NR 509 SOAP - B.F. Chest Pain PDF

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SOAP Note Template

S: Subjective Information the patient or patient representative told you Initials: B.F

Age: 58

Height

Weight

BP

HR

RR

Temp

SPO2

5’11’’

197lbs

146/ 90

104

19

36.7 C

98

Gender: Male Pain Rating 0/10

Allergies (and reaction) cation: Codeine: Nausea & Vomiting Food: N/A Environment: N/A

History of Present Illness (HPI) Chief Complaint (CC) Chest Pain – last time last Friday evening Onset On and off for the past month (3 episodes within past month) Location Middle chest, does not radiate to arm, neck, back, or shoulder Duration “Several minutes” Characteristics Tight and “uncomfortable” Aggravating Factors

Physical activity, does not worse with eating fat or spicy food

Relieving Factors

Rest

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

Treatment None Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. Length of Time Medication Dosage Frequency Reason for Use (Rx, OTC, or Homeopathic) Used Click or tap here Hypertension Lisinopril 20mg PO Daily to enter text. Click or tap here Hyperlipemia Atorvastatin 20mg PO daily at bedside to enter text. Omega - 3 Fish Oil 1200 mg PO BID Click or tap here OTC Supplement to enter text. Click or tap here to PRN Click or tap here Click or tap here to enter text. Ibuprofen enter text. to enter text. Click or tap here to enter text. Click or tap here to Click or tap here to enter Click or tap here Click or tap here to enter text.

enter text.

text.

to enter text.

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 one year ago, does not monitor BP regularly at home Hyperlipidemia: Diagnosed one year ago No surgical history Tdap 10/2014 Influenza Vaccine this season Last visit 3 months ago with PCP - Has never been seen by a cardiologist – annual stress test normal, recent EKG normal, no history of angina diagnosis 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. No past of present tobacco use Reports drinking 2-3 alcoholic beverages (beers) per week Denies use of marijuana, cocaine, heroin, and/or other illicit drugs Used to ride a bike regularly – hasn’t exercised in a couple years Tries to eat less sodium and fats, fluid intake 4 glasses water daily – 2 cups of coffee daily Civil engineer Married for 27 years, two children age 26 and 19 Reports a low stress life

Denies transportation / fiancés a barrier to healthcare

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. Father: hypertension, hyperlipidemia, obesity, died of colon cancer, age 75 Mother: type 2 diabetes, hypertension, age 80 Brother: died at age 24 due to motor vehicle accident Sister: type 2 diabetes, hypertension, age 52 Maternal Grandmother: died of breast cancer at age 65 Maternal Grandfather: died of heart attack at age 54 Paternal Grandmother: died of pneumonia at age 78 Paternal Grandfather: died of “old age” at age 85 Son: healthy, age 26 Daughter: asthma, age 19

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 If patient denies all If patient denies all If patient denies all symptoms for this system, check here: ☒ symptoms for this system, symptoms for this check here: ☐ system, check here: ☒ ☐Diplopia Click or tap ☐Earache Click or tap here ☐Hoarseness Click or tap here ☐Fatigue Click or tap here ☐Itching Click or tap to enter text. here to enter text. here to enter text. to enter text. to enter text. ☐Weakness Click or tap ☐Rashes Click or tap ☐Eye Pain Click or tap ☐Tinnitus Click or tap here ☐Oral Ulcers Click or tap here here to enter text. here to enter text. here to enter text. to enter text. to enter text. ☐Fever/Chills Click or tap ☐Nail Changes Click ☐Eye redness Click or tap ☐Epistaxis Click or tap ☐Sore Throat Click or tap here here to enter text. or tap here to enter text. here to enter text. here to enter text. to enter text. ☒Weight Gain 20lbs over ☐Skin Color Changes ☐Vision changes Click or ☐Vertigo Click or tap here ☐Congestion Click or tap here Click or tap here to the past couple years tap here to enter text. to enter text. to enter text. ☐Photophobia Click or ☐Hearing Changes Click ☐Rhinorrhea Click or tap here ☐Weight Loss Click or tap enter text. ☐Other: here to enter text. tap here to enter text. or tap here to enter text. to enter text. Click or tap here to ☐Trouble Sleeping Click ☐Eye discharge Click or ☐Other: Click or tap here to enter text. enter text. or tap here to enter text. tap here to enter text. ☐Night Sweats Click or tap here to enter text. ☐Other: Click or tap here to enter text. Respiratory Neuro Cardiac and Peripheral Vascular If patient denies all symptoms for this system, check here: ☐ If patient denies all symptoms for this If patient denies all symptoms system, check here: ☒ for this system, check here: ☒ ☐Syncope or ☒Chest pain Click or tap here to enter ☐Palpitations Click or tap ☐Cough Click or tap here to enter text. Lightheadedness Click or tap text. here to enter text. ☐Hemoptysis Click or tap here to ☐SOB Click or tap here to enter text. ☐Faintness Click or tap here here to enter text. ☐Headache Click or tap here ☐Exercise Intolerance Click or tap here to enter text. enter text. ☐Dyspnea Click or tap here to enter ☐Claudications Click or tap to enter text. to enter text. ☐Numbness Click or tap here ☐Orthopnea Click or tap here to enter text. here to enter text. to enter text. ☐Wheezing Click or tap here to enter ☐PND Click or tap here to text. text. ☐Tingling Click or tap here to ☐Edema Click or tap here to enter text. enter text.

☐Pain on Inspiration Click or tap here to enter text. ☐Sputum Production

☐Other: Click or tap here to enter text.

enter text. ☐Sensation Changes

☐Murmurs Click or tap here to enter text.

☒Other: S1,S2,S3 gallops

☐Speech Deficits Click or tap here to enter text. ☐Other: Click or tap here to enter text.

MSK If patient denies all symptoms for this system, check here: ☐

GI If patient denies all symptoms for this system, check here: ☒

GU If patient denies all symptoms for this system, check here: ☒

PSYCH If patient denies all symptoms for this system, check here: ☒

☒Pain Chest pain ☐Stiffness Click or tap here to enter text. ☐Crepitus Click or tap here to enter text. ☐Swelling Click or tap here to enter text. ☐Limited ROM

☐Nausea/Vomiting Click or tap here to enter text. ☐Dysphasia Click or tap here to enter text. ☐Diarrhea Click or tap here to enter text. ☐Appetite Change Click or tap here to enter text. ☐Heartburn Click or tap here to enter text. ☐Blood in Stool Click or tap here to enter text. ☐Abdominal Pain Click or tap here to enter text. ☐Excessive Flatus Click or tap here to enter text. ☐Food Intolerance Click or tap here to enter text. ☐Rectal Bleeding Click or tap here to enter text. ☐Other:

☐Urgency Click or tap here to enter text. ☐Dysuria Click or tap here to enter text. ☐Burning Click or tap here to enter text. ☐Hematuria Click or tap here to enter text. ☐Polyuria Click or tap here to enter text. ☐Nocturia Click or tap here to enter text. ☐Incontinence Click or tap here to enter text. ☐Other: Click or tap here to enter text.

☐Stress Click or tap here to enter text. ☐Anxiety Click or tap here to enter text. ☐Depression Click or tap here to enter text. ☐Suicidal/Homicidal Ideation Click or tap here to enter text. ☐Memory Deficits Click or tap here to enter text. ☐Mood Changes Click or tap here to enter text. ☐Trouble Concentrating Click or tap here to enter text. ☐Other: Click or tap here to enter text.

☐Redness Click or tap here to enter text. ☐Misalignment Click or tap here to enter text. ☐Other: Click or tap here to enter text.

GYN If patient denies all symptoms for this system, check here: ☒ ☐Rash Click or tap here to enter text. ☐Discharge Click or tap here to enter text. ☐Itching Click or tap here to enter text. ☐Irregular Menses Click or tap here to enter text. ☐Dysmenorrhea Click or tap here to enter text. ☐Foul Odor Click or tap here to enter text. ☐Amenorrhea Click or tap here to enter text. ☐LMP: Click or tap here to enter text. ☐Contraception Click or tap here to enter text. ☐Other:Click or tap here to enter text.

Hematology/Lymphatics If patient denies all symptoms for this system, check here: ☒ ☐Anemia Click or tap here to enter text. ☐ Easy bruising/bleeding Click or tap here to enter text. ☐ Past Transfusions Click or tap here to enter text. ☐ Enlarged/Tender lymph node(s) Click or tap here to enter text. ☐ Blood or lymph disorder Click or tap here to enter text. ☐ Other Click or tap here to enter text.

Endocrine If patient denies all symptoms for this system, check here: ☒ ☐ Abnormal growth Click or tap here to enter text. ☐ Increased appetite Click or tap here to enter text. ☐ Increased thirst Click or tap here to enter text. ☐ Thyroid disorder Click or tap here to enter text. ☐ Heat/cold intolerance Click or tap here to enter text. ☐ Excessive sweating Click or tap here to enter text. ☐ Diabetes Click or tap here to enter text. ☐ Other Click or tap here to enter text.

O: Objective Information gathered during the physical examination by inspection, palpation, auscultation, and percussion. If unable to assess a body system, write “Unable to assess”. Document pertinent positive and negative assessment findings. Pertinent positive are the “abnormal” findings and pertinent “negative” are the expected normal findings. Separate the assessment findings accordingly and be detailed.

Body System

Positive Findings

Negative Findings

General Click or tap here to enter text.

58 year old male, alert and oriented, who does not appear to be in any distress at this time but is anxious regarding on and off chest pain for the past month

Click or tap here to enter text.

Skin clean, dry, and intact, no abnormities / lesions noted

Click or tap here to enter text.

No visible abnormalities noted, patient denies and visual changes, face symmetrical, JVP 4cm above sternal angle

Fine crackles noted in bilateral posterior lower lobe

Denies cough, shortness of breath, wheezing

Click or tap here to enter text.

No issues noted

Heart sounds S1,S2, S3 noted with extra gallop

Click or tap here to enter text.

Pain with activity

Unbale to assess gait / reflexes

Skin

HEENT

Respiratory

Neuro

Cardiovascular

Musculoskeletal

Gastrointestinal

Genitourinary

Rounded abdomen

Click or tap here to enter text.

Unable to assess

Problem List 1. Chest Pain

6. Fine crackles 7. Click or tap here to enter text. 8. Click or tap here to enter text. 9. Click or tap here to enter text. 10. Click or tap here to enter text.

2. Hypertension 3. Hyperlipidemia 4. Weight gain 5. Abnormal heart sounds

11. Click or tap here to enter text. 12. Click or tap here to enter text. 13. Click or tap here to enter text. 14. Click or tap here to enter text. 15. Click or tap here to enter text.

A: Assessment Medical Diagnoses. Provide 3 differential diagnoses (DDx) which may provide an etiology for the CC. The first diagnosis (presumptive diagnosis) is the diagnosis with the highest priority. Provide the ICD-10 code and pertinent findings to support each diagnosis. Chest Pain

R07.9

Angina Pectoris

I20.9

Chronic Ischemic Heart Disease - Coronary Artery Disease

I25.1

Patient complains of chest pain, on and off for the past month, middle chest, pain does not radiate, feels “tight and uncomfortable”, worse with physical activity, pain 5/10 at worst Patient complains of internment chest pain, worse with activity, risk factors for coronary artery disease - high blood pressure, age, weight, hyperlipidemia lack of exercise Patient complains of internment chest pain, worse with activity, risk factors for coronary artery disease - high blood pressure, age, weight, hyperlipidemia lack of exercise (Malakar et al., 2019)

P: Plan Address all 5 parts of the comprehensive treatment plan. If you do not wish to order an intervention for any part of the treatment plan, write “None at this time” but do not leave any heading blank. No intervention is self-evident. Provide a rationale and evidence-based in-text citation for each intervention. Diagnostics: List tests you will order this visit Test Rationale/Citation EKG Already completed – determine rhythm, use out possible blockage / STEMI Labs – cardiac enzymes -troponin and Cardiac enzymes rise after heart attacks. (Cleveland Clinic, 2021) creatine phosphokinase - cholesterol panel Echocardiogram Stress test

Safe, non-invasive methods of determining heat function (Omerovic, 2021) “Cardiac stress testing is an important diagnostic tool for known or suspected coronary artery disease” (Gopal, 2021) x-ray Visual imagine of both heart and lungs, can visualize heart size and possible fluid collection in lungs Medications: List medications/treatments including OTC drugs you will order and “continue meds” if pertinent. Drug Dosage Length of Treatment Rationale/Citation Aspirin (chewable) 325mg Once daily Aspirin helps thin blood which in result helps prevent blood clots.

Nitroglycerin

0.5 mg sublingual

Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Referral/Consults: Cardio Consult Education: With the start of aspirin, monitor for signs of bleeding.

q5min up to 3 times

Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text.

Nitroglycerin is the first line drug therapy for angina pectoris. (Kannam & Gersh, 2021) Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text.

Rationale/Citation Rationale/Citation

Cardiac disease is one of the leading causes of death in the If chest pain persists after nitroglycerin for 3-5 or is accompanied with United States, many individuals shortness of breath, neck/jaw/shoulder/or back pain, call 911. are ambulatory and present to their primary care. (Kannam & Gersh, 2021) & (McConaghy, 2021) Follow Up: Indicate when patient should return to clinic and provide detailed symptomatology indicating if the patient should return sooner than scheduled or seek attention elsewhere. Follow up with your primary care every 6 months for re-evaluation of Click or tap here to enter text. Rationale/Citation cardiac disease. References Include at least one evidence-based peer-reviewed journal article which relates to this case. Use the correct current APA edition formatting. Cardiac Enzymes (Cardiac Biomarkers): Types, What They Indicate. (2021, November 25). Cleveland Clinic. https://my.clevelandclinic.org/health/articles/22115-cardiac-enzymes-cardiac-biomarkers Gopal S, Murphy C. Nuclear Medicine Stress Test. [Updated 2021 Apr 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557682/ Kannam, J. P., & Gersh, B. J. (2021, March 31). Nitrates in the management of chronic coronary syndrome. UpToDate. Retrieved January 26, 2022, from https://www.uptodate.com/contents/nitrates-in-the-management-of-chronic-coronary-syndrome?search=nitroglycerin&source=search_result&selectedTitle=4~150&usage_type=default&display_rank=4 Malakar, A. K., Choudhury, D., Halder, B., Paul, P., Uddin, A., & Chakraborty, S. (2019). A review on coronary artery disease, its risk factors, and therapeutics. Journal of Cellular Physiology, 234(10), 16812-16823. https://doi.org/10.1002/jcp.28350

Omerovic S, Jain A. Echocardiogram. [Updated 2021 Jul 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK558940/ Click or tap here to enter text....