Question

hi so im going to post a dicussion sooap note for a patient with chext pain and i would like you to respond to that discussion

i will also provide a sample answer use it as an example but please formulate your own thank you

here is the soap note discussion

HPI: Mr. C is a 56-year-old Asian male who presents to the clinic with chest pain x 2 days. He describes the chest pain as “a squeezing pressure” and states the pain has been intermittent. He notes the onset is gradual (over a few minutes) and it only occurs while he is performing strenuous activity such as sprinting but resolves within 5 minutes of resting. He has had a total of two episodes of chest pain since onset. The pain is localized to midsternal area and does not radiate. At its worse, he rates the pain as 7/10. Currently, he is not having any chest pain. He has taken ibuprofen with each episode of chest pain, minimal relief. He denies any diaphoresis, shortness of breath, nausea, vomiting, fatigue, palpitations, lightheadedness, or syncope. No previous history of similar chest pain. Denies any recent prolonged travel.

Past Medical/Surgical History: Hypertension (well-controlled) and type 2 diabetes. No history of coronary artery disease, cerebrovascular disease, DVT, PE, or GERD. No prior hospitalizations. History of appendectomy in 1984. No other surgeries.

Differential Diagnosis: acute coronary syndrome, myocardial infarction, acute pericarditis, acute thoracic aortic dissection, chest wall pain, costochondritis, acute congestive heart failure, cardiac tamponade, stress cardiomyopathy, pericarditis, pleuritis, pulmonary embolism, pneumonia, pneumothorax, esophageal perforation, peptic ulcer disease, GERD, pancreatitis, peptic ulcer disease, rib fracture, anxiety, herpes zoster, muscle strain (McConaghy, 2019).

Assessment (Diagnosis): Stable angina

Plan:

• Medication/Therapy:
  • Rx: Nitroglycerin 0.4 mg sublingual tablets, as needed for chest pain; take 1 tablet sublingually every 5 minutes, up to 3 times, at first sign of angina. Disp #24. (Medscape, n.d.).
    • Allow tablet to dissolve under tongue or in buccal pouch, do not rinse mouth or spit for 5 minutes after administration
    • If chest pain remains unrelieved following nitroglycerin, call 911
  • Diagnostic tests:
    • 12-lead EKG to rule out acute myocardial infarction.
    • Labs: complete blood count with differential, complete metabolic panel, lipid panel, PT/INR/PTT, TSH, and cardiac enzymes (troponin, creatine kinase (CK) or CK-MB).
    • Chest x-ray (A/P and lateral).
    • Consider referral for exercise stress test.
  • Patient education:
    • Patient provided detailed instructions on how to take medications along with side effects. Store nitroglycerin in a dark bottle protected from light.
    • Provide patient education regarding the causes and symptoms of stable angina versus unstable angina.
    • Provide patient education regarding 12-lead EKG purpose/results and potential need for exercise stress test.
  • Follow-up:
    • Refer to cardiologist for stress test and possible echocardiogram.
    • Return to clinic in 2 weeks or sooner if needed for follow-up, review of lab results, and evaluation of symptoms.
    • Seek emergency medical care or call 911 if you are experiencing chest pain that is unresolved with rest, chest pain that is new or severe, back pain concurrent with chest pain, difficulty breathing, lightheadedness, fainting, dizziness, palpitations, weakness, nausea, vomiting

sample answer as a response to that soap note discusiion(this is only an example just to show you)

You wrote an excellent SOAP note assessment for this patient. Your use of the numbers scale for this patient's pain assessment was well done. You used OLDCARTS for the HPI and your prescription was exceptionally done. Also, your succinct ROS brought all of the most pertinent positive and negative subjective information to the forefront, correlating to the chief complaint seamlessly.

You had an excellent assessment, plan, education, and medication section to this SOAP note. Perhaps it would be important to include how his blood sugars have been. Indapamide combined with metformin may cause hyperglycemia (Epocrates, 2020). It was a good idea to include the CMP in your diagnostics. What are your thoughts on adding a routine BG test in the clinic given his recent change in condition?

Thank you so much for your thoughtful and informative post.

Answer 1

SUBJECTIVE-Mrs.B is a 47 y/o woman comes in today for follow up of her chronic obstructive pulmonary disease and for new onset of chest pain,she had had 2-3 episodes of chest pain for past 8 days.Each episode of compression like pain occured in the nights of past 8 days and made her woke up from her sleep.She runs 1-2 miles every other day and does not experience any kind of chest pain or discomfort.These recent episodes of chest pain improved with positioning as propping herself up on 2 pillows seemed to relieve her discomfort for a bit.Lately, she had a larger meals,later at night than usual and that seems to be in coincide with the onset of this symptoms.She has no SOB,papilations,nause or diaphoresis.

Regarding her COPD ,she has been experiencing less shortness of breath with activity since her last visit where her inhalers were changed.She is able to climb stairs without shortness of breath.She is coughing only rarely.

She has a past history of COPD,She has no history of high cholestrol or hypertension.Her medicatons include Asprin 8.1mg daily,Calcium Carbonate/Vitamin D 600mg BID,combivent inhaler 2 puffs four times a day,albuterol inhaler as needed.

OBJECTIVE-Generally thin,Anxiousness is appearing slightly. Weight 126 lbs (without shoes), height 62 in.,BMI 23 kr/m2,Pulse 70 reg,BP (sitting) 116/64, Blood sugar level (127/84 mg/dl)

Lungs:distinct breath sounds without wheezes.

CV:RRR,NL S1 and S2,no S3 or S4,No murmurs.

Abdomen:normal bowel sounds,no tenderness to palpation.

ASSESMENT-Chest pain and COPD

-Recent onset nocturnal chest pain . It is most likely is from GERD , given that is only when recumbent and not present with exertion. Also,the change in her diet to eating larger meals at night is supportive.The chest pain might also be from heart disease though this seems less likely given nom chest pain with exertion.The chest pain might be due to chest wall strain as the pain improves with position

-COPD doing well with recent changes medications,shortness of breath doesn't occur and no cough  

PLAN-

Chest pain

She is advised to refrain from eating 2-3 hours prior to sleeping in order to prevent episodes of heart burn

If pain occurs despite from eating habits, Immediate intake of Sorbitrate (5 mg) S/L SOS should be kept under the tongue if the pain doesn't get over within dissolvation of 3 tablets, within the dissolvation of the 3rd tablet she should reach the clinic.

COPD

Bronchodilator and Corticosteroids are prescribed in addition to the past medications.Pulmonary rehabilation is also suggested to decrease the complications.

FOLLOW UP

Have an regular check up of twice a month every 2nd and 4th week.

REVIEW OF SYSTEMS

COMPREHENSIVE METOBOLIC PANEL:

Glucose 95 127/84 mg/dL

BUN 15 8-25 mg/dL

Creatinine 1.1 8.8-1.4 mg/dL

Calculated BUN /Creatinine 14 6-28

sodium 140 133/146mEq/L

Potassium 4.4 3.5-5.3 mEq/L

Chloride    104 97-110mEq/L

Carbondioxide    22 18/30mEq/L

Calcium 10 8.5-10.5 mg/dL

protein,total 7.6 6.0-8.4 mEq/L

Albumin 4.7 2.9-5.0 g/dL

calculated globulin      2.9 2.0-3.8mg/dL

calculated A/G ratio 1.6 0.9-2.5

bilirubin,total 0.4 0.1-1.3 mg/dL

Alkaline phosphate 103 32-132U/L

AST   10 5-35U/L

ALT 24   17-56 U/L