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SOAP Note #1 (Cardiac)

Name: Lee Walace
Gender: Female
Age: 45
Narrative:
45 y/o african american f. pt. presents w/ palpitations x1 year (progressively
worsening x6 months). Pt. states that the palpitations come and go Pt.
noted heart palpitations lasting 15 min x1 wk. Pt. reports that it feels like a
little thump right over her heart. Pt. rated discomfort as a 5-7/10. Pt. denies
that pain radiates. Pt. states no aggravating / alleviating factors. Pt. denies
SOB, CP, LOC, dizziness, and light headedness. Pt. takes 20mg Adderall XR
x30 years and drinks coffee 6 to 8 cups / day increased recently. Pt.
indicated that she thought it may be related to A-Fib (because her aunt had
it), wants to find out whats going on.
Subjective: Patient Interview
History of Present Illness:
Chronology:
Onset: x6 months
Frequency: Comes and goes
Duration: 15 minutes
Course: Worsening
Associated Signs and Symptoms: Feeling of a thump in her chest
Aggravating Factors: None
Alleviating Factors: None
FIFE:
Feelings: N/A
Ideas: A-fib
Effect of Function: N/A
Expectations: Find out what is going on
Past Medical History:
General Health: Generally healthy
Ongoing Illnesses: None
Serious Illnesses: None
Serious Injuries: None
Hospitalizations / Surgeries: Birth of her only son
Menstruation: N/A
Medications: Adderall XR (20mg / day for ADHD)
Vitamins / Supplements: None
Allergies: Codine Bad reaction when she had her wisdom teeth out @ age
20
Alternative Medicine: None

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Additional Physicians: Dentist
Family History:
Paternal Grandmother: Healthy Until Deceased
Paternal Grandfather: Healthy Until Deceased
Maternal Grandmother: Healthy Until Deceased
Maternal Grandfather: Healthy Until Deceased
Aunt (Father): None
Uncle (Father): None
Aunt (Mother): A-fib
Uncle (Mother): None
Father: Healthy
Mother: Healthy
Siblings: None
Children: Son (Stan) 1 Recurrent Ear Infections
Alcoholism / Allergies / Cancer / Diabetes / Hypertension / Heart Attack /
Mental Disorders / Obesity: None
Social History:
Demographic: African American, Female, Married x10 years (Husband was in
a car accident x6 months and is now wheelchair bound She has become
the primary caregiver).
Job: Administrative Assistant
Diet: Drinks 6-8 cups of coffee.
Exercise: Gym (2-3 x week). Run (1 x week).
Sleep: Not sleeping more than 4-6 hours.
Support / Relationships: None of concern (safe and supported). Takes her son
to the park and watches TV / Movies for fun. No financial or religious
restrictions that could prevent care.
Religion: N/A
Alcohol: Wine 1-2 glasses / week.
Drinking and Driving: N/A
CAGE: None
Tobacco: Cigarettes (occasionally 1 when she drinks).
Drugs: No history of recent drug use.
Sexual Function: Straight. Happily married x10 years with 1 son. Sexually
active (practices safe sex). Satisfied w/ her sex life. Coitarche 15. 4-5
partners x life / 1 x6 months. No Hx of STDs. No partner risk.
Infectious Exposure: None (TB/HIV/Flu/Asbestos/Lead)
Miscellaneous: Uses sun screen. Wears a seatbelt. Does not own firearms.
Has a smoke alarm with batteries.
Objective: Physical Examination
Overview: Pleasant woman, who has complained of palpitations. BP= 120/72.
Pulse 85 and regular. RR 12. T 98.
Skin: No suspicious nevi.

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HEENT: Normocephalic, atraumatic. Hearing intact. Sinuses nontender.
Pharynx without exudates. Teeth and gums in good status. No uvular
deviation. Difficulty from seeing out of right eye due to hemorrhage.
Neck: Supple, without thyromegaly.
Lymph Nodes: No lymphadenopathy.
Lungs: Resonant and clear. Diaphragms equal with 5cm movement. Full
thoracic expansion. Resonant percussion.
Cardiovascular: Heart rate and rhythm normal. Peripheral pulses are
symmetric and full bilaterally. JVP 6 cm above the right atrium; No carotid
bruits. No JVD. Good S1, S2. No murmurs, rubs, or gallops heard today. No
S3, S4. PMI 5th 1CS at mid clavicular line.
Abdomen: Active bowel sounds. Soft, nontender, no hepatosplenomegaly.
Extremities: Without edema.
Labs: Not available
Assessment: Differential Diagnosis
1) Palpitations (PAC / PVC / Sinus Tachycardia / Arrhythmia A-fib?)
Differential Diagnosis:
2) Adderall XR
3) Lack of sleep
4) Stress from kids / husband / work
5) Caffeine use
6) Normative factors (diet, exercise, etc)
Plan
1) Get Echocardiogram
2) Check cardiac enzymes
3) Check electrolytes (postassium, magnesium, calcium, etc)
4) Check thyroid (TSS)
5) Check CBC (look for possibility of anemia)
6) Look into trying to get a 24 hour halter monitor
7) Follow up with stress test
Follow up visit in 2 weeks.
Recommendations:
Try reducing caffeine from coffee, etc. If that does not work, try lowering
dose of Adderall XR. Look into diet (ie. soda / chocolate). Look into resources
and potentially set up an appointment with a behaviorist to look at stress
from family / work / finances. Possibly look into anti-anxiety medication or
blockers (Metoprolol) if none of the above work.