Cardiovascular System Examination-Coronary Artery Disease

Cardiovascular System Examination-Coronary Artery Disease

Comprehensive patient history can be taken by embracing SOAP notes. This acronym identifies major components: subjective data, objective data, assessment, and plan (Podder et al., 2021). SOAP notes facilitate a logical organization of ideas (Podder et al., 2021). Completeness of history taking facilitates accurate diagnosis and development of relevant treatment plans.

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Subjective

F.D. is a forty-five-year-old Caucasian female. She complains of severe chest pain, shortness of breath, and lightheadedness. She reports that the chest pain has persisted for three days. Initially, the pain was worsened by exertion and relieved by rest. However, for the past few hours, her pain is not relieved by rest. According to her, she has experienced lightheadedness and shortness of breath for the past four hours. She reports that she was diagnosed with hypertension five years ago. Furthermore, two years ago, she was diagnosed with diabetes mellitus. Nine months ago, she was hospitalized for a hyperosmolar hyperglycemic state.

Currently, the patient is taking enalapril 5 mg and amlodipine 5 mg PO daily for her hypertension. She reports using metformin 500 mg PO BD for her diabetes mellitus. The patient has no known drug or food allergy. However, she is allergic to environmental allergens such as pollen. The patient reports no family history of hypertension and other cardiovascular conditions. She says that her mother had diabetes mellitus. The patient has been married for twenty years. Despite her commodities, she says that she occasionally engages in binge drinking and has limited physical activity. The patient’s subjective data suggest coronary artery disease. A definitive diagnosis can be made after taking the patient’s objective data.

Objective

The patient’s blood pressure is 148/88, whereas her pulse rate is 110. Her respiratory rate per minute is 24. She has an oxygen saturation of 93%. An investigation of her fractional flow reserve (FFR) reveals that her FFR is 0.73. Heart murmurs, S4 gallop, and S3 gallop are revealed via auscultation. An evaluation of the extremities reveals finger clubbing and mild cyanosis.

Further examination indicates mild pitting edema. Examination of the patient’s mass and height reveals a body mass index of 27.5. Laboratory results suggest that the patient’s hemoglobin A1C is 6.5. Her random plasma glucose levels are 220 mg/dl. The patient’s lipid profile for low-density lipoproteins, high-density lipoproteins, and triglycerides are 105 mg/dl, 50 mg/dl, and 160 mg /dl, respectively. Results from nuclear imaging studies reveal coronary artery stenosis.