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