Stable Angina SOAP Note
Assignment 3
A 58 year old male patient who is unemployed and overweight presents to the office with complaints of chest pressure and jaw pain that resolved after resting yesterday. He is in a monogamous relationship with a life partner. He admits a history of hypercholesteremia but does not take medications
CC: “I had chest pain when doing laundry yesterday.” Past medical history: Anxiety, hypercholesteremia
Family History- Father died at 60 from a myocardial infarction
Vital signs: Blood pressure: 158/98; height, 5 feet 6 inches; weight, 242 lbs. Lab results:
- TC 420
- LDL 190
- HDL 32
- Glucose: 228
- Hgb 14
- Hct 38
- MCV 78
Questions:
1.What additional subjective data do you think the patient will share?
2. What additional objective data will you be assessing for?
3. What National Guidelines are appropriate to consider? What level of evidence supports these guidelines?
4. What tests will you order?
5. Will you be looking for a consult?
6. What are the medical and nursing diagnoses?
7. Are there any legal/ethical considerations?
8. What is your plan of care?
-
- medical
- nursing
- complementary therapies
9. Are there any Healthy People 2020 objectives that you should consider?
10. Using the Circle of Caring, what or who else should be involved to truly hear the patient’s voice, getting him and the family involved in the care to reach optimal health?
11. What additional patient teaching is needed?
12. What billing codes would you recommend?
STABLE ANGINA DIAGNOSIS
1. Subjective Data
There is a need to obtain a focused health history for an accurate assessment and treatment for the patient with chest pain. The critical components of the patient’s history will include an appraisal of the main symptoms of heart diseases, comprising chest pain, heart failure, dyspnea, and syncope (Dunphy et al., 2019). Besides, the clinician should ask the patient about their tolerance of exercise, particularly if exercise aggravates any of these abovementioned complaints. The history of present illness should focus on the various personal risk factors for cardiovascular disease, including family and social history. Bereavement and anxiety can trigger diffuse pain as well as chest tenderness that lasts for hours. The clinician should get a comprehensive chest pain symptom analysis that includes the onset, location, quality, duration, relieving, or aggravating factors, as well as associated signs or symptoms. Particularly, localized, moving pain, and fleeting is seldom indicative of acute cardiac pathology. Lastly, the additional subjective data will also include past medical or surgical history, the status of immunizations, medications, and allergies
2. Objective Data
A focused physical examination is vital for an accurate assessment and devising a proper treatment plan for the patient. For the majority of the patients with stable angina, the findings of the physical exam are normal. A cardiovascular assessment will be conducted including an examination of the peripheral arterial pulses, retinal fundus for vascular changes, screening for risk factors of CAD, as well as stigmata of genetic dyslipidemia syndromes like Xanthelasma and Tendon xanthomas (Melnyk & Fineout-Overholt, 2011). It is also important to diagnose the secondary causes of angina, like aortic stenosis. A positive Levine sign denoted by the fist clenched over a sternum when the patient describes his discomfort is indicative of angina pectoris. The clinician should also look for any physical signs of any abnormal lipid metabolism. They include xanthelasma, xanthoma, or diffuse atherosclerosis such as diminished or absence peripheral pulses, increase in light reflexes, and arteriovenous nicking on the ophthalmic exam, carotid bruit. The useful physical exam findings should include data on the third and fourth heart sounds owing to the LV systolic and diastolic dysfunction, as well as mitral regurgitation secondary to the papillary muscle dysfunction. Lastly, the pain triggered by the pressure of the chest wall typically originates from the chest wall.
3. National Guidelines
The American College Cardiology Foundation American Heart Association Task Force Practice Guidelines, American College Physicians, American Association Thoracic Surgery, Society for Cardiovascular Angiography Interventions, Society Thoracic Surgeons, and Preventive Cardiovascular Nurses Association offered clinical guidelines in 2012. These guidelines applied in the diagnosis and management of the Patients with the Stable Ischemic Heart Diseases (Fihn et al., 2012). The guidelines present a systematized and focused approach to an in-depth review of evidence that will assist the physicians in the selection of the best management strategy for their patients. Furthermore, the 2012 clinical practice guidelines, provide a solid foundation for the other applications, like performance measures, suitable use criteria, quality improvement, as well as clinical decision support strategies.
4. Diagnostic Tests
There are several diagnostic tests that the clinician can order to help in confirming whether the patient has angina. The following tests might be performed to diagnose the causes of angina, including Electrocardiogram, stress test without imaging, and blood tests. In addition, some imaging tests will be performed such as chest x-ray, Chest CT, Coronary computed tomography angiography, Magnetic resonance (MR) imaging, Catheter angiography, Myocardial SPECT, and Echocardiogram.
5. Consultation
The patient has non-cardiac chest pain. He was presented to the office with complaints of chest pressure and jaw pain, thinking he was experiencing a heart attack. There is a need to confirm that the chest pain is not connected to a heart attack or heart disease. If it is accurately non-cardiac chest pain, the patient can be referred to a gastroenterologist, a specialist in the digestive system disorders, for additional testing and treatment. Since the patient has had numerous episodes of non-cardiac chest pain, he can be referred to a cardiologist. The doctor specializes in diagnosing and treating conditions of the cardiovascular system.
6. Medical Diagnoses
The doctor will diagnose angina based on the description of the patient’s symptoms, whenever they appear, physical exams, risk factors, as well as family history. Three additional tests can be used in confirming the diagnosis: electrocardiogram, coronary angiogram, and exercise stress test (Ferri, 2015). First, an electrocardiogram will measure the heart’s electrical activity to detect any heart problems. Secondly, the exercise stress test that uses a stationary bicycle, treadmill, or any other exercise machine to get the patient moving while hooked to the heart-monitoring machine. The test will establish how well the coronary arteries are supplying blood to the heart when working harder, and rhythm is regular. Lastly, the coronary angiogram is a special x-ray of the screening the coronary arteries. The angiogram detects larger plaques, which cause angina.
7. Differential Diagnosis
The diagnosis of stable angina should be differentiated from acute coronary syndromes and unstable angina. If the pattern is stable, then it is chronic stable angina. If there is an acceleration of frequency, magnitude, and threshold of the chest pain, it is an acute coronary syndrome. There is a need to different the chronic Stable Angina from the Urgent Conditions. First, angina pectoris is one of the signs of coronary heart disease, but, if there is chronic chest discomfort, it is chronic stable angina. In case the discomfort happens at rest or accelerating patterns, it is an acute coronary syndrome. The acute coronary syndrome can be characterized by chest pain lasting as a minimum of 10 minutes when resting, or repeated episodes in resting lasting greater than 5 minutes or accelerating patterns of ischemic discomfort. The episodes are more frequent, more prolonged in duration, severe, and triggered by minimal exertion.
8. Legal/ethical considerations
There are various ethical concerns, legal issues, and cultural norms that should be carefully taken into consideration when treating the patient. Hence, the physician in the course of decision making ought to be guided by evidence-based information as well as the preferences (Lin, 2014). The primary patient autonomy concept is well-respected, both legally and ethically. The assumption is that the patient should fully understand the nature and character of the medical interventions and either consent or refuse. An adult patient is presumed to have apt decision-making capabilities, or else they are incapacitated and declared incompetent by the law court. The ethical issues include the necessity of potential and randomized clinical trials, oversight of novel therapies, and distributive justice concerning equitable access and transparency.
9. Treatment Plan of Care
The treatment for angina pectoris will include a combination of lifestyle changes, medicines, procedures like coronary angiography with stent placement, and the Coronary artery bypass surgery. The daily plan of care will include medications taken regularly for preventing angina; medicines are taken when the angina pain occurs, activities that the patient can do and avoid, and signs of worsening to seek emergency help. The prescribed medication will include the nitrates and calcium channel blockers for relaxing and widening blood vessels to allow more blood flows to the heart (Avanzas & Kaski, 2015). Secondly, the beta-blockers will be used to slow the heart. Next, aspirin and blood thinners medication will be prescribed to prevent the formation of blood clots. Lastly, statins medication will be used in lowering cholesterol levels and stabilizing plaque. If the medicines are not enough, the blocked arteries could be opened with the medical procedures: angioplasty and coronary artery bypass graft surgery.
10. Healthy People 2020 Objectives
The goal of the Healthy People 2020 plan is to improve the overall cardiovascular health as well as the quality of life by preventing, detecting, and treating risk factors for heart attacks and stroke. Besides, the goal is to focus on early identification plus treatment, prevention of repetitive cardiovascular episodes, and decrease in deaths linked to various cardiovascular diseases.
11. Circle of Caring-Family Support
The family can offer support to the patient to maintain the recommended lifestyle changes. The modifications will include adjusting daily activities, healthy weight loss plan, and consumption of a heart-healthy balanced diet that is low in fats and salt (Kaski, 2016). The family could encourage the patient to engage in smoking cessation and stress management. The family should offer support in taking the medications as prescribed and maintain a healthy lifestyle to prevent or delay angina pectoris.
12. Patient Teaching
There is a need to educate the patient to note the patterns of the symptoms, causes of the chest pain, including the duration, intensity, and if the medicine relieves the pain. The patient should call the emergency unit if the symptoms change abruptly, occur when resting, continue after taking medication, last longer than average, and occur unpredictably. Finally, the patient should call the healthcare provider if the symptoms worsen, new symptoms, and there are side effects from the medicines.
13. Billing Code
The ICD-10 diagnosis code for Angina Pectoris is I20.9 and is used in indicating the diagnosis for reimbursement. For prompt reimbursement, the documents should designate the kind of angina, associated symptoms, and spasm. The documentation should indicate if the patient smokes, exposed to smoke, or smoking history.
References
Avanzas, P., & Kaski, J. C. (2015). Pharmacological Treatment of Chronic Stable Angina Pectoris. Cham: Springer International Publishing.
Dunphy, L. M. H., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2019). Primary care: The art and science of advanced practice nursing. Philadelphia, PA : F.A. Davis Company.
Ferri, F. F. (2015). Ferri’s best test: A practical guide to clinical laboratory medicine and diagnostic imaging. Philadelphia, PA: Elsevier/Saunder.
Fihn, S. D., Gardin, J. M., Abrams, J., Berra, K., Blankenship, J. C., Dallas, A. P., Douglas, P. S., … Williams, S. V. (December 18, 2012). 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Journal of the American College of Cardiology, 60, 24.)
Kaski, J. C. (2016). Essentials in Stable Angina Pectoris. Cham: Springer International Publishing.
Lin, P. J. (January 01, 2014). Some Ethical Legal Issues in Heart Disease Surgery. Acta Cardiologica Sinica, 30, 6, 529-537.
Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing & healthcare: A guide to best practice. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.
Sydney, E., In Weinstein, E., & In Rucker, L. M. (2018). Handbook of outpatient medicine. Cham, Switzerland: Springer.