ACUTE CORONARY SYNDROME
Acute Coronary Syndrome SOAP Note Identifying Information Patient: A.P. 50 y/o BF. DOB: 07/10/1965 Visit: 03/30/15, 0900 Medical HX: Pt. was diagnosed with stage 2 HTN, hyperlipidemia five years ago. Both are well controlled with medication, diet, and exercise. Patient diagnosed with pernicious anemia one year ago and is currently not experiencing complications related to her disorder. No other childhood or adult diseases and immunizations UTD. She received the flu vaccination 10/2014. No psychiatric history. Surgical HX: No surgical history. OBGYN: G-3 T-3 P-0 A-0 L-3 Medications: Lisinopril/HCTZ 20-12.5 mg PO daily Lipitor 20mg PO daily Cyanocobalamin 1000mcg IM once a monthly Ibuprofen 600mg every 6 hours as needed Allergies: None. Personal/social HX: A.P. works as a nurse 36hrs/week at a local clinic. She is married with three grown children. A.P. and her husband are active members in their Baptist church and have a good support system. Her husband is a petroleum engineer and works locally. A.P. and her husband just joined a local gym close to their home. A.P. walks 3 miles 4 times a week and considers herself in good health. Drugs, Alcohol, or Smoking HX: No illegal drug use, alcohol or tobacco use. Family HX: Mother- HTN, Hypothyroidism, DM Type 2, doing well. Father- HTN-Died of MI in 2006 at age 71. No siblings. Source of information: Patient, seems reliable. Subjective CC: “I have a sharp pain on the left side of my chest” HPI: A 50 y/o BF presents with complaints of a dull, sharp pain on the left side of her chest that started yesterday morning while she was exercising at the gym. She rates her pain a 6 on the 0-10 pain scale and states that she always gets nauseated and short of breath while she is having pain. The pain does not radiate to any other parts of her body but lasts about an hour once it starts. Exercising makes the pain worse while lying down and rest makes her pain better. Ibuprofen has been unsuccessful in relieving her pain. She has noticed mild swelling to her lower extremities two days ago. Review of systems General: reports being “Very healthy”. Denies fever, chills, recent weight gain or loss, weakness, or fatigue. States her last physical exam was in November 2014. Skin, hair, & nails: (-) changes in skin (-) changes in hair (-) changes in nails. HEENT: head – (-) injury (-) headaches (+) hair loss. eyes – (-) decreased vision (-) watery eyes (-) photosensitivity. eyes- last eye exam 1/2015. ears – (-) hearing problems (+) tinnitus in right ear (-) pain bilateral ears (-) drainage. nose – (-) nasal congestion (-) allergies (-) nasal drainage (-) epistasis throat – (-) sore throat (-) tooth ache (-) pain or difficulty with swallowing. last dental exam 2 years ago. Thorax/lungs: (+) chest pain (+) dyspnea (-) orthopnea (-) paroxysmal nocturnal dyspnea (-) lung injury (-) lung disease (-) allergies (-) asthma (-) cough. Reports dull, sharp pain to left side of chest with shortness of breath during exercise, see HPI. Cardiovascular: (+) chest pain (-) irregular heartbeat (-) palpitations (-) murmurs (+) hypertension. Reports dull, sharp pain to left side of chest with shortness of breath during exercise, see HPI. No prior EKG or stress test. PVS: (+) extremity edema (-) coldness (-) leg cramps (-) ulcers. Reports mile swelling in bilateral lower extremities 2 days ago. Abdomen: Low fat, low sodium diet. (+) nausea (-) vomiting (-) bowel problems (-) abdominal pain (-) history of jaundice (-) gallbladder disease (-) liver disease. Reports nausea during chest pain episodes, see HPI. GU: (-) urinary frequency (-) hesitancy (-) incontinence (-) nocturia (-) flank pain (-) burning (-) bleeding with urination. Metabolic/Hematologic: (-) type I or II DM (-) thyroid problems (-) heat/cold intolerance (-) bruising (-) ease of bleeding. No history of blood transfusions. Musculoskeletal: (-) trauma (-) injury. Psychiatric: (-) trouble concentrating (-) nervousness (-) anxiety (-) panic attacks (-) mood changes (-) hearing voices (-) frequent unhappiness (-) desire to harm self/others (+) sleep trouble (-) nightmares (-) memory loss (+) excessive life stresses. No recent deaths in family or close friends. Neurologic: (-) history of stroke (-) seizures (-) frequent/incapacitating headache (-) tremors in right hand (-) numbness in feet. Objective Vital Signs: B/P 142/94 (elevated), P-97, R-22, T-98.9 oral, O2- 96%, Ht: 5’5”, Wt: 145 lbs, BMI 24.5 General: African American female appears younger than stated age, well kept, well-mannered. AAOX3. Appears to be in distress, leaning over and holding her left arm and hand to left side of chest. Hair: Average texture. Evenly distributed shiny, dark brown hair with no breakage, dryness, or infestations noted. Eyebrows and eyelashes present and evenly distributed. Skin: Warm, dry, supple, no bruises, rashes, or suspicious nevi to exposed skin. Nails: Smooth and well-manicured without clubbing or cyanosis. Capillary refill to finger pad is < 2 sec. Head/Neck: Normocephalic/atraumatic, no bumps, bruises, lesions. Scalp pink and dry. No sinus tenderness, and no palpable lymph node enlargement or tenderness. Neck supple; thyroid isthmus palpable, lobes not felt. Trachea midline. Eyes: Pupils 4mm constricting to 2mm, PERRLA, vision 20/20 in each eye, vision fields full by confrontation. negative strabismus and nystagmus, disk margins sharp, without hemorrhages, exudates. No anterior narrowing. Conjunctiva pink; sclera white. Ears: Acuity good to whispered voice, no tenderness or abnormalities to tragus & pinna. No inflammation or cerumen in ear canal. TM pearly white and intact with no redness or bulging. Cone of light visible bilaterally (5 o’clock right, 7 o’clock left) in right ear. Nose: Turbinates intact, nares patent, no septal deviation, nasal flaring or discharge. Throat/mouth: Membranes pink and moist. Uvula is midline, tonsils at pillars, no redness or exudates. Good dentition noted. Lungs: Respirations 22 breaths/min, breath sounds vesicular, no rhonchi, wheezes, or crackles present. Lungs resonant. Thorax is symmetric, and the diaphragms descend 4 cm bilaterally. Heart: Apical pulse 98 bpm on auscultation. S1 and S2 regular rate and rhythm with no splitting, S1 best at apex, S2 base, with no S3 or S4. Carotid upstrokes brisk with no bruits. No JVD. PMI palpable at 5th ICS 7cm lateral to mid-sternal line, discrete and tapping. No heaves, lifts, or thrills. No rubs, gallops, murmurs, or opening snaps. No pain elicited upon palpation. Breasts: Symmetric and smooth without masses or lumps. Nipples symmetrical, everted without discharge. Abdomen: Normoactive BS x 4 quadrants. No abdominal bruits. Soft, flat, and non-distended with no scars or striae. No abdominal tenderness to palpation. No palpable masses or hepatosplenomegaly. Kidneys not felt, no CVA tenderness. Lymph Nodes: Head, neck, axilla, epitrochlear, and inguinal lymph nodes non-palpable. Extremities: Extremities are warm with +1 edema bilateral lower extremities. No varicosities or stasis. Calves are supple and non-tender. No femoral bruits. Brachial, radial, femoral, popliteal, dorsals pedal, and posterior tibial pulses are all 2+ and symmetric. Full range of motion to all extremities. Genitals: Deferred Rectum/Anus: Deferred Neurologic: AAOX3. Anxious d/t acute distress. Cranial nerves II-XII intact. Normal gait. Maintains balance with eyes closed. Good, even strength and muscle tone. Reflexes are 2+ and symmetric with plantar reflexes. Rapid alternating movements intact. Pinprick, light touch, position, and vibration intact. Assessment Diagnosis- Acute Coronary Syndrome (myocardial infarction) Acute Coronary Syndrome (ACS) presents with the classic symptoms of exertional angina and shortness of breath; however, women are more likely to report atypical symptoms. Chest pain is one of the most serious of all patient complaints and common symptom of CAD. A.P. is displaying the Levine’s sign which is a clenched fist held over her chest. The Levine’s sign is an indication of ACS (Bickley, 2013). CAD is the #1 cause of death in both men and women. Death rates remain the highest for African Americans (Bickley, 2013). Chest pain is considered a life-threatening diagnosis that requires immediate attention. Unstable angina and MI are difficult to distinguish by clinical manifestations and are lumped together as ACS (Copstead & Banasik, 2010). Differential diagnosis: Angina pectoris (stable) Pulmonary Embolus III. Dissecting aortic aneurysm Myocarditis Pericarditis Cardiac tamponade VII. Aortic stenosis VIII. Mitral valve prolapse Hypertrophic obstructive cardiomyopathy Costochondritis Biliary colic XII. Gastritis/GERD XIV. Pleural effusion Plan Call local 911 EMS for transport to hospital MI is life-threatening and medical treatment should not be delayed. The patient should not drive herself to the hospital. EMS providers can provide emergency defibrillation if the patient’s heart stops. Studies have shown that heart attack patients receive faster treatment after hospital arrival when they are transported by EMS (American College of Emergency Physicians, 2015). Administer O2 at 2L/min via NC. It is important to administer oxygen while ruling out other life-threatening causes of chest pain (McCance, 2010). Administer Aspirin 325 mg PO one dose NSAIDS is part of the therapy for acute MI. During a MI, blood clots can form in the narrowed arteries and block the flow of oxygenated blood to the heart muscle. Aspirin slows the clotting and decreases the size of the blood clot that is forming (McCance, 2010). Attach/order cardiac monitor, B/P, Pulse ox and EKG Patient must be monitored while ruling out other life-threatening causes of chest pain. EKG can evaluate the rate and rhythm and may show ST elevation. A ST elevation above the baseline is caused when a blood clot is formed. An EKG can be diagnostic of AMI if ST-elevations are present which is termed ST elevations myocardial infarction (STEMI), (American College of Cardiology, 2015). However, the patient can still have a myocardial infarction without ST elevation. It is important to monitor B/P, HR, and oxygen saturation levels because any changes can indicate a worsening in the patient’s condition. (McCance, 2010). Administer Nitroglycerin Administer Nitroglycerin 0.3 mg SL q 5 min x 3 doses or until chest pain is relieved or nitroglycerin spray 0.4mg metered dose 1-2 sprays SL q 3-5 min up to 3 doses or until chest pain in relieved. Because A.P. is having chest pain in the clinic, Nitroglycerin should be administered up to 3 doses. Nitroglycerin dilates the coronary arteries and venous blood vessels which reduce resistance to blood flow in the body (Edmunds & Mayhew, 2014). If the chest pain is not relieved by the 3 doses of nitroglycerin, morphine 2-4mg may be administered IV (ACLS, 2015). Start intravenous catheter (IV) to administer IV fluids Will need an intravenous site to administer fluids, emergency cardiac medications if needed, and provide hydration because the patient may be taken to cath lab and will not be allowed to eat or drink prior to the procedure (ACLS, 2015). Obtain labs Obtain labs: Cardiac enzymes (CPK, CK-MB, Troponin I), CBC, BMP (electrolytes), PT/aPTT, ESR, CRP. Cardiac enzymes can be obtained at the same time an intravenous catheter is placed. An elevated CPK or CK-MB may indicate possible myocardial infarction; however, these cardiac markers can also be elevated from muscle breakdown anywhere in the body. These labs are probabilities and not predictors of an MI (Uphold & Graham, 2003). Troponin I is cardiac specific, so an elevated Troponin I most likely indicates an MI. A BMP will monitor the serum electrolytes. Any electrolyte imbalance may cause cardiac arrhythmias. Early detection and management of dysrhythmias are important in the immediate care of a patient with MI (Copstead & Banasik, 2010). A CBC & PT/aPTT will provide a baseline, which will be needed prior to cardiac cath lab intervention. In addition to this, a patient experiencing a MI may have leukocytosis and elevated sedimentation rate (Copstead & Banasik, 2010). Keep patient NPO The patient may be taken to the cardiac cath lab for intervention. It is essential to keep the patient NPO prior to any procedure to prevent aspiration (Uphold & Graham, 2003). Consult internal medicine for possible hospital admittance. May require hospitalization for further testing and treatment. A cardiac cath and/or stress test may be necessary (Uphold & Graham, 2003). If admitted to the hospital, the patient will need to be assessed and followed by a physician and cardiologist for medical management. If A.P. has an established cardiologist, it is important to notify her cardiologist for the continuity of care. If hospitalized, patients are more likely to be compliant with their treatment when their established physician is treating them (Edmunds & Mayhew, 2014). Refer to Cardiovascular for echocardiogram Echocardiography is recommended in all cases of unexplained chest pain or shortness of breath. The echocardiography determines the condition of heart valves, how effective the heart is at pumping blood, and checks any signs of diseases that affect the walls or chambers of the heart. The cardiac output, ejection fraction, diastolic function can be calculated (McCance,2010). Educate patient on MI It is important for the patient to understand her disease process, signs and symptoms, causes, treatment options, and prognosis. The diagnosis of MI is based on three primary indicators: signs and symptoms, EKG changes, and elevations of marker proteins in the blood (Copstead & Banasik, 2010). It is important to explain each procedure that is being done on the patient and the reason for each procedure. Including the patient in the plan of care increases compliance and decreases stress (Bickley, 2013). Discharge instructions and follow up If A.P. was diagnosed with an MI, she must be on an ACE or ARB medication with a cardio-selective beta blocker, such as metoprolol 100mg PO bid. ACE inhibitors and beta blockers reduces the risk of dying from a heart attack or heart failure (Clark et al., 2012). A.P. is already on an ACE inhibitor and diuretic (Lisinopril/HCTZ 20-12.5mg po daily). A rapid acting nitrate, such as Nitro 0.4mg SL prn every 5 minutes for 3 doses or until chest pain relieved should be prescribed PRN and the patient must be instructed on it use for the treatment of angina. Unless contradicted, the patient should take 81-350mg Aspirin PO daily or antiplatelet, such as Plavix 75mg PO daily. If the patient has stents, Plavix 75mg PO daily will be used for 3 months to prevent clotting of the stents (Edmunds & Mayhew, 2014). The patient should continue taking her Lipitor for the management of hypercholesterolemia; however, the dosage may be increased to 40mg PO daily post-MI per cardiologist recommendations. (Clark et al., 2012). NSADS can decrease the effectiveness of ACE inhibitors. The patient should be instructed to use Tylenol 650 mg PO PRN instead of NSADS (Edmunds & Mayhew, 2014). The patient should continue with her low fat, low sodium diet (DASH diet) and to continue with exercise and maintain her current weight. A.P. should be instructed to weigh herself every day at the same time and notify her doctor of any increase in weight gain and monitor her B/P daily. A follow-up appointment should me made 1-2 weeks after discharge from hospital to check B/P, weight changes, and evaluation of new medications added to the treatment plan (Bickely, 2013). It is important to assess the ACE inhibitor dosage after MI because ACE inhibitors and ARBS are not as effective in African Americans as they are in Caucasians and the dose may need to be increased or changed to a calcium channel blocker (Edmunds & Mayhew, 2014). References Bickley, L. S. (2013). Chapter 6 the skin hair and nails & chapter 7 the head and neck. In (Ed.), Bates’ guide to physical examination and history taking. Philadelphia, PA: Lippincott. Clark, M. A., Finkel, R., Rey, J. A., & Whalen, K. (2012). Pharmacology (5th ed.). Baltimore, MD: Lippincott. Copstead, L. C., & Banasik, J. L. (2010). Pathophysiology (4th ed.). St. Louis, MO: Saunders Elsevier. Edmunds, M. W., & Mayhew, M. S. (2014). Pharmacology for the primary care provider (4th ed.). St. Louis, MO: Elsevier Mosby. Heart attack treatment guidelines. (2013). Retrieved from https://www.cardiosmart.org/heart-conditions/guidelines/heart-attack-guidelines MONA: morphine,oxygen,nitroglycerin and aspirin. (2015). Retrieved from https://acls.com/free-resources/acute-coronary-syndrome/mona-morphine-oxygen-nitroglycerin-and-aspirin McCance, K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. (2010). Pathophysiology: The biologic basis for disease in adults and children (6th ed.). Uphold, C. R., & Graham, M. V. (2003). Clinical guidelines in family practice (4th ed.). Retrieved from Gainesville, FL
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