Episodic/Focused SOAP Note Exemplar
Focused SOAP Note for a patient with chest pain
S. CC: “Chest pain” HPI: The patient is a 65 12 months previous AA male who developed sudden onset of chest pain, which started early this morning. The pain is described as “crushing” and is rated 9 out of 10 when it comes to depth. The pain is positioned in the course of the chest and is accompanied by shortness of breath. The patient studies feeling nauseous. The patient tried an antacid with minimal aid of his signs.
Medicines: Lisinopril 10mg, Omeprazole 20mg, Norvasc 5mg PMH: Constructive historical past of GERD and hypertension is managed FH: Mom died at 78 of breast most cancers; Father at 75 of CVA. No historical past of untimely heart problems in first diploma family. SH : Damaging for tobacco abuse, presently or beforehand; consumes average alcohol; married for 39 years
Allergic reactions: 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 Normal–Damaging for fevers, chills, fatigue Cardiovascular–Damaging for orthopnea, PND, constructive for intermittent decrease extremity edema Gastrointestinal–Constructive for nausea with out vomiting; unfavourable for diarrhea, stomach pain Pulmonary–Constructive for intermittent dyspnea on exertion, unfavourable for cough or hemoptysis
O.
VS: BP 186/102; P 94; R 22; T 97.eight; 02 96% Wt 235lbs; Ht 70”
Normal–Pt seems diaphoretic and anxious
Cardiovascular–PMI is within the fifth inter-costal house on the mid clavicular line. A grade 2/6 systolic decrescendo murmur is heard finest on the
second proper inter-costal house which radiates to the neck.
A 3rd heard sound is heard on the apex. No fourth coronary heart sound or rub are heard. No cyanosis, clubbing, famous, constructive for bilateral 2+ LE edema is famous.
Gastrointestinal–The stomach is symmetrical with out distention; bowel
sounds are regular in high quality and depth in all areas; a
bruit is heard in the proper para-umbilical space. No lots or
splenomegaly are famous. Constructive for mid-epigastric tenderness with deep palpation.
Pulmonary– Lungs are clear to auscultation and percussion bilaterally
Diagnostic outcomes: EKG, CXR, CK-MB (Help with evidenced and pointers)
A.
Differential Analysis:
1) Myocardial Infarction (present supportive documentation with proof based mostly pointers).
2) Angina (present supportive documentation with proof based mostly pointers).
three) Costochondritis (present supportive documentation with proof based mostly pointers).
Main Analysis/Presumptive Analysis: Myocardial Infarction
A.
Differential Analysis:
1) Myocardial Infarction (present supportive documentation with proof based mostly pointers).
2) Angina (present supportive documentation with proof based mostly pointers).
three) Costochondritis (present supportive documentation with proof based mostly pointers).
Main Analysis/Presumptive Analysis: Myocardial Infarction
P. This part isn’t required for the assignments on this course (NURS 6512) however will likely be required for future programs.
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Instance of an Episodic/Focused SOAP Note
For a patient with chest pain, write a centered SOAP word.
“Chest ache,” says S. CC. HPI: The patient is a 65-year-old AA man who has been experiencing abrupt onset chest pain since this morning. The agony is described as “crushing,” with an depth score of 9 out of ten. Shortness of breath goes hand in hand with the pain within the centre of the chest. The patient claims to be nauseated. The patient tried an antacid, however it solely supplied momentary aid from his discomfort.
Lisinopril 10 mg, Omeprazole 20 mg, and Norvasc 5 mg PMH: Hypertension and GERD have a constructive historical past, however it’s underneath management. FH: Mom died at 78 of breast most cancers; Father at 75 of CVA. No historical past of untimely heart problems in
