Chest Pain SOAP Note ( Case )

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. Hypertension, Stage II - diagnosed 2018 Hyperlipidemia - diagnosed 2018 No hospitalizations No surgical history Immunizations up-to-date Influenza vaccine 2018 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. Civil engineer Married for 27 years with two children: son 26 year old and daughter 19 year old hobbies - fish, sports, and small electronics repair Does not smoke or vape Exposure to secondhand smoke - almost never Alcohol - beer; 2 or 3 beers on the weekends, bourbon occasionally No illicit drug use Blood pressure check- only during checkups Stressors - concern about this chest pain; other than that, low stress Exercise - used to bicycle until it got stolen a couple of years ago. Have not had much regular exercise since Nutrition - Breakfast: Instant breakfast or granola bar; on weekends, eggs, pancakes, bacon, hash browns Lunch: Turkey or Italian sub or salad if “feeling healthy or guilty” Dinner: Grilled meats and veggies Salt intake - Does not pay attention to it Water intake - At least four glasses, probably more a day Caffeine - one to two cups of coffee almost daily Soda - “Once in a blue moon; avoiding it 99% of the time” 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. Mother - Type II diabetes and hypertension Father - Obesity, hypertension, and hyperlipidemia; Decease at 75 years old of colon cancer Brother - Died at age 24 in motor vehicle accident Sister - Type II diabetes and hypertension Son - None Daughter - asthma, diagnosed at age 19 Maternal grandmother - died of breast cancer at the age of 65 Maternal grandfather - died of heart attack at the age of 54 Paternal grandmother - died of pneumonia at age 78 Paternal grandfather - died of “old age” at age 85 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 - denies Weakness - denies Fever/Chills - denies Weight Gain - denies Weight Loss - denies Trouble Sleeping - denies Night Sweats - denies Other: Click or tap here to enter text. ☐Itching - denies Rashes - denies Nail Changes - denies Skin Color Changes - denies Other: Click or tap here to enter text. ☐Diplopia - denies Eye Pain - denies Eye redness - denies Vision changes - denies Photophobia - denies Eye discharge - denies ☐Earache - denies Tinnitus - denies Epistaxis - denies Vertigo - denies Hearing Changes - denies ☐Hoarseness - denies Oral Ulcers - denies Sore Throat - denies Congestion - denies Rhinorrhea - denies Other: Click or tap here to enter text. Respiratory Neuro Cardiovascular Cough - denies Hemoptysis - denies Dyspnea - denies Wheezing - denies Pain on Inspiration - denies Sputum Production Choose an item. Choose an item. Choose an item. Other: Click or tap here to enter text. ☐Syncope or Lightheadedness - denies Headache - denies Numbness - denies Tingling - denies Sensation Changes - denies Speech Deficits - denies Other: Click or tap here to enter text. ☐Chest pain - Middle of chest, over “my heart.” Started while doing yard work. Three times over the past month, lasting for a couple of minutes. “Tight and uncomfortable;” 5/10 pain. Worse with physical activity. SOB - denies Exercise Intolerance - chest pain worsens with activity Orthopnea - denies Edema - denies. Murmurs - denies ☐Palpitations - denies Faintness - denies OC Changes - denies Claudications - denies PND - denies Other: Click or tap here to enter text. MSK GI GU PSYCH Pain - denies Stiffness - denies Crepitus - denies Swelling - denies Limited ROM - denies Redness - denies Misalignment - denies Other: Click or tap here to enter text. ☐Nausea/Vomiting - denies Dysphasia - denies Diarrhea - denies Appetite Change - denies Heartburn - denies Blood in Stool - denies Abdominal Pain - denies Excessive Flatus - denies Food Intolerance - denies Rectal Bleeding - denies Other: Click or tap here to enter text. ☐Urgency - denies Dysuria - denies Burning - denies Hematuria - denies Polyuria - denies Nocturia - denies Incontinence - denies Other: Click or tap here to enter text. ☐Stress - denies Anxiety - feeling anxious not knowing what’s going on with his chest Depression - denies Suicidal/Homicidal Ideation - denies Memory Deficits - denies Mood Changes - denies Trouble Concentrating - denies Other: Click or tap here to enter text.