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SOAP Note Format CHEST PAIN -SOAP Note Format for a patient with CHEST PAIN

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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

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Uploaded on
August 18, 2021
Number of pages
6
Written in
2021/2022
Type
Case
Professor(s)
Unknown
Grade
A+

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