Christina West
Chest Pain SOAP Note
NURS-60015-008-202080, ADV HEALTH ASSESSMENT
Source and Reliability:
Self and reliable
Subjective:
Chief Complaint:
“I have been having some troubling chest pain in my chest now and then for the past month.”
History of Present Illness (HPI):
Brian Foster is a 58yo male patient with periodic chest pain associated with exertion 3 times
during last month; pain rated 5/10, does not radiate, located at the mid-sternum, and described as
tight and uncomfortable. Pain is relieved with rest
Past Medical History:
HTN-Stage 2 diagnosed 1 year ago; HLD- diagnosed 1 year ago;
Past Surgical History (PSH):
None
Medications:
Lisinopril 20mg PO daily
Atorvastatin 20mg PO daily at bedtime (Last dose 10pm yesterday)
Omega 3 Fish Oil 1200mg PO BID
Allergies:
Codeine: Nausea and Vomiting
No food, environmental, latex, or animal allergies
Immunizations:
TDAP 10/2014
Influenza Vaccine completed this season
Family History:
Mother Type 2 Diabetes, HTN Age 80
Father HTN, Hyperlipidemia, Obesity, dies of colon cancer age 75
Maternal Grandmother- Died of breast cancer at age 65
Maternal Grandfather- Died of heart attack at age 54
Paternal Grandmother- Died of Pneumonia at age 78
Paternal Grandfather- Died of “old age” at 85
Daughter -Asthma age 19
Son: Healthy age 26
This study source was downloaded by 100000898062787 from CourseHero.com on 10-01-2025 04:35:01 GMT -05:00
https://www.coursehero.com/file/72103286/Cardiac-SOAP-Notedocx/
Chest Pain SOAP Note
NURS-60015-008-202080, ADV HEALTH ASSESSMENT
Source and Reliability:
Self and reliable
Subjective:
Chief Complaint:
“I have been having some troubling chest pain in my chest now and then for the past month.”
History of Present Illness (HPI):
Brian Foster is a 58yo male patient with periodic chest pain associated with exertion 3 times
during last month; pain rated 5/10, does not radiate, located at the mid-sternum, and described as
tight and uncomfortable. Pain is relieved with rest
Past Medical History:
HTN-Stage 2 diagnosed 1 year ago; HLD- diagnosed 1 year ago;
Past Surgical History (PSH):
None
Medications:
Lisinopril 20mg PO daily
Atorvastatin 20mg PO daily at bedtime (Last dose 10pm yesterday)
Omega 3 Fish Oil 1200mg PO BID
Allergies:
Codeine: Nausea and Vomiting
No food, environmental, latex, or animal allergies
Immunizations:
TDAP 10/2014
Influenza Vaccine completed this season
Family History:
Mother Type 2 Diabetes, HTN Age 80
Father HTN, Hyperlipidemia, Obesity, dies of colon cancer age 75
Maternal Grandmother- Died of breast cancer at age 65
Maternal Grandfather- Died of heart attack at age 54
Paternal Grandmother- Died of Pneumonia at age 78
Paternal Grandfather- Died of “old age” at 85
Daughter -Asthma age 19
Son: Healthy age 26
This study source was downloaded by 100000898062787 from CourseHero.com on 10-01-2025 04:35:01 GMT -05:00
https://www.coursehero.com/file/72103286/Cardiac-SOAP-Notedocx/
