UPDATED Tony Stark / FNP594 Week 3 SOAP Note: Cardiac Arrhythmia CC:, "I Have Been Having Palpitations For A While, And Have Been Seeing A Cardiologist, But They Were Getting Worse The Last Couple Of Days." EXPERT FEEDBACK (SOLUTIONS) COMPLETE 2024

D Tony Stark, DOB 1/1/1954, age 66, is a widowed Caucasian male who appears to be a reliable historian, presenting to the clinic by himself. Subjective CC: "I have been having palpitations for a while, and have been seeing a cardiologist, but they were getting worse the last couple of days." HPI T.S. is a 66-year-old male presenting to the clinic alone with a complaint of palpitations that have been increasing in intensity the last couple of days. The patient reports the palpitations started the beginning of May and he has been seeing a cardiologist since the end of June for evaluation. The patient reports he is pending insurance authorization for a ZIO monitor for assessment of arrhythmias. Patient reports trying to make an appointment with his cardiologist today to report worsening palpitations, but his cardiologist is on vacation until the end of next week. Patient denies changes in diet, medication regimen, and regular routine. Denies shortness of breath and chest pain, but reports feeling extra fatigued, lightheaded and dizzy with a 3/10 headache. Patient reports taking Tylenol 650 mg PO prior to clinic appointment this morning. Past Medical History: ● Medical: ○ Hypotension ○ Hyperlipidemia (HLD) ○ Coronary artery disease ○ Osteoarthritis ● Surgeries: ○ CABG 2017 ○ Cardiac Stents X4 2016 ○ Right total knee replacement 2000 ● Hospitalizations: ○ 2000- Right total knee replacement ○ 2016- Cardiac stents X4 ○ 2017- CABG ○ 2018- pneumonia ● Preventative care: ○ Moderna Covid Vaccine: 3/1/2020, 4/1/2020, 11/1/2020 ○ Influenza vaccine: 11/1/2021 Allergies: • No known drug allergies Medications: • Plavix 75 mg PO daily for cardiac stents • Atorvastatin 20 mg PO before bedtime for HLD • Multivitamin PO daily • Tylenol 650 mg PO PRN 4-6 hours for pain Social History: • Denies alcohol, tobacco, and recreational drug use. • Caffeine use o Reports drinking 1 cup of coffee daily. • Exercise o Denies regular exercise routine. • Employment o Retired architect. Family History: • Father passed away at the age of 78 from congestive heart failure. • Mother passed away at the age of 72 from a pulmonary embolism. 3 ROS • Constitutional: Denies fevers, faintness, and shakiness. • Cardiovascular: Denies chest pain and lower extremity edema. Reports palpitations. • Pulmonary: Denies shortness of breath. • Neurological: Denies numbness and tingling. Reports lightheadedness, dizziness, and 3/10 headache. • Psychiatric: Denies anxiety and depression. • Endocrine: Reports fatigue. Denies heat or cold intolerance. Objective Vital Signs H 42 BP 92/62 RR 20 Temp 97.9 F SpO2 94% room air Pain 3/10- R headache Weight 145 lbs. (65.77 kg) BMI 24.1 (normal)Height 55 inches (139.7 cm) Physical Exam • General survey: Appears tired, but comfortable. Well groomed. No apparent distress noted. • Cardiovascular: Irregular apical pulse. Irregular radial pulse to palpation. No gallops, murmurs, or rubs heard. S1and S2 are present. No leg swelling noted. • Pulmonary: Respiration rate within normal limits. Clear lung sounds in all lung fields. • Neurological: Alert and oriented X 4. Follows commands and responds appropriately.