Case 4 Work on a two SOAP notes. One SOAP note per day.Day 1:Patient Details: · Age: 79 years and 65 kg

Case 4

Work on a two SOAP notes. One SOAP note per day.

Day 1:

Patient Details:

·
Age: 79 years and 65 kg

·
Gender: Male

·
Medical History:

· Hypertension (well-controlled)

· History of smoking (20 pack-years)

·
Home medications:

· Lisinopril 40 mg PO QD

Presenting Symptoms:

The patient presented to the emergency department with severe chest pain (rated 9/10 on the pain scale), radiating to the left arm, associated with shortness of breath and nausea. He appeared anxious and diaphoretic.

Initial Examination:

·
BP: 85/50 mmHg

·
HR: 112 bpm

·
RR: 28 breaths/min

·
Oxygen saturation: 92% on room air

·
Temperature: 37.2°C

·
Heart Sounds: S1, S2 normal; no murmurs

·
Lung Sounds: clear

·
Extremities: Cool, clammy, and edematous with peripheral cyanosis

ECG Findings:

·
ST Elevation in leads II, III, aVF, and V1-V4, consistent with
Inferior + Anterior STEMI.

Significant Labs:

·
Troponin I: > 1000 ng/L

·
Creatinine: 1.8 mg/dL

Day 4:

The patient became progressively hypotensive. ECG showed rapid atrial fibrillation with a ventricular rate of 140 bpm. Patient has been having orthopnea and difficulty breathing since day 2. Increased jugular venous distension (JVD) was noted.

Vital signs:

·
BP: 124/90 mmHg

·
HR: 135 bpm

·
RR: 26 breaths/min

Significant Labs:

·
Creatinine: 2.4 mg/dL

·
BNP: 1324 pg/mL (elevated, suggestive of heart failure)

Chest X-Ray:

· Lungs: Bilateral rales at the bases

CT pulmonary angiogram:

· was performed after the patient developed sudden hypoxemia, and it revealed a pulmonary embolism (PE) affecting the right lung

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