Daniel DeMarco                                               SOAP Note #3                           Internal Medicine

S

ES is a 59yo female with PMH chronic intermittent swelling of left lower extremity initially complaining of abdominal pain and found to have superior mesenteric artery dissection and left renal infarct. Work up revealed fibroelastoma on the non-coronary cusp of the aortic valve. She is hospital day 10. This AM she is in good spirits. She is looking forward to going home soon. She is tolerating her diet, having non-bloody normal BM, and states that her abdominal pain has resolved since discontinuing steroids. No complaints at this time. Denies nausea, vomiting, fever, chills, abdominal pain.

O

VS

T 36.8C, HR 78bpm, BP 134/85, RR 15 breaths/min, SpO2 92% RA

PE

Gen: Sitting comfortably in bed. Speaking and AOx3. No apparent distress.

CV: Regular rate and rhythm. S1 and S2. No murmurs, gallops, rubs.

Pulm: Chest expansion symmetrical. No accessory muscle use. Clear to auscultation bilaterally. No wheezing, rhonchi, rales, dullness. Resonant to percussion throughout. No dullness.

Abd: Non-distended. Normoactive BS in all quadrants. Non-tender to palpation throughout. No guarding, rebound. Non-tympanic to percussion throughout.

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

Labs

3/29/2019

10.6

11.59> 31.1 <282

 

137 |105 | 19 < 95

3.3  | 23  | 0.8

Mg2+: 1.9

11.6 | 59.1

^

1.1

 

3/28/2019

FOBT: Positive

3/23/2019, 3/24/2019

Beta-2 Glyco 1 IgA, IgG, IgM <9

ANCA-Cytoplasmic, ANCA-Perinuclear, ANCA-Atypical <1:20 titer

PTT Lupus Anticoagulant 42.8s, Dilute Russell Viper Venom Test 43.9s

 

Diagnostic Imaging/Procedures

3/26/2019

CV TEE w Therapeutic IV PNL

EF: 60-65%

No atrial thrombus

1+ mitral regurgitation

Aortic valve is trileaflet with a 0.6cm x 0.3cm globular mass on the left ventricular aspect of the non-coronary cusp of the aortic valve, consistent with a papillary fibroelastoma. There is 1+ regurgitation.

Trivial tricuspid regurgitation, pulmonic regurgitation.

3/29/2019

Left Knee XR

No acute fracture or dislocation. Mild medial joint space narrowing with no significant osteophyte formation. No radiographic joint effusion.

 

A/P

ES is a 59yo female with PMH chronic intermittent swelling of left lower extremity with superior mesenteric artery dissection, left renal infarct, and fibroelastoma of aortic valve.

Cardiovascular

#Superior Mesenteric Artery Dissection

#Left Renal Infarct

– Cont. Heparin gtt

– Cont. Coumadin 10mg PO qd, INR: 1.1. Goal of INR: 2-3.

– Cont. acetaminophen tablet 650mg PO q6h PRN, morphine sulfate injection 2mg IV q2h PRN pain 4-6 on pain scale, morphine sulfate injection 4mg IV q2h PRN pain 7-10 on pain scale

– f/u Hypercoaguable work up as outpatient

#Fibroelastoma on the Non-Coronary Cusp of the Aortic Valve

– Outpatient resection of the mass with Dr. Dimeo

Hematology

#Iron-Deficiency Anemia – Stable

– 3/28/2019 FOBT: Positive

– Cont. to monitor and transfuse as necessary (hemoglobin < 7)

– No further GI workup

#Slight Elevation of WBC – Decreasing

– Due to recent Solumedrol use

– Cont. to monitor

Metabolic

#Hypokalemia

#Hypomagnesemia

– Potassium Chloride 30mEq PO one time

– Magnesium Sulfate 1g PO one time

Musculoskeletal

#Left Knee Pain

#Chronic Intermittent Swelling of Left Lower Extremity

– XR showed mild medial joint space narrowing with no significant osteophyte formation.

– Patient reassured

– f/u with PMD

DVT Prophylaxis: Heparin, Coumadin, IPC

Nutrition: Low Fiber Diet

Dispo: Plan for discharge once INR is therapeutic (INR: 2-3)

 

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

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student