CHEST PAIN - SOAP Note. Case study

SOAP Note Template Initials: B. F. Age: 58 Gender: M Height Weight BP HR RR Temp SPO2 Pain Allergies 180.34 cm 197 146/90 104 19 36.7 C 98% 0/10 Medication: Codeine (causes nausea and vomiting) Food: NKA Environment: NKA History of Present Illness (HPI) Chief Complaint (CC) Chest Pain 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 Yard work Location Middle of chest, over “my heart” Duration Three times over the past month, lasting for a couple of minutes Characteristics “Tight and uncomfortable;” 5/10 pain when having chest pain Aggravating Factors Physical activity Relieving Factors Rest Treatment Rest 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 100 mg Daily One year Hypertension Atorvastatin 20 mg Daily One year Hyperlipidemia Omega-3 Fish Oil 1200 mg BID Click or tap here to enter text. OTC supplement Tylenol . “Whatever the bottle recommends for an adult” Every couple of days Few weeks Pain Ibuprofen “Whatever the bottle recommends for an adult” 3-4 times a month Click or tap here to enter text. Pain/aches 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.