FocusedNoteExemplar.doc

Episodic/Focused SOAP Note ExemplarFocused SOAP Note for a patient with chest painS.CC: “Chest pain” HPI: The patient is a 65 year old AA male who developed sudden onset of chest pain, which began early this morning.  The pain is described as “crushing” and is rated nine out of 10 in terms of intensity. The pain is located in the middle of the chest and is accompanied by shortness of breath. The patient reports feeling nauseous. The patient tried an antacid with minimal relief of his symptoms.Medications: Lisinopril 10mg, Omeprazole 20mg, Norvasc 5mgPMH: Positive history of GERD and hypertension is controlledFH: Mother died at 78 of breast cancer; Father at 75 of CVA.  No history of premature cardiovascular disease in first degree relatives.SH : Negative for tobacco abuse, currently or previously; consumes moderate alcohol; married for 39 years Allergies: PCN-rash; food-none; environmental- noneImmunizations: UTD on immunizations, covid vaccine #1 1/23/2021 Moderna; Covid vaccine #2 2/23/2021 ModernaROS   General Negative for fevers, chills, fatigueCardiovascular Negative for orthopnea, PND, positive for intermittent lower extremity edema Gastrointestinal Positive for nausea without vomiting; negative for diarrhea, abdominal painPulmonary Positive for intermittent dyspnea on exertion, negative for cough or hemoptysis  O.VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70”General Pt appears diaphoretic and anxiousCardiovascular PMI is in the 5th inter-costal space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is heard best at thesecond right inter-costal space which radiates to the neck.A third heard sound is heard at the apex. No fourth heart sound or rub are heard. No cyanosis, clubbing, noted, positive for bilateral 2+ LE edema is noted.Gastrointestinal The abdomen is symmetrical without distention; bowelsounds are normal in quality and intensity in all areas; abruit is heard in the right para-umbilical area. No masses orsplenomegaly are noted. Positive for mid-epigastric tenderness with deep palpation.Pulmonary— Lungs are clear to auscultation and percussion bilaterallyDiagnostic results: EKG, CXR, CK-MB (support with evidenced and guidelines)A.Differential Diagnosis:1) Myocardial Infarction (provide supportive documentation with evidence based guidelines).2) Angina (provide supportive documentation with evidence based guidelines).3) Costochondritis (provide supportive documentation with evidence based guidelines).Primary Diagnosis/Presumptive Diagnosis: Myocardial InfarctionA.Differential Diagnosis:1) Myocardial Infarction (provide supportive documentation with evidence based guidelines).2) Angina (provide supportive documentation with evidence based guidelines).3) Costochondritis (provide supportive documentation with evidence based guidelines).Primary Diagnosis/Presumptive Diagnosis: Myocardial InfarctionP. This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.© 2021 Walden University LLC Page 2 of 2© 2021 Walden University Page 1 of 2