SOAP Note Report: Post-Cardiac Bypass Surgery Follow-up Assessment

This nursing assignment presents a SOAP note for a 60-year-old male patient's follow-up three weeks after cardiac bypass surgery. The subjective section details the patient's complaints of chest discomfort, dyspnea on exertion, and paroxysmal nocturnal dyspnea, along with a history of hypertension, asthma, and smoking. The objective section includes the patient's vital signs, physical assessment findings, and medication details. The assessment identifies potential differential diagnoses, including chest tightness and congestion related to asthma or surgery, and highlights the significance of paroxysmal nocturnal dyspnea. The plan outlines the continuation of current medications, lipid panel testing, follow-up appointments, and management of dyspnea through nebulizers and breathing exercises. The report emphasizes the importance of monitoring blood pressure and evaluating treatment outcomes. The assignment concludes with references to relevant research articles.

Running head: NURSING ASSIGNMENT
NURSING ASSIGNMENT
Name of the Student
Name of the university
Author’s note

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NURSING ASSIGNMENT
SOAP note for a patient who had come for a follow up after a Cardiac bypass surgery
Subjective: Mr. X is a 60 years old man seen today for a follow up after three weeks after a
cardiac bypass surgery has been done. He has not reported any forms of chest pain consistent
with angina. According to him, he is having a little bit of discomfort on minimal stretching, at
the site of the surgical incision present in the chest wall. Mr. X describes dyspnea on exertion
and is unable to take a brisk mile walk for more than 7-8 minutes. The patient had also reported
paroxysmal nocturnal dyspnea. He has reported no occurrence of edema or pain in the calves
during exercising.
Mr. X had reported that he had medical history of hypertension and asthma. He was an
avid smoker, with about 2 packs of cigarettes a day, but had quit smoking 2 years back. He
claimed that since then, he had displayed less symptoms of asthma. The patient had been
checking his blood pressure twice in a week. His values are normally 130-140/80-85. He has
reported that he has not experienced any side effect from the medication. He had past history of
Coronary artery diseases, myocardial infarction and hypercholesterolemia. The medications
includes lisinopril 20mg daily, atenolol daily. He had been in Mediterranean diet.
Objective: Mr. X is an elderly male who appears a bit younger than the age that he has stated.
His BP is 133/79, Hight- 5’9’, weight- 195 lbs, BMI- 28.8.
Neck- There is no jugular venous distension, no bruits
Lungs: Presence of mild congestion

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Chest wall: Midline scar that is on the process of healing. , without the presence of any erythema
or any kind of discharge.
The dorsalis pedis pulses and the posterior tibial pulses are showing 2+ bilaterally.
Assessment: A 60 years old man had come for a follow up after the surgery, with mild chest
tightedness and hypertension. The patient does not have much exercise tolerance, but has not
reported any occurrence of an angina/chest pain. Differential diagnoses includes chest
tightedness and presence of congestion due to asthma. However, it is still not detected, whether,
it due to asthma or the surgery that has occurred. Paroxysmal nocturnal dyspnea is the
distressing symptom that can usually be caused by heart failure. Evaluation should be done for
symptoms like the need of the patient to go out in fresh air at night or if the patient get up from
sleep gasping for air. The hypertension of the patient is well managed by Atenolol, since the BP
is less.
Procedure:
For the CAD- The current medications needs to be continued. The fasting lipid panels needs to
be taken today. Follow up appointments is needed in 3 months. Patient will continue the low fat
For dyspnea- Patient will be provided with nebulizers and various relaxed breathing exercises.
Mr. X should be encouraged to continue monitoring the blood pressure. Outcome of the
treatment can be understood, if on following up after a week, the patient does not report chest
tightedness or the lung sounds are found clear on Auscultation (Hardcastle et al., 2015).

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Bibliography
Hardcastle, S. J., Taylor, A. H., Bailey, M. P., Harley, R. A., & Hagger, M. S. (2013).
Effectiveness of a motivational interviewing intervention on weight loss, physical activity
and cardiovascular disease risk factors: a randomised controlled trial with a 12-month
post-intervention follow-up. International journal of behavioral nutrition and physical
activity, 10(1), 40.
Look AHEAD Research Group. (2013). Cardiovascular effects of intensive lifestyle intervention
in type 2 diabetes. New England journal of medicine, 369(2), 145-154.
Rees, K., Hartley, L., Flowers, N., Clarke, A., Hooper, L., Thorogood, M., & Stranges, S. (2013).
'Mediterranean'dietary pattern for the primary prevention of cardiovascular disease.
Cochrane Database of Systematic Reviews, (8).