SOAP Note Format – CHEST PAIN

SOAP Note Format – CHEST PAIN Pre-Brief: This assignment provides the opportunity to conduct a focused exam on a patient presenting with recent episodes of chest pain in a non-emergency setting. Interview Mr. Foster and be sure to thoroughly assess the cardiovascular system as well as related body systems in order to compile a list of differential diagnoses. This case study offers you the opportunity to evaluate Mr. Foster's personal and family history with heart disease and identify lifestyle risk factors. During the physical examination, thoroughly examine the cardiovascular system and carefully evaluate and document the patient's heart sounds. Reason for visit: Patient presents complaining recurrent chest pain. Patient Information: Brian Foster, 58 y/o Male. Presenting with recent episode of chest pain. S. 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