Directions: Write a SOAP note for the patient scenario described below. A complete S, O and A section addressing all problems should be written. Only those problems that are primary or secondary priority need to be addressed in the plan (P section). Be sure to include references for recommendations.

Date of encounter: 5/25/20

CC: Post-discharge follow-up

Patient “Paul” is a 54 year-old Caucasian male being seen in the clinic following a recent hospital discharge 1 week ago for acute myocardial infarction. During his admission, he underwent a heart catheterization and subsequent drug-eluting stent placement to the left anterior descending coronary artery. He was initiated on atorvastatin, aspirin, and clopidogrel therapy in the hospital and discharged on these medications in addition to his previous home regimen.

Upon presentation to the clinic, the patient was noticeably limping and when asked, he stated that his hip pain has gotten much worse over the past few months. He was previously able to control the pain with OTC naproxen and acetaminophen, however he says that these medications have not been working as well lately. Additionally, he states that his legs have been swollen since he was discharged from the hospital. The swelling seems to be better in the morning, but gets worse the longer he is on his feet, so he has been spending a lot of time in his recliner. He is worried that it may interfere with him going back to work as an elementary school teacher.

PMH:

T2DM diagnosed 5 years ago

HTN diagnosed 10 years ago

OA diagnosed 5 years ago

Family History:

                Father – alive, age 80, HTN, MI x 2, T2DM

                Mother – alive, age 78, COPD, hypothyroidism

                Sister – alive, age 46, HTN

Surgical History:

                Heart catherization with LAD stent placement approximately a week and half ago

Social History:

                Lives at home with wife, 5 year old son, and 6 months old daughter

                Works as an elementary school teacher

                Tobacco: 15 pack-year smoking history; quit 2 months ago

                Alcohol: 1-2 drinks/day with dinner

                Negative illicit drug use

                Compliant with prescribed medication regimens

Allergies: NKDA

Medication List:

                Metformin 500 mg PO BID with meals

                Lisinopril 10 mg PO daily

                Metoprolol tartrate 50 mg PO BID

                Acetaminophen ER 650 mg PO every 8 hours as needed for hip pain (OTC)

                Naproxen sodium 220 mg PO BID (OTC)

                Atorvastatin 20 mg PO daily – new medication started in hospital

                Aspirin EC 81 mg PO daily – new medication started in hospital

                Clopidogrel 75 mg PO daily – new medication started in hospital

Vaccinations:

                PPSV23 in 2015

                Yearly flu vaccine

                Td in 2016, never received Tdap

Height: 72 inches

Weight: 224 pounds

Vitals:

BP 162/98 mmHg

HR 76; RR 18

Temp 98.9°F

O₂ sat 97% on RA

Physical Assessment: WNL aside from 3+ bilateral lower extremity edema

Diagnostic studies: TTE completed during hospitalization showed LVEF of 30%

Labs:

Drawn as outpatient – 2 days prior to clinic visit
Na – 138mEq/L	WBC – 7.5x 103 cells/mm3
K – 3.6 mEq/L	Hgb – 13.4 g/dL
Cl – 104 mEq/L	Hct – 41.0 %
CO2 – 30 mEq/L	Plt – 265 x 103 cells/mm3
BUN – 19 mg/dL	Bilirubin, total – 0.68 mg/dL
SCr – 1.1 mg/dL	AST – 38 IU/L
Glucose – 168 mg/dL	ALT – 44IU/L
Ca – 9.2 mg/dL	Alkaline phosphatase – 92 IU/L
HbA1c – 8.2%

Develop a thorough SOAP note for this patient, addressing all primary and secondary problems fully within the plan.

1. (Triglyceridase/Lipoprotein lipase/Lipoprotein hydrase/Pyruvate) is an enzyme that removed excess triglycerides from the bloodstream and put them into fat storage. This enzyme is found to have a higher rate of activity in obese individuals.

2. When more calories are taken in than expended energy balance is said to be (consistent/positive/negative/reversed)

3. Adipose tissue is made up of both fat and the (myofibrils/osteocytes/adipocytes/neurons) that store the fat.

4. The enzyme responsible for pulling circulating, excess triglycerides out of the bloodstream and placing them into fat storage is called (triglycerades/Lipoprotein lipase/protease/hydrolase)

5. While genetics have been found to play a role in a person’s susceptibility to develop obesity, lifestyle factors such as diet, stress management, and physical activity have been shown to play a role in the development of obesity. These factors are known as (epigenetic/ susceptibility/ genetic/ intrinsic) factors

6.When body fat increases, the hormone (cortisol/leptin/testosterone/ ghrelin) increases suppresses appetite.

7. (Gherlin/ Estrogen/ Norleptin/ Norepinephrine) is produced in the stomach and promotes appetite and weight gain. Levels generally increase before a meal and decrease after a meal.

Bolded part are the options to choose from for each question.

Which body fat measure is considered the best and why?

 

Muscular system

a ) the week number that the organ system begins developing ;

b) the medical specialty or subspecialty that focuses on the organ

      system; provide brief information on the course of preparation required

     for that specialist to do the work;

c) provide details of one (1) function accomplished by the organ system;

Match each function to the correct item. Answers can only be used once, so choose the BEST answer.

Question Generator potential Touch Acuity Smell Transmits sensory information about proprioception to cortex All Answer Choices A. Chemoreceptor B. Interneuron C. Autonomic nervous system D. Receptor density E. Mechanoreceptor F. Afferent neuron G. Efferent neuron H. Electroreceptor I. Dorsal Column

1. The walls of the veins contain smooth muscle which is innervated by sympathetic nerve fibers. Sympathetic stimulation ____________ venous vasoconstriction and drives __________ blood into the heart. Fill in the blanks with one of the following term combinations.

		increases / more
		increases / less
		decreases / more
		decreases / less

Fill in the blanks below with the following terms. (some terms will be used more than once and other terms will not be used at all)

(Acetylcholine, Cholecystokinin, Gastric Inhibitory Peptide (GIP), Gastrin, Glucagon-Like Peptide 1, Histamine, Secretin, Somatostatin, chylomicrons, HDLs, LDLs, VLDLs, Cephalic, Gastric, Intestinal,)

a. __VLDLs__ are low density lipoproteins carrying more triglycerides than cholesterol.

b. ________, _________ and __________ are secreted into the bloodstream in response to amino acids in the digestive tract.

c. __________, __________ and __________ increase H+ secretion from parietal cells.

d. __Chylomicrons__ are the lowest density of lipoproteins taken up by lacteals.

e.________, ________ and __________ decrease H+ secretion from parietal cells.

f. _________ and _________ are hormones that stimulate insulin release from pancreatic Beta cells.

g. The ________ phase of digestion occurs from stimuli in the stomach while the ________ phase of stimulation can be started by simply seeing or smelling food.

h. Gastric motility and emptying is increased by __________ while it is slowed by __________, _________ and _________.

i. __HDLs__ are lipoproteins used for removing excess cholesterol from the body.

j. Very low pH in the stomach stimulates _____________ to _________ (increase/decrease) gastrin release while higher pH than normal leads to a(n) ______ (increase/decrease) of gastrin secretion from G-cells.

k. The hormone ___________ stimulates pepsinogen secretion from the gastric mucosa while the hormone _________ stimulates pancreatic protease secretions like trypsinogen, and chymotrypsiongen.

l. __LDLs__ are lipoproteins comprised of the largest amount of cholesterol and are considered ‘bad cholesterol’.

m. The hormone ___________ stimulates smooth muscle contractions of the stomach and small intestine.

n. Secretion of the hormone ___________ is stimulated by fatty acids and promotes secretion of pancreatic enzymes and gallbladder contractions.

In lifting a basket of laundry off the floor, fill in the blanks below, detailing one muscle working at the designated joint, and in what manner.

Joint	Muscle	Concentric/Eccentric/Isometric
Shoulder
Elbow
Wrist
Hand

In going from standing to sitting, fill in the blanks below, detailing one muscle working at the designated joint, and in what manner.

Joint	Muscle	Concentric/Eccentric/Isometric
Hip
Knee
Ankel

1. Fill in the blanks: Bile is produced by the _________ and stored and concentrated in the _______.

2. Folds of the small intestinal mucosa are known as:

a. microvilli

b. circular folds

c. intestinal crypts

d. villi

3. True/False: Mark the following statements as true (T) or false (F). If the statement is false, correct it so it becomes a true statement.

____ a. The peritoneal cavity is located between the visceral peritoneum and the mesentery.

____ b. The shortest segment of the small intestine is the duodenum.

____ c. Filiform papillae are keratinized projections from the tongue that help physically break down food.

____ d. Pancreatic islets are the exocrine portion of the pancreas.

____ e. The ileocecal valve regulates flow from the stomach to the duodenum.

____ f. The vermiform appendix is a blind-ended sac that contains lymphoid follicles.

If someone had extra long chordae tendineae on their mitral valve this would most likely affect the valve how and why?

why does the maximum contractile force generated by heart increase with preload?