Question

hio so im going to post a soap note that i want you to write a response to in regard of theses questions

formulate a substantive response to a minimum of two different students. Is objective and subjective data included in the right format? Please be specific to information related to the SOAP note format.

1. Does HPI have relevant information related to CC?
2. Medication listed with right timing, dosing, and number of tablets specified?
3. PMH, FH, and SH has all the appropriate information?
4. Does information in ROS correlate to CC?
5. Is there any information lacking in physical documentation of CC (Students often get confused between ROS and objective findings)?
6. Includes assessment, plan, follow up information, and patient education?

here is the soap note that i would like you to response to (its a discussion question )

Subjective)

CC: “I have pain in my chest for two days”

HPI: Mr. Tom Nguyen is a 56-year-old Asian male who presents to the clinic with a primary complaint of chest pain that started two days ago after lifting a heavy object at work. Pain is to left lateral chest, radiates to left side of neck, jaw, and mid back. He describes the pain as “Off and on” sharp tight 9/10 pain and is worse with activity. He took a nitroglycerine tab once yesterday evening that he thinks helped but made him dizzy, so he did not use it again. Shortly after the pain improved but returned this morning so he took another Nitro tab, but it did not help. He states similar chest pain has occurred once before. Three months ago, and he went to the Emergency Department and was kept overnight as observation. At discharge, he was prescribed Nitroglycerine but has not had to use until the current episode. He was also prescribed Plavix, Lipitor, and Metoprolol. He admits he does not take the medications regularly and only takes if he remembers. He does not check his blood pressure daily and never followed up with the cardiologist due to his busy work schedule. He works in San Jose for an electrical company and is a reliable historian.

Allergies: Aspirin (body rash)

PMH: high cholesterol, hypertension, angina

Surgical: No known surgery                          

Medications: Plavix 75 mg Daily, Lipitor 40 mg Daily, Metoprolol 25 mg BID.

immz: Flu Vaccine current, all other Vaccines up to date

screening tests: TB skin test negative within 6 months

FH:      Father died of stroke at age 63; Mother Alive DM age 73; Brother Alive age 52 DM

SH:      Graduated High School, immigrated from Vietnam at age 5. Married 30 years with 4

adult children who live on their own. Mother lives with him and wife.

            Exercise: Goes for walks in the evening with wife when weather permits.

            Diet: Eats a regular diet. Mostly traditional Vietnamese cooking that his mother and wife

make.

Tobacco: Prior ½ ppd smoker quit 20 years ago       

Alcohol/drugs: Family functions drinks up to 12 beers. Last time was 4 months ago at a    

friend’s wedding.

ROS:

General: Reports sweating this morning when chest pain restarted while he was laying in bed.

Denies recent weight changes, fevers, or chills

Derm: Denies rash or skin changes

HEENT: Denies vision changes, sinus pain, pressure, or discharge

Neck: reports pain to the left side of the neck but denies stiffness

Respiratory: Feels SOB with chest pain

C-V: See HPI current chest pain 8/10

GI: Denies n/v of abnormal bowel pattern

Peripheral Vascular: Denies swelling to extremities or changes in skin color.

Musculoskeletal: Pain to left ribs, denies pain to joints

Neurologic: Denies numbness tingling

Endocrine: Denies excessive thirst, hunger, or hx of diabetes

Psychiatric: Denies anxiety, depression or other mental health histories

Objective)

VS: BP 170/90 ; T 99.0 ; P 87 ; R: 22 O2 Sat 95% RA

            General: Mild distress and anxiety, cooperative                                           

            Skin: diaphoretic, pallor

            Neck: Good ROM, trachea midline

            Thorax & lungs: Struggling to breathe deeply, otherwise, lungs sound clear in all fields

            Heart/pulses: S1, S2 no murmur bruit or thrills. Radial,Ped/Tibial pulses +2

            Abdomen: Soft non-distended, no pain to palpation, bowel sounds x4

            Lower extremities: No edema noted, cool to touch

            Musculoskeletal: Pain to left ribs does not worsen with palpation, remains constant.

Active ROM all extremities

            Neurologic: Mental status: A/O x4, sensation and coordination intact

Differential Diagnosis:      

1. ACS
2. Unstable Angina

Assessment: Acute MI

Plan:

Dx: EKG, Nitro 0.4 mg SL, and call EMS to get him to ED for evaluation and need for percutaneous coronary intervention (PCI)

IF CHEST PAIN WERE STABLE:

Diagnostics and Labs

• Chest x-ray to r/o rib fracture or acute pulmonary issue. Can also get a good idea of cardiac size.
• CBC w/diff, Lipid panel, cardiac markers Troponin, CK, HA1C, D-dimer
• stress test
• Echo
• CT angiogram of chest.

MEDICATIONS:

• Nitro 0.4 mg SL Q5 min for chest pain, do not exceed 3 doses.
• Plavix 75 mg Daily
• Lipitor 40 mg Daily
• Metoprolol 25 mg BID

PATIENT EDUCATION:

            Medication compliance, side effects, when to hold medications.

            It is important to monitor blood pressure prior to taking BP medication and keep a log

            S&S to monitor for: Chest Pain that does not go away with rest, n/v, diaphoresis.

            If pain persists after 3 Nitros and resting call EMS.

            Must keep all appointments made. Attend cardiologist appointment. F/U with Clinic x1

week for lab review.

Answer 1

Does HPI have relevant information related to CC?

Ans: Yes

Medication listed with right timing, dosing, and number of tablets specified?

No, the timing is not provided that is when drug is to be taken( like morning afternoon, night)

Eg Tab Lipitor 40 mg at night time

PMH, FH, and SH has all the appropriate information?

Ans: yes

Does information in ROS correlate to CC?

No

Cc informed that he developed chest pain during his work two days back, after that he is getting on and off similar chest pain episode, today morning the nitroglycerin didn't improve his symptom.

Is there any information lacking in physical documentation of CC (Students often get confused between ROS and objective findings)

Ans: yes, the auscultatory findings of respiratory system was to be mentioned in ROS and not objective findings also bowel sounds recording

Plan : if symptomatic along with ECG , plan for 3D echo also,