Daniel DeMarco SOAP Note #2 Internal Medicine
S
AC is a 75yo male former smoker HD4 with PMH CAD s/p CABG, multiple PCI, DM2, COPD, Interstitial Fibrosis a/w acute on chronic systolic heart failure. He was recently admitted and discharged from Plainview Hospital (3/2019) for lower extremity cellulitis.
O
VS
T 36.4C, HR 68bpm, BP 103/49, RR 18 breaths/min, SpO2 92% NC 3LPM
PE
Gen: Appears stated age. AxO x 3. No apparent distress.
CV: Regular rate and rhythm. S1 and S2 are normal. No murmurs, S3, S4, splitting of heart sounds, friction rubs.
Pulm: Clear to auscultation bilaterally. Chest expansion symmetrical. No wheezing, rhonchi, rales, dullness.
Abd: Soft, nondistended, non-tender. BS presents in all four quadrants. No guarding, rebound.
Extremities: Minimal edema. B/L LE with reddish, dark purple discoloration. No ulcers present.
Labs
3/18/2019
11.8
6.79> 36.9 < 303
138 | 98 | 55 < 97
5.0 | 28 | 0.8
Uric Acid: 11.5
TSH: 1.11
A/P
AC is a 75yo male with PMH CAD s/p CABG, multiple PCI, DM2, COPD, interstitial fibrosis a/w acute on chronic systolic heart failure, now with AKI
#Acute on Chronic Systolic Heart Failure – Dietary Indiscretion – improving
- Carvedilol 6.25mg PO bid
- Cont. Losartan 50mg PO bid
- Cont. Atorvastatin 40mg PO qd
- Appreciate Cardiology recommendations
- Cont. I/Os, daily weights
#AKI – 2’ to Diuresis – improving
- NS Bolus prn
- Cont. to monitor
#B/L LE Venous Stasis Changes
- Rec. compression stockings
- Rec. elevation
- Cont. wound care prn
- f/u with Vascular Surgery
DVT prophylaxis with Heparin SubQ and intermittent pneumatic compression
GI prophylaxis with H2 blocker
Anticipate discharge tomorrow pending normal renal function (BUN/Cr); resolution of AKI
Case discussed with Dr. Mathew MD who agrees with A/P.
/s/ Daniel DeMarco, PA-S
Physician Assistant Student