Discuss SOAP Note on a 66 year old female with shortness of breath. Mrs. Hernandez. History of Diabetes and HTN , Non-compliant with meds due to stressors in her life. Husband died 6 mos ago and trying to obtain custody of her 12 yr old grandson. Patient is tired and not feeling well and worried about her breathing which gets worse at night and she needs to sleep on an extra pillow. Complains of trouble breathing in bed especially when lying flat, denies chest pain, denies palpitations, no fever, no chills, No URI, no cough, no diaphoresis, no dizziness, no nausea , no vomit, but states her ankles and lower legs are swollen, and she has increased blurred vision. Temp 98.5, HR 100, Resp. 22, Oxygen 93%, BP 170/110, weight 174lbs. General: Mrs. Hernandez appears somewhat anxious and slightly pale, but otherwise comfortable. She is able to speak in full sentences, without dyspnea. She is oriented to place, person, and time. Repeated vital signs: Heart rate: 100 beats/minute Respiratory rate: 22 breaths/minute Blood pressure: 170/110 mmHg HEENT: Eyes: No conjunctival injection or pallor, pupils equal and reactive to light and accommodation. Oropharynx: No injection or exudates. No pallor of mucosa. Neck: Trachea midline, no adenopathy, carotid pulses 2+ bilaterally, normal wave form, no bruits, jugular vein distention (JVD) present to 3 cm. Chest: Symmetrical, normal excursion. Lungs: Bibasilar rales, no rhonchi, slight dullness to percussion at bases, no egophony, no whispered pectoriloquy. Heart: PMI in the left axillary line, no heaves, normal S1, S2. Regular rate and rhythm. S3 present Abdomen: Bowel sounds present, no bruits, soft, non-tender, no hepato-splenomegaly, no shifting dullness, no masses or hepatojugular reflux. Extremities: 2+ pitting edema of lower extremities to the ankle bilaterally, healing circular area 1 cm diameter on left lower leg without surrounding erythema or discharge, dorsalis pedis pulses 1+ bilaterally. Skin: Cool and clammy Mrs. Hernandez is a 66-year-old female with poorly controlled diabetes and hypertension and recent non-adherence to medications who presents with a one-week history of progressive dyspnea on exertion, orthopnea, PND. Most Likely Diagnoses Myocardial infarction A recent myocardial infarction can overwhelm cardiac reserve and result in a new presentation of CHF. Acute MI is generally associated with chest pain. However, patients with diabetes may present with so-called ″silent″ MI– painless but evident on ECG. During an acute MI, patients frequently experience hypotension, complicating the use of evidenced-based acute treatments such as nitrates and beta-blockers, both of which lower blood pressure. Arrythmias Arrhythmias, such as atrial fibrillation, can lead to inadequate filling of the left ventricle and subsequent heart failure. Arrhythmias cause heart failure by impeding the forward flow of blood through the heart. Atrial fibrillation and flutter commonly do this particularly when they are associated with rapid ventricular response. Without the atrial kick the ventricle does not fill as well, a problem which is exacerbated by the decreased filling time that occurs with tachycardia. Paroxysmal supraventricular tachycardia (PSVT) may also cause this. Ischemic cardiomyopathy Ischemic cardiomyopathy is the most common cause of CHF and is most often the result of long-term risk factors such as hypertension, hyperlipidemia, diabetes and behavioral factors resulting in significant CAD. Over time, damage to the myocardium and scarring lead to reduced systolic function. Uncontrolled hypertension After CAD, the second most common cause of CHD is diastolic dysfunction, often due to uncontrolled hypertension. Please use the diagnosis of Left Ventricular Hypertrophy. Pleases also use for plan: echocardiogram and stress test She was discharged after three days in the hospital with the following discharge medication list: Ramipril 20 mg daily Hydrochlorothiazide 25 mg daily Metoprolol succinate 50 mg daily Metformin 1000 mg twice daily NPH insulin 10 units every morning before breakfast and evening before dinner Enteric-coated aspirin 81 mg daily Atorvastatin 80 mg every evening