Soap Note: Gastroesophageal Reflux Disease, Acute Coronary Syndrome, Anxiety, Angina Pectoris

“I have chest pain.”

JF was admitted to the hospital with complaints of pain in her chest that woke her from sleep the previous night. She describes the pain as squeezing and tightness in her chest with the pain radiating to her jaw, neck, and left arm. The pain in her chest is midsternal. The patient also complains of sweating excessively when she felt chest pain. She reported that the pain lasted for twenty minutes, and then it suddenly subsided. JF admits that she has had similar attacks two to three times in the last six months, but they were less intense and only lasted for less than two minutes. The attacks occurred when she was playing with her grandchildren or when she was emotionally overwhelmed. The pain immediately subsided when she had a rest, and for this reason she did not seek any medical attention. Last night, the pains were not relieved when she tried sitting upright or taking antacids, and she could not recall anything that alleviated the pain. The aggravating factors in the previous attacks were physical activity and emotional distress. However, the patient could not identify any precipitating factors last night. The patient denies any burning sensation in the throat, modification of diet, or acid reflux. She also said that she did not have any light-headedness, dyspnea, coughing, or falling unconscious. JF also denies any new chest pains since yesterday night.

Hydrochlorothiazide 25mg daily oral for her hypertension.

Atorvastatin 20mg daily oral for her hyperlipidemia.

The patient denies the use of any over-the-counter drugs.

Allergies:

The patient does not have allergies to latex or food. 

Medication Intolerances:

The patient is intolerant to sulfur medications as well as to penicillin.

Chronic Illnesses/Major traumas:

The patient has a history of hyperlipidemia and hypertension. However, she denies having any history of diabetes, cancer, seizures, asthma, urinary disorders, thyroid problems, kidney diseases, or depression.

Hospitalizations/Surgeries:

The patient had tonsillectomy when she was a teenager, so she was hospitalized for three days.

Father: Died of myocardial infarction at the age of sixty-five years.

Mother: Although she is eighty-seven years old, the woman is still in good health. She stays at a home for the elderly.

Sister: Suffers from hypertension and obesity.

Brother: Died from a car accident at twenty-two years of age.

The patient denies any family history of diabetes, bleeding disorders, tuberculosis, or mental illness.

JF is a college graduate from the University of Pennsylvania, and she has been employed as an accountant all her life in different firms. She retired twenty years ago and had been living alone in her farmhouse since that time. JF is single. She admits to smoking cigarettes and drinking alcohol. However, JF emphasizes that she drinks occasionally, during the events she is invited to. She denies use of any other recreational drugs. The patient frequently walks her dog outside in the evening but does not engage in any weight-bearing activities. Moreover, JF eats a diet with fewer amount of fat and has drastically reduced her salt intake. She has also increased her intake of fruits and vegetables. Her immunizations are up-to-date, and she had her influenza shot three months ago. She practices safe sex by using condoms and always wears a safety belt.

The patient denies any changes in body weight, temperature, chills, or decreased energy levels. She, however, admits to having night sweats accompanying her chest pains.

She complains of chest pain that woke her from her sleep. In addition, she describes the pain as squeezing and tight around her midsternal region. The chest pains were occasionally present during the previous attacks. She denies any palpitations, swelling in the extremities, paroxysmal nocturnal dyspnea, or shortness of breath when lying flat.

The patient denies any discolorations of the skin, rashes, wounds, or moles. However, she has some stretch marks on her hips.

The patient does not mention cough or a cough with blood, dyspnea at rest or with exertion, wheezing, or any difficulties with breathing from time to time. She also denies any history of tuberculosis or pneumonia.

The patient wears corrective lenses as she is short-sighted but has not had a modification in the lens power for the past ten years.

She denies any change in her bowel habits, pain in the abdomen, nausea, vomiting, reflux, hemorrhoids, melena, or any alterations in feeding patterns.

She does not suffer from otalgia, hearing loss, tinnitus, or any discharge from the ears.

The patient denies any changes in her urine color, incontinence, pain on urination, or a variation in her urinating pattern.

Moreover, she has no complaints of itchiness, as well as discharge or tenderness in her vagina, but reports a drop in libido and has been less sexually active in the preceding years. The patient denies any history of pregnancy or contracting any sexually transmitted infections.

The patient denies any nasal congestion, epistaxis, drainage from the nose, or any changes in her sense of smell. She also does not suffer from such health issues as sore throats, difficulty in swallowing, toothaches, bleeding gums, or a dry mouth.

She has no complaints of arthritis, arthralgia, pain in the back, or any history of osteoporosis and fractures.

JF also denies any masses, lesions, discoloration, or discharge from her breast.

The patient does not mention any headaches, fainting, muscle weakness, transient paralysis, paresthesia, or dizziness.

JF does not have any history of sweating at night until recently when she has had chest pains. She is HIV negative and denies having swollen nodes, excessive thirst or hunger, and intolerance to heat and cold.

She denies having mood swings, anxiety, depression, or any suicidal ideas.

JF is a friendly, well-dressed, and neatly groomed obese female in no acute distress. She is well oriented in time and space, alert, and reliable judging from the way she answers the questions. The patient was uneasy at first but relaxed as the conversation continued.

The integument is brown, intact, dry, warm, and clean with no lesions or rashes observed.

The head is normal, non-tender, and with no visible scars. PERRLA. The eyelashes and eyebrows are appropriate for her ethnicity, and there are no lesions noted on her eyes. The external meatus of the ears are open, and the eardrum is shiny gray and reflects light. The nasal mucosa is pink with normal conchae, and the septum is midline. The mucosa in the throat is pink without erythema or any exudate. The teeth are in good condition, and there is no notable irritation caused by the gums.

Neck

The trachea is midline, and the neck is not sensitive to touch, able to bend, and quite supple – that is to say it has an optimal range of motion. The thyroid is not enlarged, and no palpable nodules are present.

Crisp S1, S2 is heard with normal rate and rhythm, without additional heart sounds, murmur, or gallop. The apical pulse is not visible, and it is faintly palpable at the mid-clavicular line, fifth intercostal space with no thrill or heave. There is no apparent jugular venous distention, and the jugular venous pressure is less than 8 centimeters. The upstrokes on the carotid were brisk but no bruits were heard. Edema was absent and the capillary refill time was measured as less than 3 seconds.

The thorax is non-tender, not distorted, and with symmetric expansion. The patient does not cough, and her breathing is regular and with ease. The lung fields resonate upon percussion; crackles are absent.

JF’s abdominal region is soft, fat, non-tender, and without palpable organ enlargement. The bowel sounds can be heard in the four sections. Following percussion, there were areas of dullness noted.

The breasts are wrinkled and have no discoloration. There is no discharge; they are free from masses or tenderness.

Examination of the external genitalia reveals pubic hair with normal distribution and no skin discoloration. No lesions were seen on the vulvar, and the vaginal walls were pink, rugated, and with no lesions. The bladder is slightly distended, ovaries are not palpable, and there are no adnexal masses. No hemorrhoids were found following a rectal assessment.

She has a relative range of motion in her upper limbs and limited range of motion in her lower limbs as she walks around in the room.

Her speech is fluent and in a good tone. She demonstrates a normal gait and stable balance.

The patient is alert and well oriented in time and space. She answers the questions asked accordingly and maintains eye contact during the conversation. Her speech has normal rate.

1. Chest x-ray, anterior-posterior and lateral.

2. 12 lead electrocardiogram to check for T wave inversion or any changes in ST segment.

3. Complete Blood Count.

4. Lipid panel.

Troponin test to check for troponin proteins in blood and determine the extent of heart damage.

1. Gastroesophageal reflux disease.

2. Acute Coronary Syndrome.

3. Anxiety.

· Final diagnosis

Angina pectoris

This diagnosis is supported by the precordial chest pain described by JF as tightness with the pain radiating to the left arm and accompanied by excessive sweating that lasted for 20 minutes (Mohan, 2010). The patient also has predisposing factors such as hypertension, hyperlipidemia, and obesity. The earlier attacks occurred due to physical exertion and emotional distress that resolved suddenly. Since JF does not have continuous chest pain, most probably it is not Acute Coronary Syndrome. Additionally, it is not a gastroesophageal reflux disease as the patient denied any reflux and the pain did not subside after taking antacids. Anxiety, however, deprives one of sleep which may be the underlying cause of multiple health issues (Mayo Clinic Staff, 2014).

· Further testing

1. Ultrasonic cardiogram.

2. Exercise electrocardiogram.

· Medication

1. Metoprolol 25mg daily oral for angina.

2. Acetyl Salicylic Acid 81mg daily oral as antiplatelet therapy.

3. Nitroglycerine 0.4mg sublingually when there is an urgent need to eliminate acute pain in her chest.

· Education

The patient is advised on how to take the medication and how important it is to comply with the medication regimen. She is also recommended to store nitroglycerine away from light. What is more, JF is also encouraged to consider weight loss programs to reduce her weight. The practitioner also urged her to continue with her antihypertensive drugs and the statins for her hyperlipidemia.

· Nonmedication Treatments

The patient should stop smoking at all costs. She should increase her intake of fruits and fibers and reduce consumption of foods with high cholesterol levels. She should also avoid stress and have enough time for rest (Mayo Clinic Staff, 2014).

· Follow-up

JF should return to the hospital for further tests on her heart and regular check-ups to observe the progress with hypertension and hyperlipidemia.