Cardiovascular System Examination-Coronary Artery Disease
Comprehensive patient history can be taken by embracing SOAP notes. This acronym identifies major components: subjective data, objective data, assessment, and plan (Podder et al., 2021). SOAP notes facilitate a logical organization of ideas (Podder et al., 2021). Completeness of history taking facilitates accurate diagnosis and development of relevant treatment plans.
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Subjective
F.D. is a forty-five-year-old Caucasian female. She complains of severe chest pain, shortness of breath, and lightheadedness. She reports that the chest pain has persisted for three days. Initially, the pain was worsened by exertion and relieved by rest. However, for the past few hours, her pain is not relieved by rest. According to her, she has experienced lightheadedness and shortness of breath for the past four hours. She reports that she was diagnosed with hypertension five years ago. Furthermore, two years ago, she was diagnosed with diabetes mellitus. Nine months ago, she was hospitalized for a hyperosmolar hyperglycemic state.
Currently, the patient is taking enalapril 5 mg and amlodipine 5 mg PO daily for her hypertension. She reports using metformin 500 mg PO BD for her diabetes mellitus. The patient has no known drug or food allergy. However, she is allergic to environmental allergens such as pollen. The patient reports no family history of hypertension and other cardiovascular conditions. She says that her mother had diabetes mellitus. The patient has been married for twenty years. Despite her commodities, she says that she occasionally engages in binge drinking and has limited physical activity. The patient’s subjective data suggest coronary artery disease. A definitive diagnosis can be made after taking the patient’s objective data.
Objective
The patient’s blood pressure is 148/88, whereas her pulse rate is 110. Her respiratory rate per minute is 24. She has an oxygen saturation of 93%. An investigation of her fractional flow reserve (FFR) reveals that her FFR is 0.73. Heart murmurs, S4 gallop, and S3 gallop are revealed via auscultation. An evaluation of the extremities reveals finger clubbing and mild cyanosis.
Further examination indicates mild pitting edema. Examination of the patient’s mass and height reveals a body mass index of 27.5. Laboratory results suggest that the patient’s hemoglobin A1C is 6.5. Her random plasma glucose levels are 220 mg/dl. The patient’s lipid profile for low-density lipoproteins, high-density lipoproteins, and triglycerides are 105 mg/dl, 50 mg/dl, and 160 mg /dl, respectively. Results from nuclear imaging studies reveal coronary artery stenosis.
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Question 
The patient’s objective and subjective data confirm the diagnosis of coronary artery disease. Notably, a fractional flow reserve (FFR) of 0.73, S4 gallop, S3 gallop, coronary artery stenosis, chest pain (angina), shortness of breath, and lightheadedness confirm the diagnosis of coronary artery disease (Abd Samir et al., 2018). This disease results from plaque deposition in coronary arteries.
Actual or Potential Risk Factors
The two risk factors for the patient are dyslipidemia and hypertension. Laboratory results indicate that the patient has elevated low-density lipoproteins, elevated levels of triglycerides, and low levels of high-density lipoproteins. The average values for these lipid profiles are 100 mg/dl, 150 mg/dl, and 60 mg/dl, respectively (Clevelandclinic.org, n.d.). Elevated levels of low-density lipoproteins increase the risk of atherogenesis and coronary stenosis (Abd alamir et al., 2018). As a result, the patient’s likelihood of developing coronary artery disease increases. Low-density lipoproteins are easily oxidized and transported to the endothelium. Oxidized low-density lipoproteins prevent the endothelium’s vasodilation by inhibiting nitric oxide synthase activity (Abd alamir et al., 2018). Furthermore, oxidized low-density lipoproteins promote the accumulation of cholesterol (Abd alamir et al., 2018). These actions encourage atherogenesis and increase the risk of coronary artery disease.
The patient is a known hypertensive, increasing his risk for coronary artery disease. Hypertension triggers endothelial dysfunction (Vidal-Petiot et al., 2018). By so doing, hypertension compounds the process of atherosclerosis and increases the risk for coronary artery disease. Left ventricular hypertrophy resulting from chronic hypertension leads to myocardial ischemia (Vidal-Petiot et al., 2018). This worsens the manifestation of coronary artery disease.
References
Abd alamir, M., Goyfman, M., Chaus, A., Dabbous, F., Tamura, L., Sandfort, V., Brown, A., & Budoff, M. (2018). The Correlation of Dyslipidemia with the Extent of Coronary Artery Disease in the Multiethnic Study of Atherosclerosis. Journal of Lipids, 2018, 1–9. https://doi.org/10.1155/2018/5607349
Clevelandclinic.org. (n.d.). Lipid Panel. https://my.clevelandclinic.org/health/diagnostics/17176-lipid-panel
Podder, V., Lew, V., & Ghassemzadeh, S. (2021). SOAP Notes. https://www.ncbi.nlm.nih.gov/books/NBK482263/
Vidal-Petiot, E., Greenlaw, N., Ford, I., Ferrari, R., Fox, K. M., Tardif, J. C., Tendera, M., Parkhomenko, A., Bhatt, D. L., & Steg, P. G. (2018). Relationships between Components of Blood Pressure and Cardiovascular Events in Patients with Stable Coronary Artery Disease and Hypertension. Hypertension, 71(1), 168–176. https://doi.org/10.1161/HYPERTENSIONAHA.117.10204
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