SOAP Note: Acute Exacerbation of Congestive Heart Failure (CHF)

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Differential diagnoses
1 Acute exacerbation of congestive heart failure (CHF)
1 I50. 33 Acute on chronic diastolic (congestive) heart failure
2 Based on the past medical history of the patient involving cardiac issues, such as non-rheumatic mitral regurgitation, viral cardiomyopathy with EF of 10%, and chronic systolic heart failure, a diagnosis related to congestive heart failure is likely. In addition to this, the patient currently presents with paroxysmal nocturnal dyspnea, orthopnea, shortness of breath, fatigue, bibasilar crackles, cyanosis, hypoxia, and bipedal edema which are signs and symptoms of patients with acute exacerbation of congestive heart failure (King & Goldstein, 2021).
2 Pneumonia
3 J15.9 Bacterial pneumonia; J12.9 Viral Pneumonia
4 Given the current age of the patient, there is an increased susceptibility to pneumonia (Mangen, et al., 2017). The patient presents with respiratory symptoms such as moderate respiratory distress (poor shallow breathing, cyanotic nail beds, and chest retraction), coughing, crackles, and fatigue. These signs and symptoms with the sudden onset of difficulty in breathing are consistent with pneumonia. However, fever, chills, and chest pain are some characteristics of pneumonia that are not seen on the patient (Jung, et al., 2017).
3 Respiratory allergies
5 J30.2 Seasonal allergies
6 The patient states having allergies that present with respiratory symptoms when exacerbated. The main complaint of the patient is shortness of breath. This complaint including coughing, shallow breathing, and runny nose are characteristics of respiratory allergies (Vigo, et al., 2018). The low oxygen levels of the patient may also because of the difficulty in breathing that the patient experiences which compromises efficient oxygen intake. It also aligns with the duration of the patient’s cough and runny nose which are common to last from days to a few weeks depending on the presence of the allergens (Scadding, et al., 2017). However, there are other possible conditions due to the chronic conditions that the patient already has including the presence of signs and symptoms which may be caused by systemic conditions.
Health Promotion/ Disease Prevention: Z91.81 Fall Prevention; Z00.00 Well Woman preventive care; Z23 Adult Immunization
Plan
Health Promotion/ Disease Prevention: Z91.81 Fall Prevention; Z00.00 Well Woman preventive care; Z23 Adult Immunization
Testing/Diagnostics
* Chest X-ray: This diagnostic procedure will provide a visual image of the patient’s lungs and will reveal the presence of consolidations, infiltrates, or fluids, aiding in the treatment of the patient’s respiratory distress and other symptoms.
* ECG: The electrical signals will provide an opportunity to check the patient’s heart. This is also possible even with the presence of her biventricular ICD.
* Sputum culture: The patient is experiencing cough, and it is beneficial to check for the presence of bacteria or infection that may be causing the respiratory symptoms of the patient. In addition to this, the mucus that is produced will provide infor...