Focused SOAP Note Of Chest Pain Assignment
Focused SOAP Note Of Chest Pain Assignment
Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Documentation
SUBJECTIVE DATA:
Chief Complaint (CC): “Uncomfortable and tight feeling in my chest that keeps on recurring”
- Location: The pain was located on the chest above his heart, which does not radiate to the back or arms.
- Quality: He describes the pain as an uncomfortable and tight feeling.
- Quantity or severity: He rates the pain as 5 on a scale of 10.
- Timing, including onset, duration, and frequency: The pain started a month ago and has occurred three times since its onset.
- Setting in which it occurs: The client reported that he first experienced the pain while working in the yard. The second time he experienced the pain while climbing stairs at work.
- Aggravating or relieving factors: The pain increase with exercise are reduce upon lying down.
- Associated manifestations: No associated symptoms were reported Focused SOAP Note Of Chest Pain Assignment
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Medications:
- Atorvastatin 20 mg orally once a day,
- Lisinopril 20mg orally every day,
iii. Omega-3 fish oil 1200mg orally twice a day.
- Tylenol for managing headaches.
Allergies: Reports being allergic to codeine.
Past Medical History (PMH): The client reports a history of hyperlipidemia and hypertension stage 2, which were diagnosed last year.
Past Surgical History (PSH): The client denies any surgery.
Sexual/Reproductive History: Married with a daughter.
Personal/Social History: The client takes three beers weekly. Denies tobacco or illicit drugs use. He denies any stressors. He does not engage in exercise or physical activities regularly. He reports frequent water and coffee intake. The client reported undergoing stress tests and EKGs annually and the results were normal. He reports visiting his primary care provider every six months.
Immunization History: The client’s childhood immunization are updated. He received the flu vaccine last year.
Significant Family History: The client reports that his father had been diagnosed with hyperlipidemia, hypertension, and obesity. He died of colon cancer at 75 years. He adds that his mother is 80yo and has hypertension and type 2 diabetes (T2DM). Similarly, her 52yo sister has been diagnosed with T2DM and hypertension.
Review of Systems:
General: The client denies fever.
Cardiovascular/Peripheral Vascular: Currently, the client denies chest pain. He reposts tightness in the chest that occurred last month. He added that chest pain occurs while engaging in activity and reduces upon lying down.
Respiratory: Denies sputum production or cough.
Gastrointestinal: Denies constipation, nausea, or vomiting.
Musculoskeletal: Denies joint pain, back pain, or joint swelling. Psychiatric: Denies insomnia or suicidal thoughts Focused SOAP Note Of Chest Pain Assignment
OBJECTIVE DATA:
Physical Exam:
Vital signs: BP 146/90, Pulse 104, O2 sat 98%, RR 19, Temp 36.7C, Weight: 197lbs, and Height: 5’ 11”
General: The client is presentable and appropriately dressed. He is attentive and expresses himself well throughout the interview.
Cardiovascular/Peripheral Vascular: A gallop noted.
Respiratory: Breathing is not accompanied by intercostal retraction.
Gastrointestinal: No blood in the stool.
Musculoskeletal: Normal back curvature.
Neurological: Motor is 5/5 throughout
Skin: No pigmentation.
Diagnostics:
EKG: No ST changes. Normal Sinus was detected.
ASSESSMENT:
- Angina Pectoris: This condition is the primary diagnosis for this client. It is characterized by pressure, tightness, or discomfort in the chest that recurs over time. The pain is prompted by exertion or physical exercise and relieved by lying down (Ford & Berry, 2020). The client has this condition since he reported chest pain that increases with exercise and reduces upon lying down.
- Coronary artery disease: This is another potential diagnosis for this client since it is characterized by some reported symptoms, including pressure like chest pain, which radiates to the left shoulder (Ford & Berry, 2020). However, it is ruled out since the client stated that the pain does not radiate to the back.
- GERD: This condition is characterized by a burning sensation in the chest and chest pain, making swallowing difficult (Clarrett & Hachem, 2018). This condition is ruled out since the client denies difficulty swallowing.
- Acute Pericarditis: The client also qualifies for this diagnosis. This condition is characterized by stabbing and sharp chest pain, which occurs quickly (Ismail, 2020)Focused SOAP Note Of Chest Pain Assignment. Nonetheless, this condition is ruled out since the client’s pain does not occur quickly.
References
Clarrett, D. M., & Hachem, C. (2018). Gastroesophageal reflux disease (GERD). Missouri medicine, 115(3), 214.
Ford, T. J., & Berry, C. (2020). Angina: contemporary diagnosis and management. Heart, 106(5), 387-398.
Ismail, T. F. (2020). Acute pericarditis: update on diagnosis and management. Clinical Medicine, 20(1), 48 Focused SOAP Note Of Chest Pain Assignment.
Focused Exam: Chest Pain
SUBJECTIVE DATA
Chief Complaint: “Uncomfortable and tight feeling in my chest that keeps on recurring”
HPI: The client B. F is a 58yo, Caucasian male. He presented to the clinic with chest pain that occurs intermittently. The client reports that the pain started a month ago. He describes the pain as an uncomfortable and tight feeling in the chest above his heart, which does not radiate to the back or arms. He rates the intermittent pain as 5 on a scale of 10. B.F reveals that he first experienced the pain while working in the yard. The second time he experienced the pain while climbing stairs at work. The client reports exercise as aggravating factor while lying down relieves the pain. He denies using any pain relievers to manage the pain. He added that he experienced the pain thrice in the past month. Every time the pain lasts for some minutes Focused SOAP Note Of Chest Pain Assignment.
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PMH: The client reports a history of hyperlipidemia and hypertension stage 2, which were diagnosed last year.
Past Surgical History (PSH): The client denies any surgery.
Allergies: He reports being allergic to codeine, which causes nausea and vomiting.
Social History: The client takes three beers weekly. Denies tobacco or illicit drugs use. He denies any stressors. He does not engage in exercise or physical activities regularly. He reports frequent water and coffee intake. The client reported undergoing stress tests and EKGs annually and the results were normal. He reports visiting his primary care provider every six months Focused SOAP Note Of Chest Pain Assignment.
Medications:
- Atorvastatin 20 mg orally once a day,
- Lisinopril 20mg orally every day,
- Omega-3 fish oil 1200mg orally twice a day.
- Tylenol for managing headaches.
Immunization History: The client’s childhood immunization are updated. He received the flu vaccine last year.
Family History: The client reports that his father had been diagnosed with hyperlipidemia, hypertension, and obesity. He died of colon cancer at 75 years. He adds that his mother is 80yo and has hypertension and type 2 diabetes (T2DM). Similarly, her 52yo sister has been diagnosed with T2DM and hypertension Focused SOAP Note Of Chest Pain Assignment.
ROS:
General: The client denies fever.
HEENT: Denies having any headaches, blurred vision, hearing difficulty, or swallowing difficulty.
Skin: Denies itching or rashes.
Cardiovascular/Peripheral Vascular: Currently, the client denies chest pain. He reposts tightness in the chest that occurred last month. He added that chest pain occurs while engaging in activity and reduces upon lying down.
Respiratory: Denies sputum production or cough.
Musculoskeletal: Denies joint pain, back pain, or joint swelling.
Neuro: Denies dizziness or fainting.
Allergic: Reports being allergic to codeine. Focused SOAP Note Of Chest Pain Assignment
OBJECTIVE
Physical examination
Vital Signs: BP 146/90, Pulse 104, O2 sat 98%, RR 19, Temp 36.7C, Weight: 197lbs, and Height: 5’ 11”
General: The client is presentable and appropriately dressed. He is attentive and expresses himself well throughout the interview.
HEENT: No head injuries and pupils are sensitive to light.
Chest: Breathing is not accompanied by intercostal retraction.
Lungs: Crackling sound is audible.
Heart: A gallop noted.
Abdomen: No tenderness noted.
Musculoskeletal: Muscle strength detected.
Neurological: The client does not seem to be agitated.
Skin: No pigmentation. Focused SOAP Note Of Chest Pain Assignment
Diagnostics
EKG: No ST changes. Normal Sinus was detected.
ASSESSMENT
- Angina Pectoris: This condition is the primary diagnosis for this client. It is characterized by pressure, tightness, or discomfort in the chest that recurs over time. The pain is prompted by exertion or physical exercise and relieved by lying down (Ford & Berry, 2020). The client has this condition since he reported chest pain that increases with exercise and reduces upon lying down.
- Coronary artery disease: This is another potential diagnosis for this client since it is characterized by some reported symptoms, including pressure like chest pain, which radiates to the left shoulder (Ford & Berry, 2020). However, it is ruled out since the client stated that the pain does not radiate to the back.
- GERD: This condition is characterized by a burning sensation in the chest and chest pain, making swallowing difficult (Clarrett & Hachem, 2018). This condition is ruled out since the client denies difficulty swallowing.
- Acute Pericarditis: The client also qualifies for this diagnosis. This condition is characterized by stabbing and sharp chest pain, which occurs quickly (Ismail, 2020). Nonetheless, this condition is ruled out since the client’s pain does not occur quickly.
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References
Clarrett, D. M., & Hachem, C. (2018). Gastroesophageal reflux disease (GERD). Missouri medicine, 115(3), 214.
Ford, T. J., & Berry, C. (2020). Angina: contemporary diagnosis and management. Heart, 106(5), 387-398.
Ismail, T. F. (2020). Acute pericarditis: update on diagnosis and management. Clinical Medicine, 20(1), 48 Focused SOAP Note Of Chest Pain Assignment