NR 509 Week 4 Chest Pain SOAP Note

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SOAP Note Template Initials: BF Age: 58 Gender: M Height Weight BP HR RR Temp SPO2 Pain Allergies 5’11 97kg 146/ 90 104 19 36.7C 98% Medication: Codiene( Nausea/Vomitting) Food: NFA Environme... nt: NA History of Present Illness (HPI) Chief Complaint (CC) I have been having some troubling chest pain in my chest now and then for the past month. CC is a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance "headache", NOT "bad headache for 3 days”. Sometimes a patient has more than one complaint. For example: If the patient presents with cough and sore throat, identify which is the CC and which may be an associated symptom Onset Early this month. Location Middle chest. Duration Last a minute or more. Characteristics Tight and uncomfortable in the middle of chest that does not radiate. Aggravating Factors Yard work and climbing stairs. Relieving Factors Rest Treatment None Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. Medication (Rx, OTC, or Homeopathic) Dosage Frequency Length of Time Used Reason for Use Metoprolol 100mg PO daily 1 year High blood presure Atorvastatin 20mg PO bedtime 1 year High cholesterol Tylenol 650mg PO Q 8 hours PRN Headaches Fish oil 1200mg 1 tab PO daily 1 year supplements Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses, hospitalizations, and surgeries. Depending on the CC, more info may be needed. Patient is hypertensive and high cholesterol. No surgery, reports immunization is up to date. S: Subjective Information the patient or patient representative told you Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent data. Include health promotion such as use seat belts all the time or working smoke detectors in the house. Patient is married, lives with his wife and 2 children.He is a civil engineer and enjoys riding his bike a lot but has not done so in 2 years since it got stolen. Denies illcit drug use or tobacco.Social drinker,drinks 2 to 3 bottles on the weekends. Uses his seatbelt while driving and has working smoke detectors at home. Denies routine exercise. Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent. Dad : Died of Colon cancer. Mom: Living High blood pressure and Type 2 Diabetics. Brother: passed at 24 years old from a MVA. Sister:Living 52yo Type 2 diabetics and hypertension. Paternal grand dad: Died at 85yo unknown causes. Paternal grand mom: Died at 78 from pneumonia. Maternal grand dad: Died at 54 from a heartattack. Maternnal grand mom:died at 65 from Breast cancer. Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive symptom and provide additional details. Constitutional Skin HEENT ☐Fatigue Click or tap here to enter text. ☐Weakness Click or tap here to enter text. ☐Fever/Chills Click or tap here to enter text. ☒Weight Gain Gained 15 pounds in a couple of yearschest ☐Weight Loss Click or tap here to enter text. ☐Trouble Sleeping Click or tap here to enter text. ☐Itching Click or tap here to enter text. ☐Rashes Click or tap here to enter text. ☐Nail Changes Click or tap here to enter text. ☐Skin Color Changes Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☐Diplopia Click or tap here to enter text. ☐Eye Pain Click or tap here to enter text. ☐Eye redness Click or tap here to enter text. ☐Vision changes Click or tap here to enter text. ☐Photophobia Click or tap here to enter text. ☐Eye discharge Click or tap here to enter text. ☐Earache Click or tap here to enter text. ☐Tinnitus Click or tap here to enter text. ☐Epistaxis Click or tap here to enter text. ☐Vertigo Click or tap here to enter text. ☐Hearing Changes Click or tap here to enter text. ☐Hoarseness Click or tap here to enter text. ☐Oral Ulcers Click or tap here to enter text. ☐Sore Throat Click or tap here to enter text. ☐Congestion Click or tap here to enter text. ☐Rhinorrhea Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☐Night Sweats Click or tap here to enter text. ☐Other: Click or tap here to enter text. Respiratory Neuro Cardiovascular ☐Cough Click or tap here to enter text. ☐Hemoptysis Click or tap here to enter text. ☐Dyspnea Click or tap here to enter text. ☐Wheezing Click or tap here to enter text. ☐Pain on Inspiration Click or tap here to enter text. ☐Sputum Production ☐Other: Click or tap here to enter text. ☐Syncope or Lightheadedness Click or tap here to enter text. ☐Headache Click or tap here to enter text. ☐Numbness Click or tap here to enter text. ☐Tingling Click or tap here to enter text. ☐Sensation Changes ☐Speech Deficits Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☒Chest pain chest pain my chest now and then for the past month. ☐SOB Click or tap here to enter text. ☒Exercise Intolerance Experienced while climbing the stairs at work. ☐Orthopnea Click or tap here to enter text. ☐Edema Click or tap here to enter text. ☐Murmurs Click or tap here to enter text. ☐Palpitations Click or tap here to enter text. ☐Faintness Click or tap here to enter text. ☐OC Changes Click or tap here to enter text. ☐Claudications Click or tap here to enter text. ☐PND Click or tap here to enter text. ☒Other: S3 sound heard MSK GI GU PSYCH ☐Pain Click or tap here to enter text. ☐Stiffness Click or tap here to enter text. ☐Crepitus Click or tap here to enter text. ☐Swelling Click or tap here to enter text. ☐Limited ROM ☐Nausea/Vomiting Click or tap here to enter text. ☐Dysphasia Click or tap here to enter text. ☐Diarrhea Click or tap here to enter text. ☐Appetite Change Click or tap here to enter text. ☐Heartburn Click or tap here to enter ☐Urgency Click or tap here to enter text. ☐Dysuria Click or tap here to enter text. ☐Burning Click or tap here to enter text. ☐Hematuria Click or tap here to enter text. ☐Polyuria Click or tap here to ☐Stress Click or tap here to enter text. ☐Anxiety Click or tap here to enter text. ☐Depression Click or tap here to enter text. ☐Suicidal/Homicidal Ideation Click or tap here to enter text. ☐Memory Deficits Click or tap ☐Redness Click or tap here to enter text. ☐Misalignment Click or tap here to enter text. ☐Other: Click or tap here to enter text. text. ☐Blood in Stool Click or tap here to enter text. ☐Abdominal Pain Click or tap here to enter text. ☐Excessive Flatus Click or tap here to enter text. ☐Food Intolerance Click or tap here to enter text. ☐Rectal Bleeding Click or tap here to enter text. ☒Other: Liver palpated 1cm beleow costal margin enter text. ☐Nocturia Click or tap here to enter text. ☐Incontinence Click or tap here to enter text. ☐Other: Click or tap here to enter text. here to enter text. ☐Mood Changes Click or tap here to enter text. ☐Trouble Concentrating Click or tap here to enter text. ☐Other: Click or tap here to enter text. GYN ☐Rash Click or tap here to enter text. ☐Discharge Click or tap here to enter text. ☐Itching Click or tap here to enter text. ☐Irregular Menses Click or tap here to enter text. ☐Dysmenorrhea Click or tap here to enter text. ☐Foul Odor Click or tap here to enter text. ☐Amenorrhea Click or tap here to enter text. ☐LMP: Click or tap here to enter text. ☐Contraception Click or tap here to enter text. ☐Other:Click or tap here to enter text. O: Objective Information gathered during the physical examination by inspection, palpation, auscultation, and palpation. If unable to assess a body system, write “Unable to assess”. Document pertinent positive and negative assessment findings. Body System Positive Findings Negative Findings General NA Pt is alert and oriented x4.No sign pf distress noted.denies pain or shortness of breath. Able to follow commands. Skin NA Skin warn and dry to touch.No tenting. HEENT NA Head and neck is symmetrical, no sweeling noted. Vision 20/20 in L,R and both eyes.PERRL noted. Nose at midline and pink and mosit Mucosa memberane pink and mosit. Ears symmetrical bilaterally. Respiratory Fine crackles in right and left posterior lower lobes. Chest is symmetrical. Breath sounds clearclear in all anterior lobes. No shortness of breath noted. Neuro NA Alert and oriented X4. No loss of consciousness noted. No dizziness or light headness noted. Cardiovascular BP 146/90, HR 104 S3 hear sound heard. PMI displaced laterally brisk and tapping less than 3cm Bruit presence and +3 thrill in right carotid artery. Popliteal,tibal aned dorsalis pedis pulse no thrill +1, Chest symmetrical S1 and S2 heart sounds heard. JVP 3cm above sternal angle. Cap refill less than 3 seconds in all extremities. Brachial,radia, femoral pulses no thrill +2 Musculoskeletal NA Range of motion equal in all exteimities. Gait is steady Gastrointestinal Liver palpated 1cm below costal margin Abdomen soft and round. No tenderness or distention or masses noted.Bowel sounds present in all 4 quadrants.Spleen and kideneys not palpable .All areas of the abdomen are tympanic. Genitourinary NA Kidneys are not palpable bilaterally. Problem List 1. Chest Pain 6 PMI displaced baterally brisk and tapping 11 Weight gain 2 High blood pressure 7 RUQ Abdomen light tenderness 12 Diminshed popliteal arteries 3 Tachycardiac 8 RLQ/LLQ abdomen Light tenderness 13 Popliteal,tibal and dorsalis pedis pulses. No thrill +1 4 Bruit and +3 Thrill found in right Carotid pulse 9 liver palpated 1cm below costal margin 14 Click or tap here to enter text. 5 Fine crackles in lungs 10 Activity intolerance 15 Click or tap here to enter text. Diagnosis ICD-10 Code Pertinent Findings Coronary artery disease with stable angina 125.119 Chest pain and tightness,High BP, tachycardia. Congestive heart failure 150.20 Fine crackles, hypertension, S3 heart sound and weight gain. Carotid artery disease 165.21 Presence of bruit and thrill +3 on right carotid pulse. Diagnostics: List tests you will order this visit Test Rationale/Citation Chest Xray Chest Xray will shows images of the heart, lungs which can help diagnose heart failure.Fine crackles in lungs shows some heart problems as evidence by S3 and bilaterally displaced PMI.Also chest xray helps to depict changes in the lungs that sterm from heart failure. Fluid in the lungs will mean pulmonary edema present in heart failure (mayoclinic.org 2019) Echocardiogram Because pf the S3 sound heard around the mitral area and Echo will be recommended. An echocardiogram uses sound waves to produce images of your heart. Parts that move weakly may have been damaged duri [Show More]

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