SOAP Note – Angina Pectoris

SOAP Note – Angina Pectoris

ID: SCT | DOB 1/1/1957 | Age 67 | Gender: Male | Race: Hispanic.

He is married. He presented to the clinic alone and is a reliable historian.

Subjective:

CC: “For the past week now, I have had chest pains.”

HPI: SCT is a 67-year-old Hispanic male presenting to the clinic with complaints of chest pains. The pain began one week ago. The pain is located centrally in his chest. The pain usually lasts a few minutes, with the longest pain episode lasting five minutes. The pain is of pressure-like character and is aggravated by exercise and alleviated rest. Whenever the pain occurs, it radiates to the left shoulder. It is intermittent, coinciding with the activity of the day. The patient notes that the pain is sometimes severe, often interfering with his activities of daily living. He gives his pain a score of 7/10. Also, the pain is sometimes associated with episodes of nausea and shortness of breath.

Past Medical History:

• Medical problem list
  • Hypertension for 10 years
  • Diabetes mellitus for five years
• Surgical:
  • The patient has a negative history of surgeries

 Preventive Care:

• The patient had a dental examination in February. He also had a prostate examination late last year. He attends his diabetes and hypertension clinics regularly.

Allergies:

• No known allergies.

Medications:

• Metformin 500mg, administered orally every 12 hours to manage type 2 diabetes mellitus.
• Nifedipine 30mg, administered orally every 24 hours for the management of hypertension.

Immunizations:

• The patient is up-to-date with all his childhood and adulthood vaccines. He recently received his booster dose of COVID-19 vaccine from Pfizer. He has also had his annual flu vaccine.

Social History:

• Chemical History: The patient is a social smoker. He smokes approximately two cigarettes occasionally during social events. He used to take alcohol but stopped after his diabetes diagnosis five years ago. He denies taking any illicit substances.
• Sexual History and Contraception/Protection: The patient is married and is sexually active. He denies using any form of contraceptive, including condoms, during sexual intercourse.

Other:

The patient is a retired salesperson and a business owner. He exercises mildly occasionally. He is currently on a diabetic diet, which restricts his consumption of high-calorie foods while encouraging fresh vegetables and high-fiber foods. He takes two cups of coffee daily. The patient lives with his wife and their three sons.

Safety:

• The patient owns two guns. He keeps his guns in a private room, only accessible to him and his wife. He currently lives in a five-bedroom mansion. He notes that his current residence is safe and has never experienced any form of crime or violence. He practices safety behaviors such as putting on a safety belt when driving and wearing gloves when indulging in outdoor activities.

Family History:

• The patient has a significant family history of cardiovascular illnesses. His father died of myocardial infarction at the age of 60. His mother has a heart disease and has been on medication. His brother is a known diabetic and was recently diagnosed with hypertension.

Review of Systems

Constitutional: SCT denies experiencing any weakness or recent weight loss or weight gain. He also denies having a fever or chills. He reports experiencing fatigue even with non-strenuous activities and activities he initially performed with ease.

Eyes: The patient denies double vision, blurred vision, or any recent visual changes. He also denies having a history of using visual aids.

Ears/Nose/Mouth/Throat: Denies experiencing tinnitus, ear discharge, or hearing loss. He also denies nasal discharge, congestion, gum bleeding, or gum swelling. The patient also denies having a sore throat or difficulty swallowing.

Cardiovascular: Denies any palpitations, irregular heart rhythms, or swelling in his extremities.

Pulmonary: The patient reports chest pain that has lasted one week. The chest pain is intermittent, aggravated by exercise, and alleviated by rest. He denies cough, wheezing, shortness of breath, or difficulty breathing.

Gastrointestinal: The patient denies any GI disturbance, abdominal pain, or changes in his bowel movements. He also denies experiencing any abdominal pain before or after food.

Genitourinary: Denies dysuria, urinary hesitance, or urinary frequency.

Musculoskeletal: Denies muscle pain, swelling, or stiffness. He also denies having any joint swelling, stiffness, or restriction in the range of motion of his joints.

Integumentary: The patient denies having any scars, lesions, swelling, nodules, or any other skin swelling. He also denies having any skin color inconsistencies, hyperpigmentation, or abnormal skin thickening in any part of his body.

Neurological: The patient denies dizziness, headaches, or recent syncope.

Psychiatric: The patient has never had any mental health illnesses or a relative with a psychiatric illness.

Endocrine: The patient is a known diabetic and is currently responsive to anti-diabetic medications. He denies heat or cold intolerance.

Hematologic/Lymphatic: Denies experiencing the ease of bruising, excessive bleeding, or anemia. He also denies any lymph node swelling or splenomegaly.

Allergic/Immunologic: The patient has no known allergies.

Objective

Vital Signs: HR 85/bpm | BP 150/90 | Temp 98.6 F | RR 16 | SpO2 98% on RA |

Height 5’11 | Weight 180 lbs. | BMI 25.1

Labs, radiology, or other pertinent studies:

A second and third BP reading of alternate hands confirmed high blood pressure, with values of 151/89mm Hg on the right arm and 150/90 mm Hg on the left arm. The thyroid function test revealed a total T3 of 1.3 ng/mL, a total T4 of 8 ug/dl, and a TSH of 2.0. A 12-lead ECG was also negative.

Complete Blood Count (CBC): This test was necessitated to check for any underlying inflammatory process. Inflammatory processes attributed to infections can cause a significant increase in blood pressure in patients with hypertension and diabetes comorbidity.

Hematology	Result	Normal range
Red cell count	5.5 x 1012/L	4.5–5.7
White cell count	12 x 109/L	4.0–10.0
Hemoglobin	160 g/L	133–167
Hematocrit	0.50	0.35–0.53
MCV	80 fL	77–98
MCH	27 pg	26–33
MCHC	332 g/L	330–370
RDW	10.5%	10.3–15.3

Physical Exam

General Survey: The patient is alert, cooperative, and responsive to the interview questions asked. No signs of chills, weight loss, wasting, or fatigue. No signs of weight loss, fatigue, or chills.

HEENT: The head is well-rounded and normocephalic. No signs of alopecia or unusual hair thickening. There are also no signs of head swelling, lumps, scars, or lesions on the scalp. The eyes are symmetrical. No signs of eye discharge, eyelid retraction, drooping, swelling, or puffiness. No signs of eye cataracts. The visual acuity is 20/20. The pupils are centered in the iris, equal and symmetrical, round with even borders, and reactive to light. The ears are symmetrical. No signs of ear discharge, abnormal skin thickening of the ear septum, or skin color inconsistencies of the ear. The ear canal is lined with hair, and the tympanic membrane is clear. The nose is symmetrical. No sign of nasal discharge, nasal swelling, or any nasal malformations. No sign of pharyngeal swelling or uvular deviation.

Neck: The neck is symmetrical. The trachea is midline on the neck. No signs of skin color inconsistencies, scars, or lesions on the neck. There is also no sign of thyroid enlargement. No visible extended veins on the neck.

CVS: The heart rate is regular and rhythmic. The S1 and S2 heart sounds were heard on auscultation. No murmurs, rubs, or gallops. There is also no sign of jugular venous pressure distension. The radial, brachial, femoral, and popliteal pulses were felt bilaterally on palpation. Pulses were present. No sign of peripheral edema, cyanosis, or jaundice.

Chest/Thorax: The chest wall is symmetrical. No sign of barrel chest or any other chest wall deformity. No sign of labored breathing or use of accessory muscle of inspiration. No wheezing, respiratory crackles, or rhonchi sounds on auscultation.

Abdominal: The abdomen is well-rounded and symmetrical. No signs of scars, lesions, rashes, or skin color inconsistencies on the abdomen. No sign of abdominal masses or abdominal distensions. Abdominal sounds were heard in the left upper, left lower, right upper, and right lower quadrants. Abdominal bruit sounds were heard on auscultation of the iliac artery and the aorta. No sign of tenderness or abdominal pain on palpation. There was also no sign of crepitus on the abdominal wall.

Integumentary: No signs of scars, skin swelling, abnormal skin thickening, uneven hair distribution, or skin color inconsistencies. There was also no sign of cyanosis, skin pallor, or finger clubbing. The capillary refill time was two seconds on both the upper and lower extremities.

Neurological Examination: The patient is alert and oriented to time, place, and event. He is dressed appropriately for the occasion. His memory is intact. His judgment is goal-directed and logical. He denies delusionary thoughts or hallucinations. He also denies having any suicidal thoughts or tendencies.

Assessment

Differential Diagnoses

1. Angina Pectoris (ICD-10 Code: I20.9): Angina pectoris, also known as stable angina, is a clinical condition characterized by chest discomfort that is triggered by exertion and alleviated by rest. Angina pectoris is a symptom of myocardial infarction and a consequence of perfusion mismatch in the myocardium. Angina pectoris manifests as chest pain or pressure-like heaviness or tightness that proceeds with exertion. The chest pains are usually episodic, with each episode lasting a few minutes. Persons with angina pectoris often have an acute or subacute presentation, with many verbalizing a pain duration of one to three weeks. Diabetes and hypertension are risk factors for the disease (Joshi & De Lemos, 2021). The patient in the presented case had complaints of chest pain lasting one week. The chest pain was triggered by physical activity, alleviated by rest, and only lasted a few minutes. Assessment findings revealed that he is a known diabetic and hypertensive. These manifestations qualify for angina pectoris, warranting the inclusion of the differential. A family history of cardiovascular illnesses and a history of diabetes and hypertension further affirmed this diagnosis, as diabetes and hypertension are risk factors for the disease (Joshi & De Lemos, 2021).
2. Gastroesophageal Reflux Disease (GERD) (ICD-10 Code: K21.9): GERD is a condition that is characterized by retrograde flow of gastric contents. Persons with GERD often present with complaints of dysphagia, heartburn, and epigastric pain. The involvement of the mouth and the respiratory system are some of the atypical manifestations of GERD and are demonstrated by the presence of chest pain, dental erosions, asthma, laryngitis, and hoarseness of the voice (Tamargo & Lopez-Sendon, 2022). The patient, in this case, presented with episodic chest pain, consistent with the chest pain sometimes seen in GERD, making GERD a plausible differential diagnosis. This differential was, however, ruled out due to the exertional component of the chest pain in the presenting case.
3. Musculoskeletal Pain (ICD-10 Code: M79.1): Musculoskeletal pain is perceived in the musculoskeletal tissues. It is a complex problem with multifactorial etiology. Trauma and inflammation of the chest wall muscles can cause pain perceived by the patient as chest pain. Chest pain attributed to trauma may be constant or intermittent, aggravated by activity, and alleviated by rest. Likewise, chest wall inflammation can manifest as a constant pain alleviated by analgesic medications (Tamargo & Lopez-Sendon, 2022). This differential was considered in this patient’s case, as musculoskeletal issues may sometimes mimic cardiac pain. Subjective assessment to reveal any history of trauma, along with a complete blood count, is necessitated to rule out musculoskeletal pain secondary to trauma and an inflammatory process of the chest wall.
4. Costochondritis (ICD-10 Code: M94.0): Costochondritis is an inflammation of the cartilage connecting the ribs to the sternum. It is a benign condition presenting with localized chest pain on the chest. Patients with costochondritis will often verbalize pain in the upper anterior chest that is exacerbated by movement, cough, stretching, or deep breath. The pain is usually described as a sharp or dull pain. This differential was considered as SCT had chest pain (Tamargo & Lopez-Sendon, 2022). A CBC to ascertain an ongoing inflammation, a history and physical examination to characterize the pain and rule out cardiac involvement, and a chest x-ray are necessary to rule out the diagnosis.

Diagnosis: The presumptive diagnosis in this case is angina pectoris ICD-10 Code: I20.9. Angina pectoris is a clinical condition characterized by chest discomfort triggered by exertion and alleviated by rest. The patient in the case had chest pain that was intermittent, triggered by exertion, and alleviated by rest. Subjective findings were negative of features supportive of GERD and musculoskeletal pain. Chest X-ray ruled out costochondritis.

Plan

1. Angina Pectoris (ICD-10 Code: I20.9)

   • Diagnostics:
     • ECG to assess myocardial ischemia or evidence of a past infarction. ECG can point to the diagnosis of myocardial ischemia, which often manifests as angina. According to the American Heart Association (AHA), ECG should be considered for all patients with hypertension presenting with chest pain (Gulati et al., 2021).
     • Chest X-ray will also be ordered to rule out non-cardiac causes of chest pain. Chest pain has a multifactorial etiology. AHA recommends that chest X-rays be performed on all hypertensive patients presenting with shortness of breath and chest pain to help rule out non-cardiac causes. Pneumothorax, infections, and trauma are some of the factors that can result in acute and subacute chest pain (Gulati et al., 2021).
     • A complete blood count will also be ordered to rule out non-cardiac causes of chest pain. CBC can help identify inflammatory processes, anemia, and the presence of infections that can also cause chest pain (Gulati et al., 2021).
   • Treatment:
     • Lifestyle modification is first-line in managing angina pectoris. Lifestyle changes to include tobacco cessation, dieting, and exercise remain effective in managing angina pectoris. The patient in the presented case will be advised to stop smoking to lower his risk of developing the disease, as cigarette smoking is a risk factor for coronary artery disease and other cardiovascular illnesses (Gulati et al., 2021).
     • The patient will also be placed in an exercise routine. Regular, moderate physical activity can improve cardiovascular health, lowering the patient’s risk of developing angina pectoris. Physical exercise can also optimize blood sugar and blood pressure control, lowering the patient’s risk of developing myocardial ischemia (Tamargo & Lopez-Sendon, 2022).
     • Diet optimization to lower saturated fats, sodium, and cholesterol can also help in managing diabetes and hypertension, lowering the patient’s risk of developing myocardial ischemia (Tamargo & Lopez-Sendon, 2022).
     • Medication such as nitroglycerine, beta-blockers, and aspirin may be considered for symptomatic control and disease prevention. In addition, the patient may be started on low-dose aspirin to lower their risk of developing another attack. He may also be initiated on nitroglycerine 2.5mg, administered every eight hours to lower the frequency of attack (Gulati et al., 2021).
   • Education:
     • The patient will be educated on the disease process and the available treatment options. He will be informed that angina pectoris is a symptom of myocardial ischemia that, if left unmanaged, can progress to acute coronary syndrome. Thus, it is important to advise the patient to consider preventive approaches against the disease (Gulati et al., 2021).
     • Lifestyle modification to include a diet low in saturated fats and sodium, along with preventive pharmacotherapy, can help prevent and control symptoms and prevent subsequent attacks. The patient should thus be advised to consider preventive options to help control the disease (Gulati et al., 2021).
     • The patient should also be advised to adhere to his prescribed anti-diabetic and antihypertensive medication to optimize his blood pressure and blood glucose control. He should be notified that diabetes and hypertension are modifiable risk factors for coronary heart disease and increase his risk of developing angina pectoris (Gulati et al., 2021).
   • Follow-Up:
     • The patient is expected to return to the clinic for follow-up after one month.

2. Type 2 Diabetes (E11.9)

• Diagnostics:
  • HbA1c levels to inform the level of blood sugar control (Quattrocchi et al., 2020).
• Treatment:
  • The patient will be advised to continue taking metformin 500mg, administered orally every 12 hours. Metformin is effective in lowering blood glucose (Quattrocchi et al., 2020).
  • The patient will also be advised to remain on the recommended diet to optimize his blood sugar control (Quattrocchi et al., 2020).
• Education:
  • The patient will be educated on the significance of integrating pharmacotherapy with lifestyle modification to optimize his blood sugar control. Adjunctive use of pharmacological and non-pharmacological interventions is superior to either agent used alone in managing diabetes (Quattrocchi et al., 2020).
• Follow-Up:
  • The patient will be advised to visit the clinic for follow-up after one month.

3. Hypertension (ICD10 Code 110)

• Diagnostics:
  • Blood pressure measurements to ascertain the level of blood pressure control (Carey et al., 2021).
  • CBC to rule out infections that may elevate blood pressure and compromise blood pressure control (Carey et al., 2021).
• Treatment:
  • The patient will be advised to continue nifedipine 30mg. Nifedipine is a calcium channel blocker that is effective in lowering blood pressure (Carey et al., 2021).
• Education:
  • The patient will be educated on the significance of integrating pharmacotherapy with lifestyle modification to optimize his blood pressure control. Adjunctive use of pharmacological and non-pharmacological interventions is superior to either agent used alone in managing hypertension (Carey et al., 2021).
• Follow-Up:
  • The patient will be advised to visit the clinic for follow-up after one month (Carey et al., 2021).

References

Carey, R. M., Wright, J. T., Taler, S. J., & Whelton, P. K. (2021). Guideline-driven management of hypertension. Circulation Research, 128(7), 827–846. https://doi.org/10.1161/circresaha.121.318083

Gulati, M., Levy, P. D., Mukherjee, D., Amsterdam, E., Bhatt, D. L., Birtcher, K. K., Blankstein, R., Boyd, J., Bullock-Palmer, R. P., Conejo, T., Diercks, D. B., Gentile, F., Greenwood, J. P., Hess, E. P., Hollenberg, S. M., Jaber, W. A., Jneid, H., Joglar, J. A., Morrow, D. A., . . . Shaw, L. J. (2021). 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 144(22). https://doi.org/10.1161/cir.0000000000001029

Joshi, P. H., & De Lemos, J. A. (2021). Diagnosis and management of stable angina: A review. JAMA, 325(17), 1765-1778. https://doi.org/10.1001/jama.2021.1527

Quattrocchi, E., Goldberg, T., & Marzella, N. (2020). Management of type 2 diabetes: Consensus of diabetes organizations. Drugs in Context, 9, 1–25. https://doi.org/10.7573/dic.212607

Tamargo, J., & Lopez-Sendon, J. (2022). Ranolazine: A better understanding of its pathophysiology and patient profile to guide treatment of chronic stable angina. Future Cardiology, 18(3), 235–251. https://doi.org/10.2217/fca-2021-0058

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