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Episodic Focused Soap Notes

Episodic Focused Soap Notes

Episodic Focused Soap Notes

QUESTION
The goal of this assignment is to practice writing a SOAP Note for a sick or episodic visit related to the focus system(s) reviewed in the previous week’s learning materials (LUNGS< THORAX< CARDIOVASCULAR AND PERIPHERAL VASCULAR). If there is not an opportunity to see a patient with a chief complaint in the focus system(s), complete a history and physical examination of the focus system on another patient seen in the clinical practicum site. Review the SOAP Note Rubric and submit your own note. Do not submit the preceptor’s note or other documentation from the patient’s record. Episodic Focused Soap Notes

ANSWER
Episodic Focused Soap Notes

Student Names
Institution Affiliation
Instructor
Course
Date

Episodic Focused Notes on a Patient with Chest Pain
Patient Information
Mr. R is a 68-year-old Caucasian American male: Married for 39 years. Referral: none Source: Patient.
Chief Complaint: The patient presents a complaint of chest pain, decreased appetite, and shortness of breath.
History of Presenting Illness (HPI)
The patient presents complaints of development of onset chest pain, which began early this morning, describing the pain as crushing, tightening, gripping, burning, and radiates to the left arm. The patient reports feeling nauseated. The patient reports not seeking any medication at the onset of the pain. However, the patient states that pain often comes while he’s at the gym exercising.
Past Medical History (PMH)
The patient denies any history of asthma, cancer, allergies, or heart attack cases. A positive history of Gastroesophageal reflux: and controlled high blood pressure: Reports no cases of surgical history.
Social History (SH)
Patients assert that he drinks from time to time: about 1-2 drinks, a negative report on tobacco abuse. The patient further denies the use of illicit drugs and confirms engagement in regular body exercises.
Family History (FH)
Mother died at 78 of Diabetes, Father at 80 of stroke. The present history of cardiovascular disease cases in first degree relatives.
Review of Systems (ROS)
General: Negative for fevers and fatigue. Cardiovascular: positive for intermittent lower edema. Respiratory: positive for intermittent dyspnea, no dry cough or hemoptysis. Gastrointestinal: Nausea is positive without vomiting, negative for abdominal pain.
Objective: Physical Assessment
Patients weigh 235lbs; Ht 70; Bp 186/102. General- the patient appears to be diaphoretic. Respiratory- lungs are clear to auscultation apparatus: Diagnostic results-EKG, CXR, CK-MB. Gastrointestinal- bowel sounds are normal in quality; the abdomen has no distension.
Differential Diagnosis
Myocardial infarction: to dissolve the thrombus in the artery and restore flow. Angina: widening blood vessels. Costocondritis: using anti-inflammatory drugs. Primary Diagnosis –Myocardial infarction.

References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
De Bliek, EC. ST-elevation: Differential diagnosis and caveats. A comprehensive review to help distinguish ST-elevation myocardial infarction from nonischemic etiologies of ST elevation. Turk J Emerg Med. 2018 Mar;18(1):1-10. [PMC free article] [PubMed]
Hornik, C., & Meliones, J. (2016). Pulmonary Edema and Hypoxic Respiratory Failure. Pediatric Critical Care Medicine, 17, S178-S181. doi: 10.1097/pcc.0000000000000823

Episodic Focused Soap Notes

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