S.O.A.P. Note Template CASE ID# ____________________________ Subjective Objective Assessment (diagnosis [primary and differential diagnosis]) Plan (treatment, education, and follow up plan)

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What brought you here today…(eg. headache)

Chest pain

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Chronological order of events, state of health before onset of CC, must include OLDCARTS in paragraph form

Onset Mr. Foster complaining of chest pain that initially began a month ago but reoccurred 5 minutes ago. He rates his pain at 6/10. He reports the pain is localized to the sub-sternal region and describes it as “squeezing pressure.” He reports the pain is constant and increasing in severity. He denies radiation but reports some pressure in the left shoulder as well. He reports the pain was accompanied by nausea at the onset. Chest pain is relieved when patient sits down. The patient reports becoming increasingly anxious.

Location Duration

Character Aggravating/associated

factors Relieving factors

Temporal factors – other things going on

Severity

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Adult Illnesses, childhood illnesses, immunizations, surgeries, allergies, current medications

Hypertension – stage II, hyperlipidemia, no surgical history, flu given during flu season, TDAP 2014 Lopressor 100mg po Q day Lipitor 20mg po at bedtime 10pm Omega 3 fish oil 1200mg po BID

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Include Parents, siblings; grandparents if applicable/known, cause of death,

Mother : hypertension, type 2 diabetes, age 80 Father :obesity, hypertension, hyperlipidemia, died of colon cancer at 75 years Sister : type 2 DM, hypertension, age 52 years old Brother : died in MVA at 24 years old Paternal grand mother : died at age 78 of pneumonia

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Education, marital status, occupation, alcohol/drug use, smoking status, sexual history if relevant, exercise, nutrition, religious preference if known

Denies use of tobacco, denies use of cocaine, heroin, marijuana and any illicit drugs. Uses alcohol 2-3 beer per week

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General: No fever, chills and fatigue Hair, Skin, & Nails: No rash

Head: No dizziness,LOC, or headache Neck: Eyes: Negative for vision, no use of glasses Ears: Negative for hearing loss, bil ear pain, bulging tympanic membrane, negative for vertigo, negative for tinnitus Nose: Negative for loss of smell, nasal congestion and nasal drainage

Mouth & Throat: Sore throat, tonsils + 2, and redness Cardiovascular:

Respiratory: Breasts:

Gastrointestinal: Musculoskeletal:

Peripheral: Neurological:

Psychiatric:

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Vital signs: 146/88, 98%, 19, 36.7, 104,

General Appearance: Well developed, 58 year old Hispanic man, no respiratory distress, well-nourished and developed, good eye contact

HEENT: Head is Norma cephalic, no scalp or sinus tenderness, eye conjunctiva is pink, PERRLA, bilateral ears bulging erythematous tympanic membranes, tonsils is enlarged + 2 and redness noted.

Neck: Trachea is midline, thyroid is not palpable, no carotids bruits. Lymph Nodes: No cervical or axillary lymphadenopathy

Chest: Breast sound clear and equal without adventitious sounds.

Cardiac: Regular heart rate 104 bpm, S1/S2 with regular rhythm, no murmurs, rubs or clicks present, chest pain 6/10 6/10

Abdomen: No distention, , no tenderness to palpation, bowel sound x 4 quad. Genitourinary: Bowel and bladder continent

Skin: Skin is warm and dry Musculoskeletal: Able to move all extremities

Neurologic: Cranial nerves II- XII grossly intact Psychiatric: AOX4,mood and thoughts appropriate to situation, no evidence of disordered thinking

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Primary diagnosis: Coronary artery disease with stable angina

Differential Diagnosis: GERD, PERICARDITIS, AORTIC ANEURYSM, CHF

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1. Cardiac enzymes : CBC, BNP, AIC, LIPID PANEL, LFT

2. ECHO, STRESS TEST, CAROTID DOPPLER, CARDIAC CONSULT,12 LEAD ECG, XRAY,NITRO FOR CHEST PAIN

3. May return to clinic if symptoms worsens or go to the nearest ER

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