Episodic/Focused SOAP Note Exemplar

Episodic/Focused SOAP Note Exemplar

Focused SOAP Note for a patient with chest pain

S.

CC: “Chest pain”

HPI: The patient is a 65 year old AA male who developed sudden onset of chest pain, which began early this morning.  The pain is described as “crushing” and is rated nine out of 10 in terms of intensity. The pain is located in the middle of the chest and is accompanied by shortness of breath. The patient reports feeling nauseous. The patient tried an antacid with minimal relief of his symptoms.

Medications: Lisinopril 10mg, Omeprazole 20mg, Norvasc 5mg

PMH: Positive history of GERD and hypertension is controlled

FH: Mother died at 78 of breast cancer; Father at 75 of CVA.  No history of premature cardiovascular disease in first degree relatives.

SH : Negative for tobacco abuse, currently or previously; consumes moderate alcohol; married for 39 years

Allergies: PCN-rash; food-none; environmental- none

Immunizations: UTD on immunizations, covid vaccine #1 1/23/2021 Moderna; Covid vaccine #2 2/23/2021 Moderna

ROS

General–Negative for fevers, chills, fatigue
Cardiovascular–Negative for orthopnea, PND, positive for intermittent lower extremity edema
Gastrointestinal–Positive for nausea without vomiting; negative for diarrhea, abdominal pain
Pulmonary–Positive for intermittent dyspnea on exertion, negative for cough or hemoptysis

O.

VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70”

General–Pt appears diaphoretic and anxious

Cardiovascular–PMI is in the 5th inter-costal space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is heard best at the

second right inter-costal space which radiates to the neck.

A third heard sound is heard at the apex. No fourth heart sound or rub are heard. No cyanosis, clubbing, noted, positive for bilateral 2+ LE edema is noted.

Gastrointestinal–The abdomen is symmetrical without distention; bowel

sounds are normal in quality and intensity in all areas; a

bruit is heard in the right para-umbilical area. No masses or

splenomegaly are noted. Positive for mid-epigastric tenderness with deep palpation.

Pulmonary— Lungs are clear to auscultation and percussion bilaterally

Diagnostic results: EKG, CXR, CK-MB (support with evidenced and guidelines)

A.

Differential Diagnosis:

1) Myocardial Infarction (provide supportive documentation with evidence based guidelines).

2) Angina (provide supportive documentation with evidence based guidelines).

3) Costochondritis (provide supportive documentation with evidence based guidelines).

Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction