NURS 112 SOAP Note Chest Pain Pennsylvania State University -Download To Score An A

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SOAP Note Chest Pain 1. Identifying data: Brain Foster is a 58-year-old Caucasian male. 2. Chief Complaint or Reason for Visit: he c/o having chest pain for 1 month. 3. History... of Present Illness: He experienced periodic chest pain with exertion 3 times during last month; pain rated 5/10, does not radiate, located at the mid-sternum, and described as tight and uncomfortable. His pain usually last few minutes and goes away when he rests. His most recent chest pain was when he ate a large meal at restaurant, states “it has never gotten really bad”. He did not think it was emergency, but thought he might need to be checked. 4. Past Medical History: HTN-Stage 2 diagnosed 1 year ago; HLD- diagnosed 1 year ago; no surgical history Review of Systems (ROS): he denies any heartburn, SOB, cough, n/v, or diarrhea. Denies lower extremities pain or cramps; no prostate exam; denies erectile dysfunction; no recent illness; had physical exam 3 months ago, labs and EKG done with no abnormal finding. 5. Physical examination and available lab results: Ht: 180cm, wt: 89.4 kg, BMI: 27.5 V/S: BP 146/90 (Right arm, sitting), HR 104, RR 19, O2 98%, Temp 98.1 F. Brain Foster is a 58-year-old male, graying hair, well groomed, answers questions appropriately with no acute distress. Cardiac: S1, S2 without murmur, S3 heard at mitral area. PMI displaced laterally. Peripheral vascular: right side carotid bruit, JVP 3cm above sternal angle. Right carotid pulse with thrill, 3+, L carotid pulse with no thrill, 2+. Brachial, radial, femoral pulses without thrill, 2+. Popliteal, tibial and dorsalis pedis pulses without thrill, 1+. Cap refill <3 secs in all four extremities. Resp: unlabored evenly breathing, breath sound clear in all anterior lobes and posterior upper and middle lobes; posterior bases have fine crackles. GI: ABD soft, round, non-tender with normoactive bowel sounds in all 4 quadrants; no bruits on AA, non tender on light or deep palpation. Tympanic sound on percussion throughout. Liver is 7cm at the MCL and 1 cm below the right costal margin; spleen and bilateral kidneys are not palpable. Neuro: AO x3, follows commands, moves all extremities. Skin: warm, dry, pink and intact. No tenting EKG: sinus rhythm, no ST elevation. 6. Differential Diagnosis: Atherosclerosis, CAD, PAD, Carotid artery stenosis CHF Aortic aneurysm Pericarditis GERD 7. Assessment: Due to his angina happens with exertion, or overeating, and resolve within few mins with rest, patient has no fever, chills. The cause should be vascular or GI, hence, Atherosclerosis, CAD, (PAD due to his weak pulses in lower extremities; Carotid artery stenosis-bruits) or GERD and not pericarditis (which improved by sitting up or lean forward). The presence of crackles at base of posterior lungs may indicate chest pain may be pulmonary cause. The bruit in the carotid artery may indicate aortic aneurysm or carotid artery stenosis. S3 and L lateral displace of PMI indicate CHF. 8. Plan: he should have a 12 lead EKG, chest X-ray, and echo to evaluated his heart and lungs. labs (cardiac enzymes, electrolytes, CBC, BNP, CMP, HgbA1C, lipid profile, and LFT) to conform diagnosis, overall health and evaluate current medication regimen effectiveness. For his carotid bruit, he need Doppler, he will be referred a vascular surgeon. He will need a stress test to address his angina. He will be prescribed Cardizem to reduce his HR and diuretic offload fluid and ACE inhibitor to reduce the workload of his heart. He will also get Nitroglycerin for his PRN chest pain use. ABI to see if he has peripheral vascular disease. References Bickley, L. S., & Szilagyi, P. G. (2013). Bates’ guide to physical examination and history-taking(11th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. [Show More]

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