chest can also cause pain. J.S. has described the pain he feels as a chest discomfort that occurs as a burning under the sternum. He does not refer to it as pain but rather as discomfort.

Differentials Diagnoses:

Coronary Artery Disease (CAD)

According to Fox et al. (2020), coronary artery disease, also referred to as angina, is caused by the blockage or narrowing of the coronary arteries. The condition is often caused by atherosclerosis, which is the build-up of fatty deposits and cholesterol, referred to as plaques, inside the arteries. The plaques can cause damage to the arteries and clog the arteries, which limits or inhibits the flow of blood into the heart muscles. Angina is often described as a squeezing, fullness, numbness, burning, aching, pressure, tightness, heaviness, and chest discomfort. Although the pain is often felt in the chest, it may also radiate to the jaw, back, neck, arms, or shoulder. Patients may also experience vomiting and nausea, dizziness, lightheadedness, irregular or rapid heartbeats, and anxiety or weakness. Several risk factors predispose J.S. to CAD, and this includes high blood pressure, obesity, diabetes, a lack of physical exercise, being male, age, and stress (Hajar, 2017). In addition, minorities and blacks have a higher propensity to anginas than Whites (American College of Cardiology, 2018). However, this is not considered a possible primary diagnosis because the patient does not report experiencing chest discomfort typical of an angina; there is no chest tightness.

Heartburn

Heartburn is a problem caused by acid reflux, where the stomach contents are forcefully pushed back into the esophagus (Yamasaki, O’Neil, & Fass, 2017). A burning pain is created in the lower side of the chest. Most times, a person will feel heat or warmth and sometimes a burning sensation in the throat and chest that is caused by stomach acid. Other symptoms include an acrid, foul taste in the mouth; indigestion-like and burning pain; rising pain that goes all the way to the jaw; and a burning sensation that is experienced in the middle of the chest. One risk factor predisposing a person to heartburn is being overweight: J.S. is obese class 1. Eating large fatty meals is also known to cause heartburn (Domingues, Moraes-Filho, & Fass, 2018).

Collapsed Lung

A collapsed lung, also called pneumothorax, occurs when air enters the pleural space (Meleiro, Correia, & Mora, 2018). As the air builds up, there is increased pressure in this space, which causes the lung to collapse. The pressure also prevents the lung from expanding when a person attempts to inhale. This, in turn, causes a person to have shortness of breath and chest pain. Primary spontaneous pneumothorax is a kind of collapsed lung that occurs for no apparent reason because it happens without a person having any underlying disease of the lung. The condition can also occur in persons who are otherwise healthy. A secondary spontaneous pneumothorax occurs from an underlying disease of the lungs, such as cystic fibrosis and chronic obstructive pulmonary disease (Leong et al., 2017). The patient could have undiagnosed COPD; his father was diagnosed with COPD.

Gallbladder and Pancreas Problem

Chang et al. (2018) point out that Gallstones are an inflammation of the pancreas and gallbladder, which causes radiating pain from the abdomen to the chest. The exact cause of gallstones is unknown, but theories exist on the same. The first is the excessive accumulation of cholesterol in the bile, which can cause yellow cholesterol stones. The hard stones may develop in the liver, making more cholesterol than can be dissolved by the bile. Also, excessive bilirubin produced by a damaged liver as well as certain blood disorders, causes the formation of pigment gallstones. These gallstones are black or dark brown in color. The gallbladder needs to properly empty the bile so as to function in a healthy manner. Failure to do so results in the overconcentration of bile, which causes the formation of stones. A person with gallstones will experience indigestion, stomach pain, diarrhea, burping, clay-colored stool, dark urine, vomiting, and nausea. A gallbladder problem may cause the patient to feel full or experience pain in the right side of the lower chest or the abdomen’s upper side after a person takes a fatty meal (Gross, Bacaj, & Williams, 2020).

Panic Attack

A panic attack is a sudden feeling of terror that strikes a person with no warning (Greenslade et al., 2017). A panic attack can occur anytime, even while a person is asleep. A person experiencing a panic attack may believe they are having a heart attack, are going crazy, or are dying. The terror and fear that a person experiences are not in proportion to reality and may sometimes be unrelated to the events occurring around the person. Most people will experience symptoms such as breathing difficulties, chest pains, feeling a loss of control, having chills or feeling sweaty, dizziness, fainting or weakness, and a racing heart. Panic attacks last less than 10 minutes though some symptoms may go on longer. Once a person has a heart attack, they are likely to have another, and if the episodes are frequent, then the person is said to have a panic disorder (Greenslade et al., 2017). J.S. is experiencing chest pains though other symptoms have not been identified. One of the predisposing factors of panic attacks is a traumatic event such as illness or death of a loved one. Although J.S. is now remarried, he had to endure the trauma of losing his first wife in a road accident. The event of his loss may be triggering delayed panic attacks. J.S. has also had to have major surgery involving a left-knee total replacement, and this could also cause him to have panic attacks. J.S. has resulted in spending less time doing things that he once loved to do and opts to spend his weekends indoors. This social withdrawal is among the symptoms in persons with panic attacks.

Diagnostic Evaluation

Costochondritis can be assessed using an MRI. A case report by Cubos et al. (2010) shows the effectiveness of MRI and cardiac stress testing in accurately prescribing costochondritis. The study did not indicate any sensitivity or specificity. Coronary heart disease can be identified using an EKG, where the heart electoral activity is assessed both at rest and when a person is active. Nunes, Ramirez, and Aiello (2018) determined that a woman with ischemic heart disease admitted due to chest pain and shock had angina by carrying out an EKG. The electrocardiogram showed PR interval of 122 ms, sinus rhythm, HR of 103 bpm, QT interval of 367 ms, QRS duration of 159 ms, and corrected QT of 480 ms. Heartburn can be assessed using an endoscopy. Gyawali, P (n.d) carried out on a patient an esophageal, high-resolution manometry which revealed 7 sequences with suboptimal contraction vigor (distal contractile integral <450 mm Hg.sec.cm) and 3 failed sequences. These results fulfilled the ineffective esophageal motility criteria. Chest radiography can be used to detect a collapsed lung. In their case patient, Sharma et al. (2020) showed that a chest CT showed a diffuse centrilobular micronodular pattern without focal consolidation in diagnosing a collapsed lung. Lastly, an ECG can be used to determine panic attacks in patients. Elsayed (2018) determined in the case study that during the patient’s anxiety episode, the ECG recordings showed quadrigeminy through all ECG leads. Quadrigeminy is a cardiac arrhythmia where every fourth beat is an extrasystole (premature ventricular contraction) or three sinus beats that occur between extrasystoles.

Plan

Patient and Family Inclusion to Assist In Diagnostic Error Avoidance

The relationship between physicians and patients is part of the larger system in the society and is impacted by the patient’s kin. The family members of a patient can be a source of valuable health information and can work with the physician for a more accurate diagnosis as well as in creating a strategy for a treatment plan. However, in all this, a physician needs to keep a balance when addressing the patient’s concerns to maintain the alliance between family members, patient, and physician. The involvement of family members in patient care improves the communication between the patient, family, and physician and aids in making an accurate diagnosis. Also, family members help patients cope with the illness while collaborating in the treatment plan. In this case, both of J.S.’s parents are deceased, but he is aware of the diseases they had, as mentioned earlier (Keitner, 2014).

Health IT Resources to Improve Diagnostic Accuracy

Electronic documentation can be used to increase diagnostic accuracy and reduce diagnostic errors. IT resources allow for speed, ease, and information search selectivity and aid cognition through contextual relevance, trending, aggregation, and minimization of superfluous data. The resources should also provide space for recording succinct assessments that are thoughtful, unanswered questions, contingencies, differential diagnoses that facilitate the review and sharing of assessments by clinicians and patients. The resources also need to carry forward information for recollection, avoiding repetitive querying and recording of patients while at the same time reducing copying and pasting of data. Lastly, problem list information must be integrated into the workflow to enable continuous updating (Balogh, Miller, & Ball, 2015).

Evidence-Based Evaluation of Implementation of Health IT Resources

The IOM report asserted that health IT safety is a shared responsibility and is described in ways that healthcare organizations, governmental agencies, users, health IT vendors, and others can collaborate to improve health IT safety. When users work with health IT vendors, safety can be proved in all product design phases, from requirements gathering to testing the products. Also, the IOM requested additional funding from the Office of the National Coordinator for Health Information Technology (ONC) to expand processes that promote health IT product development (IOM, 2012). Further, the ONC and health IT vendors need to work in collaboration to ensure that usability in diagnostic processes integrates measurement capability, is incorporated in human factors knowledge, is in line with the workflow in clinics, offers decision support for clinics, and allows for information to flow in a timely manner among healthcare professionals and patients in the process of diagnosis.

Pharmacologic Interventions

Costochondritis responds to nonsteroidal anti-inflammatory medications such as ibuprofen (dosage is 200 to 400 mg orally every 4 to 6 hours as needed). Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) are used in the treatment of angina (dosage is at Amlodipine 5 to 10 mg orally once a day). Antacids can aid in neutralizing stomach acid and quickly relieve heartburn (dosage at Aluminum Hydroxide 320 mg orally every hour). Pleurodesis is indicated by obliterating the pleural space, and Iodopovidone is a safe and effective chemical that can be used to achieve this. The choice of gallstone treatment is dependent on the sizes of the stones. Oral bile acids are used to treat gallstones < 6 mm in diameter using ursodeoxycholic acid 10 mg/kg/day or chenodeoxycholic acid 15 mg/kg/day or given alone or in combination (5 mg/kg/day each). Panic attacks can be treated using Selective Serotonin Reuptake Inhibitors (SSRIs). SSRIs increase serotonin levels and include sertraline, paroxetine, and fluoxetine.

References

American College of Cardiology. (2018). Cover Story | One Size Does Not Fit All: The Role of Sex, Gender, Race and Ethnicity in Cardiovascular Medicine. https://www.acc.org/latest-in-cardiology/articles/2018/10/14/12/42/cover-story-one-size-does-not-fit-all-sex-gender-race-and-ethnicity-in-cardiovascular-medicine

Balogh, E. P., Miller, B. T., & Ball, J. R. (2015). Improving diagnosis in health care.

Cubos, J., Cubos, A., & Di Stefano, F. (2010). Chronic costochondritis in an adolescent competitive swimmer: a case report. The Journal of the Canadian Chiropractic Association, 54(4), 271.

Domingues, G., Moraes-Filho, J. P. P., & Fass, R. (2018). Refractory heartburn: a challenging problem in clinical practice. Digestive diseases and sciences, 63(3), 577-582.

Elsayed, Y. M. H. (2018). An electrocardiographic anxiety-induced quadrigeminy and re-assurance. The Egyptian Journal of Critical Care Medicine, 6(1), 21-23.

Flowers, L.K. (2020). Costochondritis Clinical Presentation. https://emedicine.medscape.com/article/808554-clinical

Fox, K. A., Metra, M., Morais, J., & Atar, D. (2020). The myth of ‘stable’coronary artery disease. Nature Reviews Cardiology, 17(1), 9-21.

Greenslade, J. H., Hawkins, T., Parsonage, W., & Cullen, L. (2017). Panic disorder in patients presenting to the emergency department with chest pain: prevalence and presenting symptoms. Heart, Lung and Circulation, 26(12), 1310-1316.

Gross, A. R., Bacaj, P. J., & Williams, H. J. (2020). Educational Case: Gallstones, Cholelithiasis, and Cholecystitis. Academic Pathology, 7, 2374289520951902.

Gyawali, P (n.d). Case Study: Evaluation of pH Testing in Symptomatic Reflux Disease. http://gifellowadvisor.com/ViewArticle.aspx?d=Patient%2BCases&d_id=507&i=October+2016&i_id=1368&a_id=38256

Hajar R. (2017). Risk Factors for Coronary Artery Disease: Historical Perspectives. Heart views : the official journal of the Gulf Heart Association, 18(3), 109–114. https://doi.org/10.4103/HEARTVIEWS.HEARTVIEWS_106_17

IOM (Institute of Medicine) (2012). Health IT and patient safety: Building safer systems for better care. Washington, DC: The National Academies Press.

Keitner, G (2014). Involve Families in Patient Treatment. https://www.psychiatryadvisor.com/home/practice-management/involve-families-in-patient-treatment/

Leong, P., Tran, A., Rangaswamy, J., Ruane, L. E., Fernando, M. W., MacDonald, M. I., … & Bardin, P. G. (2017). Expiratory central airway collapse in stable COPD and during exacerbations. Respiratory research, 18(1), 163.

Meleiro, H., Correia, I., & Mora, P. C. (2018). New evidence in one-lung ventilation. Revista Española de Anestesiología y Reanimación (English Edition), 65(3), 149-153.

Nunes, R., Ramirez, H., & Aiello, V. D. (2018). Case 6 – Woman with Ischemic Heart Disease Admitted due to Chest Pain and Shock. Arquivos brasileiros de cardiologia, 111(6), 860–863. https://doi.org/10.5935/abc.20180231

Sharma S, Hashmi MF, Rawat D. Case Study: 33-Year-Old Female Presents with Chronic SOB and Cough. [Updated 2020 Apr 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK500024/

Yamasaki, T., O’Neil, J., & Fass, R. (2017). Update on functional heartburn. Gastroenterology & hepatology, 13(12), 725.

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Soap Notes on the John Smith Case

The final case analysis allows the student to demonstrate a thorough but directed clinical history, with initial

hypothesis generation and subsequent testing through specific questioning, selection of a primary diagnosis and differential diagnoses in order of likelihood, physical examination directed at gathering further data necessary to confirm or refute the hypotheses, thoughtful and critical selection of investigations to gather additional data such as appropriate diagnostic studies and implementation of a targeted and rationalized management plan that considers the holistic patient and includes appropriate medication selection.

Case

John Smith is a 50 year old Native American Male who presents with chest discomfort described as burning under the sternum.  He has a history of Hypertension, Hyperlipidemia, Hypothyroidism, Diabetes Mellitus Type II and a sore on the right lower extremity draining purulent exudate He was last seen in the clinic one year ago.  He has no current medications available.  He states he ran out a few months ago.

Complete the final assignment with a page limit of 8-10 pages (Excluding Title, Reference, and Appendices).

Utilize APA format.  It is expected that there will be at least five current evidence based sources in this scholarly paper.

Rubric:

Competency	10 points	8 points	6 points	0 points
Thorough directed clinical history	Includes the ROS, PMH, PSH, and Social history in discussion of clinical history	Discusses clinical history but misses one important consideration (ROS, PMH, PSH, and Social history)	Discusses clinical history but misses two important consideration (ROS, PMH, PSH, and Social history)	Content not presented, No submission
Evidence-supported primary hypothesis for a differential diagnosis	Develops an evidence-supported primary hypothesis for a differential diagnosis	Omits the primary diagnosis or the scientific base	Omits the identification of the most likely diagnosis instead generates a list of potential diagnoses	Content not presented, No submission
Alternate hypotheses (differential diagnoses) and supports with evidence	Develops a list of five alternate hypotheses (differential diagnoses) and supports with evidence	Develops a list of four alternate hypotheses (differential diagnoses) and supports with evidence	Develops a list of 3 or less alternate hypotheses (differential diagnoses) and supports with evidence	Content not presented, No submission
Physical assessment signs that support each differential diagnosis presented	Describes physical assessment signs that support each differential diagnosis presented	Describes physical assessment signs that support most (4) differential diagnosis presented	Describes physical assessment signs that support some Less than 4 differential diagnosis presented	Content not presented, No submission
Prescribes diagnostic studies to evaluate hypotheses.  Includes the specificity and sensitivity of each study	Prescribes diagnostic studies to evaluate all hypotheses.  Includes the specificity and sensitivity of each study	Prescribes diagnostic studies to evaluate most (4) hypotheses.  Includes the specificity and sensitivity of each study	Prescribes diagnostic studies to evaluate all hypotheses.  Does not include specificity and sensitivity for tests	Content not presented, No submission
Patient and family inclusion to assist in diagnostic error avoidance	Thoroughly discusses patient and family inclusion to assist in diagnostic error avoidance	Discusses patient inclusion without any family or community discussion or strategy presentation	Discusses generalized importance of Patient and family inclusion but provides no planned strategy	Content not presented, No submission
Health IT resources to improve diagnostic accuracy	Describes Health IT resources to improve diagnostic accuracy	Describes Health IT resources but does not relate to specific case or diagnostic accuracy	Speaks in general about Health IT without discussion of its impact on diagnostic accuracy	Content not presented, No submission
Evidence-based evaluation of implementation of Health IT resources	Provides evidence-based support of implementation of Health IT resources to improve diagnostic accuracy	Describes evidence-based implications but does not relate to specific case AND diagnostic accuracy	Describes evidence-based implications but does not relate to specific case OR diagnostic accuracy	Content not presented, No submission
Pharmacologic interventions appropriate to each differential diagnosis	Chooses pharmacologic interventions appropriate to each differential diagnosis	Chooses pharmacologic interventions appropriate to most (4) differential diagnoses	Chooses pharmacologic interventions appropriate to some (less than 4) differential diagnoses	Content not presented, No submission
	5	4	3	0
Demonstrates graduate level writing skills without grammatical errors	No grammatical errors	One to two grammatical errors	Three to four grammatical errors	Content not presented, No submission
Demonstrates compliance with APA	No APA errors	One to two APA errors	Three to four APA errors	Content not presented, No submission

Submission status