Pulmonary Hypertension SOAP Note Transcription Sample Report
CHIEF COMPLAINT: Pulmonary hypertension with an estimated pulmonary artery systolic pressure of 50-60 on recent echocardiogram, hypertrophic nonischemic cardiomyopathy with normal systolic function, home oxygen therapy 3 liters at rest, 4 liters with activity starting today.
SUBJECTIVE: The patient is a very pleasant (XX)-year-old woman who we see for what we thought was chronic obstructive pulmonary disease and pulmonary hypertension, which was recently diagnosed on an echocardiogram. We walked her in the hall today, and her oxygen saturation did drop down to 86% on 3 liters of home oxygen. Therefore, we have recommended that she use oxygen 3 liters at rest and 4 liters with activity.
Her chest x-ray looks like she has some congestion on it when I checked it last. We recommended that she continue her Lasix 60 mg twice daily and watch her salt intake.
Her pulmonary hypertension stems from the fact that this echocardiogram, from last month, shows an estimated pulmonary artery systolic pressure of 50-60. This was not mentioned on a previous echocardiogram from two years ago. I am wondering if she is fluid overloaded. Her BNP is over 600. Although it was better than her previous BNP, she may have elevated left-sided pulmonary venous pressures causing her pulmonary hypertension.
We discussed this with her and her family today and they are not interested in having a right-sided heart catheterization at this time. I agree.
OBJECTIVE: Blood pressure 108/62, heart rate 72, oxygen 95%. Chest is clear. Cardiac: Regular rate and rhythm.
ASSESSMENT AND PLAN:
1. Pulmonary hypertension: We will repeat her echocardiogram five months from now, and we will see her the month after.
2. Chronic obstructive pulmonary disease: Her pulmonary function test looked more restricted than obstructed. However, she does have some concavity to the expiratory limb in the flow volume curve. Her vital capacity, however, is low at 54% of predicted. I am wondering if this is secondary to congestive heart failure or if this is real restriction. Her chest x-ray does not show congestive heart failure at this time.
3. Shortness of breath with ambulation: We recommended that she take 2 inhalations of Combivent 20 minutes prior to coming to the doctor. We also recommended that she increase her ambulatory oxygen to 4 liters and use 3 liters at rest.
We will see her back in six months. We will get an echocardiogram in five months and discuss the results of this. When I see her back, she will get a walking oximetry test and pulmonary function test.
