Case 1

CC: Sudden onset substernal chest pain that “woke me up “and lasted until now (about 45 mins) 

HPI: 70 y/o man with h/o hypertension, hyperlipidemia, 40 pack-years smoking history, and brother who died of MI at 60y/o brought in by ambulance to the ED with c/o substernal chest pain.  The pain is described as pressure-like and radiating to the left arm and jaw, accompanied by nausea, diaphoresis, and shortness of breath.  Nitroglycerin was administered sublingually, but only provided temporary relief.  Aspirin was given to the patient to chew in the ambulance.

PE:

VS: BP 150/70, HR 110, Temp 37.1 ͦC, R 30  Pulse oximetry: 96% on room air

Gen: obese, pale, diaphoretic patient

Lungs: clear to Auscultation and Percussion

Heart: RRR, S4 gallop noted

Ext: No cyanosis or edema

Labs:

CBC: Hemoglobin & hematocrit normal, WBC 11,000 (slightly high)

Electrolytes: Normal

Troponins: Troponin T and I are elevated

CK-MB: normal

EKG: sinus tachycardia, elevated ST segments in leads II, III, and AVF

Assessment: Acute Inferior wall MI

Plan:  Start Morphine drip IV, O₂ via nasal cannula, Metoprolol, urgent transfer to interventional cardiology lab

The patient has a balloon angioplasty and stent placement and is transferred to the telemetry unit for monitoring.  You see the patient the next day and need to document your visit in a progress note in the SOAP format. [See next page for information you need to write it]

The next day you visit the patient and must write a progress note to include the following:

A very brief synopsis of what occurred the day previously (including the treatment given in interventional cardiology)

His current medications:

Aspirin 81 mg orally, once a day

Plavix 75 mg orally, once a day

Lopressor 25 mg orally every 12 hours

His report of his condition today:  much more comfortable.  No pain, no shortness of breath.  Some mild fatigue when walking from room to nursing station

The EKG this morning shows normal sinus rhythm with no ST elevations and no Q waves

The physical exam which includes: HR 72, BP 130/70, R 24, Temp 37.4   ͦC

General: appears comfortable. 

Extremities: peripheral pulses are slightly diminished and 1+

Heart: Regular rate and rhythm, no gallops or murmurs

Lungs: clear

Groin: femoral and pedal pulses intact and 2+ .  No hematoma

You believe he is doing well and that the same plan should be continued for now.  You would like the nurse to check his vital signs every 4 hours for one more day and then every 8 hours. 

If all goes well, he can be discharged in 3 days.

Please write a SOAP note for your visit:

S: 70 y/o M with H/O HTN, HLD, and 40 pack yr smoking history recently admitted for Acute Inferior Wall MI. Pt had Balloon Angioplasty and Stent Placement, he was transferred to the Telemetry Unit for monitoring. Today pt appears to have clinically improved overall.

Current Medications:  Aspirin 81 mg orally (once a day), Plavix 75 mg orally (once a day), Lopressor 25 mg orally (every 12 hours)

O: VS: HR 72, BP 130/70, R 24, Temp 37.4   ͦC

PE shows:

General: appears comfortable. 

Extremities: peripheral pulses are slightly diminished and 1+

Heart: Regular rate and rhythm, no gallops or murmurs

Lungs: clear

Groin: femoral and pedal pulses intact and 2+. No hematoma

A:  70 y/o M with H/O HTN, HLD, and 40 pack yr smoking history who was recently dx with Acute Inferior Wall MI (s/p Angioplasty and stent placement): Pt is improving.

P:

1. Acute Inferior Wall MI, Improving:
2. Continue with Aspirin 81mg orally once a day,
3. Continue with Plavix 75mg orally once a day
4. Continue with Lopressor 25mg orally every 12 hours
5. Check vitals every 4 hours for one more day, and then every 8 hours
6. Tentative discharge day in 3 days  
7. Schedule follow up with outpatient Cardiologist upon discharge

Case 2A

CC: “Really bad headache that won’t go away” since yesterday afternoon.

HPI Information (note – it would typically be written in narrative style rather than OLD CARTS format as below): 36 y/o female smoker (15 pack-years) and chronic cough x 4 years presents with c/o right sided headache that began yesterday afternoon while at work and was severe enough that she had to leave work.  The patient is known to your clinic and had her last complete history and physical about 3 months ago.

Onset: about 3 o’clock yesterday

Location: the right side of my head and the right forehead

Duration: since then (about 18 hours now)

Character: throbbing/pounding

Aggravating/Alleviating: going outside makes it worse.  Lying down with a cold cloth over my eyes makes it a little better

Radiation: none

Related symptoms: About 30minutes before it began, I started seeing weird wavy lines.  “Do you think I’m having a stroke?”

Timing: constant since yesterday.  Began after working at computer screen for about 4 hours on a report due yesterday at 5:00, “but I had to leave before it was done”.  She has had this kind of headache before – 3 times in the past 2 years, “But this was the worst”. 

Severity: 8-9/10

Physical Exam:

VS: P100, R 20, BP 140/88, Temp 98.6 ͦF

Pupils are round and reactive to light, but patient notes pain when the light is directed at her eyes

She appears in considerable distress and seems to want to avoid opening her eyes or moving her head

Extra ocular movements are full, but patient notes pain on extreme lateral gaze

visual acuity is unchanged from last exam (20/40 Bilaterally)

Examination of her chest reveals clear lungs and a regular heart rate and rhythm with no murmurs or gallops

Inspection of her nose shows pink mucosa, no masses or lesions, bilateral nares are clear of discharge and patient can breathe through both sides normally

Penlight exam of her throat shows no redness or exudates, palate lifts symmetrically, tongue protrudes in the midline

He color is generally within normal limits with no cyanosis and her conjunctivae are pink.

Skin is warm, moist, and has normal turgor

What is your assessment (include a differential diagnosis)?

1. Most likely Migraine due to unilateral headaches, photophobia, and presence of aura.
2. Glaucoma
3. Stroke
4. Subarachnoid Hemorrhage
5. Brain Tumor

Cold is unlikely since pt’s physical exam revealed clear lungs, no bilateral nares discharge, no redness or exudates in her throat, plus she was afebrile.

What is your plan for this patient?

1. Start Amitriptyline 50mg every night and use Zolmitriptan 2.5mg nasal spray (up to 2 doses) as rescue mediation. Return to clinic if pain does not subside after starting medications.
2. Order CT to r/o Stroke, Tumor, Subarachnoid Hemorrhage
3. Refer pt to see Ophthalmologist for Glaucoma evaluation

Case 2B

The previous patient has been diagnosed with probable migraine headache and treated with amitriptyline 50 mg. at bedtime and zolmitriptan 2.5 mg via nasal spray – up to two doses for an acute headache.  She comes back to see you a few months later and reports that she has had no headaches since the last visit. However she has been feeling “really sleepy all day” and feels like she isn’t functioning so well at work.  She also says that about a month ago she started to see the “wavy lines” and feel a little nauseous so she took one dose of the zolmitriptan and her complaints resolved without ever having a headache. Your exam is essentially the same as the last time except that she is not having pain on EOMs or when the penlight is shone into her eyes. 

She has a problem list in her chart and #3 is Migraine Headache – Uncomplicated with visual aura

Please write a SOAP note for this visit:

S: 36 y/o F with Migraines c/o sleepiness that lasts all day and effects her function at work since she started Amitriptyline and Zolmitriptan.

Pt had the beginning symptoms of her migraine, however it resolved once she took Zolmitriptan.

Denies having HA since her last visit.

Medications: Amitriptyline 50mg every night, Zolmitriptan 2.5mg nasal spray (up to 2 doses)

O:

VS: P100, R 20, BP 140/88, Temp 98.6 ͦF

PE:

No pain on EOMs, No Photophobia

visual acuity is unchanged from last exam (20/40 Bilaterally)

Examination of her chest reveals clear lungs and a regular heart rate and rhythm with no murmurs or gallops

Inspection of her nose shows pink mucosa, no masses or lesions, bilateral nares are clear of discharge and patient can breathe through both sides normally

Penlight exam of her throat shows no redness or exudates, palate lifts symmetrically, tongue protrudes in the midline

Her color is generally within normal limits with no cyanosis and her conjunctivae are pink.

Skin is warm, moist, and has normal turgor

A:

Problem #3 Migraine Headache- Uncomplicated with Visual Aura

Most likely side effect of her medication, sleepiness began around the same time she started Amitriptyline and Zolmitriptan

P:                

Problem #3

Lower the dose of Amitriptyline from 50mg to 25mg every night. Continue with rescue medication Zolmitriptan 2.5mg nasal spray (up to 2 doses). Informed pt that she should return to clinic if sleepiness continues; if her sleepiness continues plan to switch Amitriptyline to a different class.

Case 3

S: 48 y/o male with history of COPD and 60 pack-year smoking history presents today with c/o fever, shortness of breath, and cough productive of green sputum since 2 days ago.  His grandson recently visited and had a “bad head cold”.    Pt. denies chest pain, wheezing, or any worsening of his baseline shortness of breath, but does note that walking a block makes him feel “winded” when previously he could walk several blocks without difficulty. 

O:         VS: P 84, reg. BP 138/84, R 28, Temp 100.8  ͦF

Gen: alert, in NAD, mildly tachypneic, spasmodic coughing periodically with green sputum production

HEENT: Nose clear, Throat mildly injected, Few shotty anterior lymph nodes palpated

Lungs: scattered wheezes on end respiration and few crackles over the right posterior lung field

Heart: RRR, no murmur or gallop

Ext: Mild cyanosis bilateral fingers and toes (usual for this patient).  1+ pitting edema over medial ankles at the level of the malleolus.

A: Pt with hx of COPD c/o new onset of fever, productive cough with green sputum, SOB, and dyspnea on exertion.

1. Most likely Pneumonia due to fever, tachypnea, cough with green sputum, wheezing and crackles
2. SARS-CoV-2
3. Influenza
4. COPD Exacerbation
5. Pulmonary Edema

P:

• Start pt on Azithromycin and Ceftriaxone.
• Will order CXR (to evaluate for Pneumonia and Pulmonary Edema)  If CXR shows infiltrate will order sputum culture, urine for Streptococcus pneumoniae and Legionella antigen. Will contact pt with results and new antibiotic regimen (if there’s a need to switch).
• COVID PCR Test Pending
• Influenza RT-PCR Nasopharyngeal Swab Pending
• Follow up in 2 weeks