Introduction
Clinical SOAP notes play a crucial role in advanced practice documentation skills, clinical reasoning, and the formation of evidence-based care plans. In this assignment, a hospital follow-up progress SOAP note will be developed based on a clinical patient from a practicum setting in an Acute Care Hospital. The assessment will include a one-sentence description of the primary working diagnosis, a description of the current illness or hospital stay, a list of affected systems, findings from the examination conducted in the last 24 hours, admission diagnostics, pertinent acute and chronic diagnoses, treatment plan, and discussion of relevant considerations.
Primary Working Diagnosis and Context
The primary working diagnosis for this patient is acute myocardial infarction with pending differential diagnoses of stable angina, acute pericarditis, and coronary artery spasm. The patient is being seen in the Acute Care Hospital.
Description of Current Illness or Hospital Stay
The patient has been hospitalized for three days due to chest pain and shortness of breath. Upon admission, an electrocardiogram (ECG) showed ST-segment elevation in leads II, III, and aVF, indicating myocardial infarction. Troponin levels were found to be elevated, further confirming the diagnosis. Echocardiogram revealed reduced left ventricular ejection fraction of 40%, suggestive of myocardial damage. The patient has been started on aspirin, clopidogrel, heparin infusion, and oxygen therapy.
Systems Affected by the Working Diagnosis
The working diagnosis of acute myocardial infarction affects various systems in the body.
1. Cardiovascular System:
– Positive Effects: The working diagnosis leads to increased awareness of heart health and the need for lifestyle changes. It also facilitates the identification and management of underlying cardiovascular risk factors.
– Negative Effects: The working diagnosis contributes to myocardial damage, decreased cardiac output, and potential complications such as arrhythmias or heart failure.
2. Respiratory System:
– Positive Effects: The working diagnosis of acute myocardial infarction prompts assessment and management of potential pulmonary congestion and aids in the prevention of fluid overload or acute respiratory distress.
– Negative Effects: The working diagnosis increases the risk of respiratory distress due to associated cardiac dysfunction and impaired gas exchange.
3. Renal System:
– Positive Effects: The working diagnosis prompts monitoring of kidney function and the prevention of acute kidney injury by maintaining adequate fluid balance and avoiding nephrotoxic medications.
– Negative Effects: The working diagnosis may result in decreased renal perfusion due to reduced cardiac output, potentially leading to impaired renal function.
4. Musculoskeletal System:
– Positive Effects: The working diagnosis increases awareness of the importance of physical activity and exercise for cardiac health. It also motivates the implementation of cardiac rehabilitation programs to improve musculoskeletal function.
– Negative Effects: The working diagnosis may restrict physical activity temporarily and lead to muscle weakness or deconditioning during the hospital stay.
5. Gastrointestinal System:
– Positive Effects: The working diagnosis prompts monitoring of gastrointestinal perfusion, prevention of stress ulcers, and appropriate administration of medications with consideration for potential drug interactions.
– Negative Effects: The working diagnosis may contribute to decreased gastrointestinal motility, nausea, or anorexia due to sympathetic stimulation and side effects of medications.
Examination Findings within the Last 24 Hours
Within the last 24 hours, the following systems were examined:
1. Cardiovascular System:
– Pertinent Findings: On auscultation, S1 and S2 heart sounds were audible without murmurs. Blood pressure was 130/80 mmHg, heart rate was 88 beats per minute, and rhythm was regular. No new murmurs or gallops were noted.
2. Respiratory System:
– Pertinent Findings: Respiratory rate was 18 breaths per minute, lungs were clear to auscultation with equal air entry bilaterally, and there was no respiratory distress or use of accessory muscles.
3. Renal System:
– Pertinent Findings: Urine output was within normal limits, and there were no signs of fluid overload or decreased renal function.
4. Musculoskeletal System:
– Pertinent Findings: Range of motion in the extremities was within normal limits, and no muscle weakness or joint deformities were observed.
5. Gastrointestinal System:
– Pertinent Findings: The patient had a bowel movement within normal limits, and there were no signs of gastrointestinal bleeding or distension.
Admission Diagnostics
The following admission diagnostics were conducted for this visit or within the last 24 hours:
1. ECG (CPT Code 93000)
2. Troponin levels (CPT Code 84484)
3. Echocardiogram (CPT Code 93306)
4. Complete blood count (CPT Code 85025)
5. Basic metabolic panel (CPT Code 80053)
Pertinent Acute and Chronic Diagnoses
The pertinent acute diagnosis for this patient is acute myocardial infarction. The chronic diagnoses include hypertension, dyslipidemia, and obesity. Differential diagnoses of stable angina, acute pericarditis, and coronary artery spasm have been eliminated based on clinical findings and diagnostic results.
Treatment Plan
The treatment plan for this patient includes admission to the hospital for cardiac monitoring and management of acute myocardial infarction. The patient will undergo percutaneous coronary intervention (PCI) within the next 24 hours. Prescribed medications include aspirin, clopidogrel, atorvastatin, enalapril, and metoprolol. The dosages are as follows: aspirin 81 mg daily, clopidogrel 75 mg daily, atorvastatin 40 mg daily, enalapril 10 mg twice daily, and metoprolol 25 mg twice daily. Cardiac rehabilitation will be initiated upon discharge. No relevant consults or follow-up procedures are needed at this time.
Relevant Considerations
Ethical considerations for this patient include obtaining informed consent for the planned percutaneous coronary intervention (PCI), ensuring confidentiality and privacy of patient information, and respecting the patient’s autonomy in decision-making. Legal considerations involve adherence to documentation requirements, maintaining accurate and complete medical records, and compliance with regulatory standards. Geriatric-specific considerations include frailty assessment, management of polypharmacy, and addressing age-related physiological changes in treatment planning and monitoring.
Conclusion
In conclusion, this hospital follow-up progress SOAP note provides a comprehensive assessment of a patient with acute myocardial infarction. The note includes the primary working diagnosis, description of the current illness, affected systems, examination findings, admission diagnostics, acute and chronic diagnoses, treatment plan, and relevant considerations. The advanced practice documentation skills demonstrated in this SOAP note are essential for providing high-quality patient care and effective interdisciplinary communication.
