Reinier Galvez Piedramiami Regional University Encounter Dat ✓ Solved
Reinier Galvez Piedramiami Regional University Date Of Encounterprecep
Reinier Galvez Piedramiami Regional University Date of Encounter: Preceptor/Clinical Site: Clinical Instructor: Patricio Bidart, MSN, APRN, FNP-C Soap Note # _1___ Main Diagnosis : Heart Failure PATIENT INFORMATION Name : Age : Gender at Birth: Gender Identity : Source : Allergies : Current Medications: · PMH: Immunizations: Preventive Care : Surgical History : Family History : Social History : Sexual Orientation : Nutrition History :
Subjective Data: Chief Complaint : Symptom analysis/HPI: The patient is … Review of Systems (ROS) CONSTITUTIONAL : NEUROLOGIC : HEENT : RESPIRATORY : CARDIOVASCULAR : GASTROINTESTINAL : GENITOURINARY : MUSCULOSKELETAL : SKIN :
Objective Data: VITAL SIGNS: GENERAL APPREARANCE : NEUROLOGIC: HEENT: CARDIOVASCULAR: RESPIRATORY: GASTROINTESTINAL: MUSKULOSKELETAL: INTEGUMENTARY: ASSESSMENT: Main Diagnosis (Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 6th or 7th Edition.
Differential diagnosis (minimum 3) - - - PLAN: Labs and Diagnostic Test to be ordered (if applicable) · - · - Pharmacological treatment: - Non-Pharmacologic treatment : Education (provide the most relevant ones tailored to your patient) Follow-ups/Referrals References (in APA Style) Examples Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.). ISBN Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult th ed.). Print (The 5-Minute Consult Series).
Sample Paper For Above instruction
Introduction
The management of heart failure (HF) requires a comprehensive approach, integrating detailed history-taking, thorough physical examination, accurate diagnosis, and appropriate management strategies. This case study outlines a detailed SOAP note for a patient presenting with symptoms indicative of HF, emphasizing evidence-based practice aligned with current clinical guidelines.
Patient Information and Subjective Data
The patient is a [age]-year-old [gender] with a history suggestive of heart failure. The chief complaints include dyspnea on exertion, fatigue, and bilateral lower extremity swelling. The history of present illness (HPI) indicates a gradual worsening of symptoms over the past few weeks. The review of systems (ROS) highlights constitutional symptoms such as fatigue, and respiratory complaints like shortness of breath. The patient reports no known drug allergies and is on medications including lisinopril and furosemide.
Objective Data and Physical Examination
Vital signs reveal elevated blood pressure, tachycardia, and mild edema. General appearance shows patient appears fatigued but alert. Cardiovascular examination reveals displaced apical impulse, presence of S3 gallop, and bilateral pitting edema. Lung auscultation indicates bibasilar crackles. Other physical exam findings are consistent with volume overload states.
Assessment and Diagnosis
The primary diagnosis identified is Heart Failure with reduced ejection fraction (HFrEF), corresponding to ICD-10 code I50.2. This diagnosis is supported by clinical findings and review of echocardiogram results indicating decreased ejection fraction.
Differential Diagnoses
- Chronic obstructive pulmonary disease (COPD) – ICD-10 code J44.9
- Pulmonary hypertension – ICD-10 code I27.20
- Anemia – ICD-10 code D64.9
Plan and Management
Laboratory and Diagnostic Tests
- Echocardiogram to assess ejection fraction
- B-type natriuretic peptide (BNP) levels
- Complete blood count (CBC)
- Electrolyte panel
Pharmacological Treatment
- ACE inhibitor (e.g., lisinopril) to improve survival
- Beta-blocker (e.g., carvedilol) for rate control and mortality benefit
- Diuretics (e.g., furosemide) for volume overload
- aldosterone antagonists if indicated
Non-Pharmacologic Management
- Low-sodium diet
- Fluid restriction
- Weight monitoring to detect fluid retention
- Physical activity as tolerated
Patient Education and Follow-Up
Education includes medication adherence, symptom monitoring, and lifestyle modifications. Follow-up is scheduled in 1-2 weeks to reassess clinical response and medication titration. Referral to a cardiologist may be indicated for advanced therapies or device management.
Conclusion
This case emphasizes the importance of a systematic approach to diagnosing and managing heart failure. Incorporating evidence-based guidelines, patient education, and regular follow-up optimizes outcomes in HF patients.
References
- Codie, M. T. (2014). Family nurse practitioner certification intensive review (2nd ed.). McGraw-Hill Education.
- Domino, F., Baldor, R., Golding, J., & Stephens, M. (2010). The 5-minute clinical consult (20th ed.). Wolters Kluwer.
- Yancy, C. W., Jessup, M., Bozkurt, B., et al. (2017). 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation, 136(6), e137–e161.
- Hunt, S. A., Abraham, W. T., Chin, M. H., et al. (2009). 2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the diagnosis and management of heart failure in adults. Journal of the American College of Cardiology, 53(15), e1–e90.
- McMurray, J. J., Adamopoulos, S., Anker, S. D., et al. (2012). ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012. European Heart Journal, 33(14), 1787–1847.
- Ponikowski, P., Voors, A. A., Anker, S. D., et al. (2016). 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Journal of Heart Failure, 18(8), 891–975.
- Lee, C., & Mudd, J. O. (2019). Heart failure: Pathophysiology and management. BMJ, 366, l5291.
- Nichols, M., Townsend, N., Scarborough, P., & Rayner, M. (2019). Cardiovascular disease in Europe: Epidemiological update 2019. European Heart Journal, 40(20), 1881–1890.
- American College of Cardiology Foundation/American Heart Association Task Force. (2013). 2013 ACCF/AHA guideline for the management of heart failure. Circulation, 128(16), e240–e327.