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CHF Soap

The patient is a 76-year-old male presenting with a dry cough, extreme fatigue, shortness of breath at night, and a 10 pound weight gain over the past few weeks. His physical exam reveals an S3 heart sound, rales in the lower lungs bilaterally, jugular vein distension of 6 cm, and he is overweight. Potential diagnoses include congestive heart failure, anemia, pneumonia, asthma complications, or cancers like leukemia based on his symptoms and family history of his father passing from CHF. Laboratory tests ordered include a CBC, BMP, and chest x-ray to check for signs of heart failure or other issues.

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6K views

CHF Soap

The patient is a 76-year-old male presenting with a dry cough, extreme fatigue, shortness of breath at night, and a 10 pound weight gain over the past few weeks. His physical exam reveals an S3 heart sound, rales in the lower lungs bilaterally, jugular vein distension of 6 cm, and he is overweight. Potential diagnoses include congestive heart failure, anemia, pneumonia, asthma complications, or cancers like leukemia based on his symptoms and family history of his father passing from CHF. Laboratory tests ordered include a CBC, BMP, and chest x-ray to check for signs of heart failure or other issues.

Uploaded by

murex8125
Copyright
© © All Rights Reserved
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Download as PDF, TXT or read online on Scribd
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Jesse Grieb

N01506291
FACR Make Up
11/14/14
SOAP Note for Congestive Heart Failure
S: Pt is a 76 y/o male accompanied by his wife in the ER. He presents with a dry cough and
reports he has been extremely tired recently. He has woken up in the night short of breath,
which he has never experienced prior. He also complains of weight gain in the past couple
weeks of about 10 pounds.
HPI: 76 y/o Male presenting with cough without sputum and fatigue. Pt complains of abnormal
recent weight gain as well as pillow orthopnea, paroxysmal nocturnal dyspnea, and dyspnea.
Pts parents are deceased with his father passing away at 80 with CHF and his mother passing
away at 96 from natural causes. Potential diagnoses at this point can include CHF, anemia,
pneumonia, complications due to asthma, cancers such as leukemia, or sleep apnea.
Pt has had no surgeries and is on no medication, with no allergies to environment, food, or
medicine.

O:
Physical Exam
BP: 124/76, RR: 22, Pulse: 55 BPM, Temp 97.6 F
Overweight male with observable SOB
Heart has an S3 sound
Lungs have rales in lower lobes bilaterally with decreased breath sounds
Abdomen is soft, NTND, BS+ and no organomegaly
Genitalia has no masses, lesions, deformities or discharges
Skin is warm, dry, with no lesions or rashes.
Neurologically intact
+JVD 6 cm
Three laboratory tests to order include a CBC, BPM, and chest X-ray. Three diagnostic tests
would be an EKG, a stress test, and sleeping tests.
The CBC would be largely normal with possible pertinent abnormal findings correlating to kidney
disfunction. BPM would also be normal except for kidney function testing, and the chest X-ray
could reveal fluid in the lungs or cardiomegaly.The CBC would exclude a cancer such as
leukemia or anemia. The EKG would show an abnormal rate of the heart, excluding sleep
apnea or complications from asthma.The stress test could show pertinent findings to CHF or
pneumonia,

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