Daniel DeMarco                                          SOAP Note #1                                      Internal Medicine

S

MC is a 55yo female former smoker with PMH HLD who presented yesterday (3/17/2019) for a 3d complaint of chest pressure with exertion. Endorsed nausea and SOB. Denied fever, chills, cough, lightheadedness. Also complains of 3wk history of left arm tingling and weakness with hand grasp. Denies loss of sensation, seizures, fainting.

O

VS

T 36.6C, HR 73bpm, BP 110/77, RR 16 breaths/min, SpO2 99% RA

 

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: No deformity or joint abnormality. No edema. Peripheral pulses intact.

 

Labs

3/18/2019

         14.4

8.44> 44.2 < 231

 

141 | 107 | 15  < 87

4.8  | 22  | 0.8

 

Trop: <0.01

 

3/17/2019

Trop: < 0.01

BNP: 29

Total Cholesterol: 211 (H)

Triglycerides : 153 (H)

HDL: 59

LDL: 121 (H)

Total Cholesterol:HDL: 3.58

 

Imaging/Diagnostic Studies

3/17/2019

EKG: NSR

CT Brain: Unremarkable

CT Cervical Spine: Degenerative changes at C5-C6, C6-C7

 

A/P

MC is a 55yo former smoker with PMH HLD with likely Angina Pectoris and Cervical Radiculopathy

#Chest Pain – Musculoskeletal vs. Angina vs. Acute MI – improving

• CTA Coronary Arteries with Calcium Scoring this am
• Trop x 2 negative
• Repeat EKG
• Cont. Pravastatin 40mg PO qd
• Cont. ASA 81mg PO qd

#L Arm Pain – 2’ to Cervical Radiculopathy vs. ACS

• If cardiac w/u negative, f/u with PMD for likely L Arm Pain 2’ to Cervical Radiculopathy given CT findings

#HLD

• Cont. Pravastatin 40mg PO qd

 

DVT prophylaxis with intermittent pneumatic compression

 

Anticipate discharge today (3/18/2019) pending negative CTA Coronary Arteries with Calcium Scoring

 

Case discussed with Dr. Mathew MD who agrees with A/P.

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student