SOAP Note Format – CHEST PAIN

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SOAP Note Format – CHEST PAIN 1/24/18 Pre-Brief: This assignment provides the opportunity to conduct a focused exam on a patient presenting with recent episodes of chest pain in a non-emergency se... tting. Interview Mr. Foster and be sure to thoroughly assess the cardiovascular system as well as related body systems in order to compile a list of differential diagnoses. This case study offers you the opportunity to evaluate Mr. Foster's personal and family history with heart disease and identify lifestyle risk factors. During the physical examination, thoroughly examine the cardiovascular system and carefully evaluate and document the patient's heart sounds. Reason for visit: Patient presents complaining recurrent chest pain. Patient Information: Brian Foster, 58 yo Male. Presenting with recent episode of chest pain. S. CC: Patient states intermittent chest pain that is tight and uncomfortable. HPI: Onset: Earlier in the month Location: Middle of chest, does not radiate. Duration: Pain lasts “several” minutes. Pain passes with rest. Has experienced CP 3x this month. Last episode of CP last Friday per patient. Characteristics: Denies sweating, nausea, vomiting, SOB or palpitations with pain. Has never experienced this pain before. Describes pain as “tight” and “uncomfortable”. States pain a 5/10 at worst. Currently no pain. Denies crushing, gnawing or burning pain. Aggravating Factors: Physical activity. Fist occurrence when Mr. Foster was doing yardwork, second occurrence when he had to use stairs at work to 5th floor office when elevator was broken. Pain does not worsen when eating any type of food. Relieving Factors: Rest, “lying still”, sitting down to rest. Treatment: Patient has not taken any medications for the chest pain. Current Medications: Metoprolol (Lopressor) 100mg PO Daily, Atorvastatin (Lipitor) 20 mg PO Daily at bedtime last dose 2200 yesterday, Omega-3 Fish Oil 1200 mg PO BID last dose 0800 (OTC). Reviewed chart for last doses of medications due to patient unable to remember. Does not take Aspirin Occasionally takes Tylenol or Ibuprofen for aches or pains 3-4x/month. Allergies: Codeine (nausea, vomiting) PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed • Immunizations: Tdap 10/2014, Influenza this season • PMHx: HTN – Stg II - diagnosed 1 year ago, Hyperlipidemia – diagnosed 1 year ago, • SurgHx: No surgical hx • Has never been diagnosed with angina • No DM, CAD and no previous treatment for CP. • Pt does not monitor BP at home and does not know what his typical BP is. • Last EKG 3 months ago, last Stress Test 1 year ago. Per pt doctor said “everything looked fine”. • PCP: Dr. Melinda Smith. Last visit 3 months ago. Does not have a cardiologist. Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use, any other pertinent data. Always add some health promo question here - such as whether they use seat belts all the time or whether they have working smoke detectors in the house. • No past or present tobacco use • Reports drinking 2-3 alcoholic beverages (beer) on weekends. • Denies use of heroin or other illicit drugs. • Pt states low stress job and low stress lifestyle • Denies regular exercise ever since bike was stolen • Breakfast: granola bar or breakfast shake, Lunch: turkey or Italian sub or salad, Dinner: grilled meat and vegetable. Big breakfast on weekends. • Does not monitor salt intake. • Drinks 1L water/day. 2 cups coffee daily, whole pot of coffee on Sundays, does not drink soda. Fam Hx: o Maternal grandfather died of MI, no family history of stroke of PE. o Remainder of family history obtained from patient’s chart • Father: HTN, HLD, obesity, deceased Colon CA age 75 • Mother: T2DM, HTN, age 80 • Brother: died age 24 in MVA • Sister: T2DM, HTN, age 52 • Maternal Grandmother: died of Breast CA, age 65 • Maternal Grandfather: died of MI age 54 • Paternal Grandmother: died of PNA, age 78 • Paternal Grandfather: died of “old” age, age 85 • Son: healthy, age 26 • Daughter: Asthma, age 19 ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: Constitutional: Head: EENT: etc. You may list these in paragraph format or bullet format. Always document the systems in order from head to toe. You may focus the ROS to match the chief complaint unless you are doing a complete health history. Example of Complete ROS: CONSTITUTIONAL: Denies fatigue. 15-20 lb weight gain in past couple of years – states due to being less active, bike got stollen. CP interferes with daily living, patient notices pain more with movement and he feels he should sit down and take a deep breath. HEENT: Denies changes to vision, denies change in sense of taste, no sore throat and no dysphagia. SKIN: Denies cyanosis or pallor. CARDIOVASCULAR: Denies palpitation or edema. Currently no report of CP. Denies edema, circulatory issues, history of blood clots, diagnosis of heart mur [Show More]

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