Clinical Focused SOAP Note For Chest Pain Discussion SUBJECTIVE DATA: Chief Complaint (CC): chest pain  History of Present Illness (HPI): BF is a 58-year-old Caucasian man who suffers from recurring chest pain that has occurred three times in the last month

Clinical Focused SOAP Note For Chest Pain Discussion

SUBJECTIVE DATA:

Chief Complaint (CC): chest pain

 History of Present Illness (HPI): BF is a 58-year-old Caucasian man who suffers from recurring chest pain that has occurred three times in the last month. The patient reports that the pain is lessened by sitting or laying down and that it worsens with activity. The patient also claims that the discomfort is greater while they are standing or walking. There is a 5/10 degree of discomfort reported by the patient in each episode lasting around 5 minutes. When asked where he feels the pain, the patient says it is “tight and uncomfortable” in the centre of his chest. Denies the existence of pain that is spreading to the arm or back, as well as the neck. Denies having any breathing difficulties. The client is presently denying that he is experiencing any chest pain and rating their level of pain as 0 out of 10. Clinical Focused SOAP Note For Chest Pain Discussion

ORDER HERE A PLAGIARISM-FREE PAPER 

Medications:

Lisinopril 20mg daily

Omega-3 Fish Oil 1200mg BID

Atorvastatin 20mg QHS

Allergies:

Codeine- nausea, vomiting,

Past Medical History (PMH):

Hyperlipidemia

Hypertension

Denies history of hospitalizations

Past Surgical History (PSH): Denies surgical history

Sexual/Reproductive History: Identifies as heterosexual and is in a monogamous relationship. Has two children.

Personal/Social History: Denies tobacco or illicit drug use. Reports occasional alcohol use.

Immunization History:

Tdap 10/2014.

Influenza 10/2021.

COVID-19 2021

Significant Family History:

Father- deceased from colon cancer, history of obesity, hypertension, and hyperlipidemia,

Mother – diabetes, Hypertension,

Sister- diabetes, hypertension

Paternal grandmother-died from pneumonia

Maternal grandfather-died from stroke.

Maternal grandmother-died from breast cancer.

Review of Systems:

General: Denies weight change, fatigue , or fever.

Cardiovascular/Peripheral Vascular: Reports pain in the middle of the chest. Denies palpitations or swelling.

Respiratory: Denies wheezing, cough, or shortness of breath.

Gastrointestinal: Denies diarrhea, constipation, vomiting, nausea, or abdominal pain.

Musculoskeletal: Denies muscle pain, or injury. Denies joint pain or injury. Denies history of sprains or fractures.

Psychiatric: Denies history of anxiety, depression or other mental illnesses.

OBJECTIVE DATA: Clinical Focused SOAP Note For Chest Pain Discussion

Physical Exam:

Vital signs: 146/90, P-104, R-19, T-36.7C. Ht- 5’11. Wt 197lbs. BMI 27.5

General: Alert and oriented x 4. Appears well-dressed, well-nourished, and well-groomed.  Able to maintain eye contact. Cooperative. Clear and coherent speech

Cardiovascular/Peripheral Vascular: S1, S2, S3 noted with gallops. No murmurs or rubs. PMI displaced laterally at mitral area. Capillary refill less than 3 seconds. EKG-normal sinus rhythm with no ST elevations.

Respiratory: Breath sounds clear to auscultation. Unlabored breathing noted.. Fine crackles in right middle lobe and posterior left lower lobe.

Gastrointestinal: Symmetric, round, soft abdomen, no abnormalities. No abdominal bruits Normoactive bowel sounds. All areas are generally tympanic on percussion. No tenderness to both light and deep palpitation..

Musculoskeletal: 5/5 strength and Full ROM in both extremities.

Neurological: Alert and oriented x 4. Cranial Nerves grossly intact. DTR’s intact

Skin: no visible abnormalities in nails. No cyanosis, skin tenting, or lesion noted

Diagnostic Test/Labs: