Focused SOAP Note for Chest Pain Evaluation

It looks like you have a detailed case report for a focused exam on a cough. Here’s a summary of the key points and suggestions for your documentation and analysis:

### Summary of Findings

#### Subjective Data:
– **Patient:** Danny
– **Chief Complaint:** Cough lasting 4-5 days, described as “watery and gurgly.”
– **Associated Symptoms:**
– Pain in the right ear
– Mild sore throat
– Fatigue due to nighttime coughing
– Frequent colds and runny nose
– **Past Medical History:** Frequent ear infections as a child, pneumonia last year.
– **Social History:** Lives with family; father smokes cigars indoors.

#### Objective Data:
– **Vital Signs:**
– BP: 120/76
– Pulse: 100
– RR: 28
– Temp: 37.2°C
– O2 Saturation: 96% on room air
– **Physical Exam:**
– HEENT: Erythematous right tympanic membrane, enlarged and tender right cervical lymph node, cobblestoning of the posterior pharynx, nasal discharge.
– Respiratory: Increased respiratory rate, audible crackles, clear lung sounds with cough.
– **Spirometry:** FEV1: 3.15 L, FVC: 3.91 L (FEV1/FVC: 80.5%).

### Differential Diagnoses:
1. Acute viral rhinopharyngitis
2. Strep throat
3. Allergic rhinitis
4. Acute otitis media
5. Asthma

### Plan:
– Strep throat culture to rule out strep throat.
– 10-day course of antibiotics for acute otitis media.
– Referral for allergy testing and pulmonary function tests.
– Increase fluid intake and encourage handwashing.
– Recommend antitussive treatment at night for better sleep.

### Suggestions for Improvement:
1. **Document Pertinent Negatives:** Include negative findings for the left ear and neck, as well as other systems examined. This adds clarity to your assessment.
2. **SOAP Format:** Ensure your documentation follows the SOAP format (Subjective, Objective, Assessment, Plan) clearly.
3. **Supportive Evidence:** Provide rationale for differential diagnoses based on findings. For example, link the sore throat and tympanic membrane findings to the likelihood of acute otitis media.
4. **Reflection:** Consider reflecting on the patient’s social environment and its impact on health (e.g., secondhand smoke exposure).

### Additional Considerations:
– Assess for potential environmental triggers for allergies or asthma.
– Monitor for any changes in symptoms, especially after initiating treatment.

Feel free to reach out if you need more specific guidance or have further questions!

 

 

Certainly! Here’s a structured SOAP note exemplar for a patient with chest pain:

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### Focused SOAP Note

**Patient:** 65-year-old AA male

**S.**
**CC:** “Chest pain”
**HPI:** The patient reports sudden onset of chest pain early this morning. The pain is described as “crushing” and is rated 9/10 in intensity. It is located in the middle of the chest, accompanied by shortness of breath and nausea. He tried an antacid with minimal relief.
**PMH:** Positive for GERD and well-controlled hypertension.
**FH:** Mother died at 78 of breast cancer; father at 75 of CVA. No family history of premature cardiovascular disease.
**SH:** Denies current or past tobacco use; consumes moderate alcohol; married for 39 years.
**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°F; O2 96%. Wt: 235 lbs; Ht: 70”.
– **General:** Patient appears diaphoretic and anxious.
– **Cardiovascular:** PMI in the 5th intercostal space at the midclavicular line. Grade 2/6 systolic decrescendo murmur at the second right intercostal space, radiating to the neck. A third heart sound at the apex. No fourth heart sound or rub. Positive for bilateral 2+ LE edema.
– **Gastrointestinal:** Abdomen symmetrical without distention; normal bowel sounds; bruit in right para-umbilical area; positive for mid-epigastric tenderness.
– **Pulmonary:** Lungs clear to auscultation and percussion bilaterally.

**Diagnostic Results:**
– **EKG:** Shows ST-segment elevation (evidence for myocardial infarction).
– **CXR:** No acute findings, may rule out other causes of chest pain.
– **CK-MB:** Elevated (support for myocardial infarction).

**A.**
**Differential Diagnosis:**
1. **Myocardial Infarction**
– Support: Classic symptoms, risk factors (age, gender, hypertension), elevated CK-MB, EKG changes.
– Guidelines: AHA/ACC guidelines recommend immediate treatment and consideration for PCI if STEMI is confirmed.

2. **Angina**
– Support: Symptoms suggestive of cardiac ischemia, intermittent dyspnea.
– Guidelines: AHA states that angina can present similarly; however, duration and severity differentiate it from MI.

3. **Costochondritis**
– Support: Possible with localized pain; however, less likely given systemic symptoms and risk factors.
– Guidelines: Typically presents with tenderness at the costosternal junction, which was not noted in this case.

**Primary Diagnosis:**
**Presumptive Diagnosis:** Myocardial Infarction

**P.**
*Not required for this assignment.*

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Feel free to adjust any sections based on specific details or additional findings!

 

Sure! Here’s an example of how to structure the subjective and objective documentation for a focused exam, following the guidelines you’ve provided.

—

### Subjective Documentation

**Chief Complaint (CC):**
“Chest pain”

**HPI:**
The patient is a 65-year-old African American male who developed sudden onset of chest pain early this morning. The pain is described as “crushing” and rated 9/10 in intensity. It is located in the middle of the chest and is accompanied by shortness of breath and nausea. He reports minimal relief after taking an antacid.

**Current Medications:**
– Omeprazole (for GERD)
– Lisinopril (for hypertension)

**Allergies:**
No known drug allergies.

**Past Medical History:**
– Gastroesophageal reflux disease (GERD)
– Hypertension (controlled)

**Family History:**
– Mother: Died at 78 of breast cancer
– Father: Died at 75 of cerebrovascular accident (CVA)
– No premature cardiovascular disease in first-degree relatives.

**Social History:**
– Denies tobacco use, current or past.
– Consumes moderate alcohol.
– Married for 39 years.

**Review of Systems (ROS):**
– **General:** Negative for fever, chills, fatigue.
– **Head:** No headaches, dizziness, or visual disturbances.
– **EENT:** Negative for ear pain, nosebleeds, or sore throat.
– **Cardiovascular:** Positive for intermittent lower extremity edema; negative for orthopnea or paroxysmal nocturnal dyspnea (PND).
– **Gastrointestinal:** Positive for nausea without vomiting; negative for diarrhea or abdominal pain.
– **Pulmonary:** Positive for intermittent dyspnea on exertion; negative for cough or hemoptysis.

—

### Objective Documentation

**Vital Signs:**
– BP: 186/102 mmHg
– Pulse: 94 bpm
– Respiratory Rate: 22 breaths/min
– Temperature: 97.8°F
– O2 Saturation: 96%
– Weight: 235 lbs
– Height: 70 in

**General:**
Patient appears diaphoretic and anxious.

**Cardiovascular:**
– PMI located in the 5th intercostal space at the midclavicular line.
– Grade 2/6 systolic decrescendo murmur heard best at the second right intercostal space, radiating to the neck.
– A third heart sound present at the apex; no fourth heart sound or rub detected.
– Positive for bilateral 2+ lower extremity edema.

**Gastrointestinal:**
– Abdomen symmetrical, non-distended.
– Bowel sounds present in all quadrants.
– Bruit auscultated in the right para-umbilical area.
– Mid-epigastric tenderness noted with deep palpation; no masses or splenomegaly.

**Pulmonary:**
– Lungs clear to auscultation and percussion bilaterally.

**Diagnostic Results:**
– **EKG:** ST-segment elevation observed.
– **CXR:** No acute findings.
– **CK-MB:** Elevated levels.

—

### Differential Diagnoses

1. **Myocardial Infarction**
– Supported by classic symptoms, elevated CK-MB, and EKG changes.

2. **Angina**
– Considered due to intermittent dyspnea and risk factors.

3. **Costochondritis**
– Less likely but considered due to possible localized pain.

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This format ensures clarity, organization, and thoroughness, providing all pertinent information for clinical evaluation and decision-making.

 

 

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