Question

Write a SOAP note presentation of chest pain in primary care visit.

CC: 56-year-old Asian male c/o of chest pain for 2 days.

Your information in the subjective and objective data can be based on a hypothetical case.

here is an example of a soap note u can use to write your own answer . im only providing the example to help u please write something different and simple thank you

here is the example

SOAP NOTE

Name	Date:			Time: 00
	Age:			Sex: F
SUBJECTIVE
CC: "I have a sharp pain in the chest for the past 2 days"
HPI: 28 year old black American female presents to the office with   chest pain of 4/10, sternal area, on and off, while walking and sometimes even when just sitting, lasts for about 5 - 10 minutes, and even hurts on deep breathing. No cough, no shortness of breath, no orthopnea. meloxicam helps the pain a little bit.
Medications: Nitroglycerin 0.4 MG Sublingual Tablet Sublingual; Place 1 tablet sublingualy one time prn chest pain Albuterol Sulfate (2.5 MG/3ML) 0.083% Inhalation Nebulization Solution; Inhale 1 ml by inhalation Q4-6H prn for asthma and wheezing; BACLOFEN 10 MG TABLET 90BLISTER; TAKE ONE TABLET BY MOUTH TWICE A DAY AS NEEDED FOR MUSCLE SPASM; Clotrimazole Bethametasone creame; Apply BID cream; Dulcolax 5 MG Oral Tablet Delayed Release; Take 1 tablet orally daily prn constipation. Ferrous Sulfate 325 (65 Fe) MG Oral Tablet; Take 1 tablet by mouth TID . Flonase Allergy Relief 50 MCG/ACT Nasal Suspension; Use 2 squirt in the nostrils BID FLUoxetine HCl 20 MG Oral Capsule; Take 1 capsule by mouth DAILY Meloxicam 15 mg ; Take 1 tablet by mouth DAILY Pantoprazole Sodium 40 MG Oral Tablet Delayed Release; Take 1 tablet orally daily ProAir HFA 108 (90 Base) MCG/ACT Inhalation Aerosol Solution; Inhale 1.5 puff BID prn for asthma and wheezing TRAZODONE HCL 50MG TABLET 50 MG; TAKE ONE TABLET BY MOUTH ONCE DAILY Triamcinolone Acetonide 0.1 % External Cream; Apply BID topically Ultram 50 MG Oral Tablet; Take 1 tablet Q6h prn for pain
PMH Asthma, obesity, tinea Gerd Allergies: Xanax ,Vicodin, Morphine , Hydralazine ,Wellbutri Medication Intolerances: None Chronic Illnesses/Major traumas None Hospitalizations/Surgeries:Cyst removal on the ovary 2013
Family History Father Hx: Alive age 57 Mother Hx: Deceased age 30's of HIV 3 Brothers, 2 deceased and 1 Alive and healthy
Single with no children, working as a cashier at Everbank fields Education- Some college Non smoker, No alcohol, 1 cup of coffee a week Hrs of sleep:4-6 Living with:Fiance and 2 birds Mental state:Depressed Exercise - Running
ROS
General No weight change, denies fatigue, no fever,			Cardiovascular Chest pain, no palpitations, no orthopnea, no edema
Skin No skin discolorations,			Respiratory No cough, no wheezing,no SOB
Eyes No visual changes of any kind			Gastrointestinal No abdominal pain, no constipation
Ears No ear pain,			Genitourinary/Gynecological No urgency sexual activity, no STDS    Fe: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx Male: prostate, PSA, urinary complaints
Nose/Mouth/Throat No nose bleeding, no sore throat, no difficulty swallowing.			Musculoskeletal No back pain Rom: Full Muscle tone NL
Breast No lumps no discharge			Neurological No seizure no syncope,
Heme/Lymph/Endo No bruising, HIV negatine			Psychiatric No depression, anxiety, sleeping difficulties, suicidal ideation
OBJECTIVE
Weight        BMI		Temp		BP
Height		Pulse		Resp
General Appearance Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first, then brighter later.
Skin Skin is warm, dry, clean and intact. No rashes or lesions noted.
HEENT Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. No missing
Cardiovascular S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.
Respiratory Symmetric chest wall. Respirations even and unlabored ; lungs clear to auscultation bilaterally.
Gastrointestinal Abdomen obese; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly.
Breast Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin.
Genitourinary Bladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation.
Musculoskeletal Full ROM seen in all 4 extremities as patient moved about the room.
Neurological Speech clear. Good tone. Posture erect. Balance stable; gait normal.
Psychiatric Alert and oriented 4 . Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.
Lab Tests None
Special Tests EKG
Diagnosis
Differential Diagnoses 1)R079; Chest pain, unspecified 2)K210; Gastro-esophageal reflux disease with esophagitis 3)J4531; Mild persistent asthma with (acute) exacerbation 4)M940; Chondrocostal junction syndrome
Plan/Therapeutics
EKG done NTG SL prn refer to Cardio continue Meloxicam prn pain continue Pantoprazole monitor BP continue other current meds. F/u if not better. Follow up if conditions worsen. to ER if worse Patient instructed of above care plan. Monitor Blood Pressure. Continue current medications. All questions answered to the patient's satisfaction. Electronically prescribed medication(s) this visit.
Evaluation of patient encounter

Answer 1

NOTE NO.01

Tuesday 06 October

Current condition: Chest pain(Angina)

Goal: To relieve chest pain (angina),and shortness of breath.

Ravi is 18 years old Male .

Referral : None

(S)Subjective:

Cheif Complaints:- Fast heart rate at times at past three weeks with chest pain level of 5/10.The pain is right over mt heart. I have shortness of breath.

Ravi has been checking blood pressure twice a week.His values are usually 140/90. He has not experienced side effects of medication.

Complaints with daziness only during position change.

(O)Objective:

Pluse: 72 b/m

Blood pressure:- 140/90

Height:- 5'10''

BMI: 28.7

Neck : No jugular vein distension

Lungs: Clear to ascultation

No edema , no heart murmurs

No cyanosis

(A) ASSESSMENT:

18 years old man(Ravi) seen for follow up after surgery and for hypertension.

Good exercise tolerance.

Hypertension well controlled with atenolol . Since B.P less than 140/90.

(P) PLANING:

• Continue current medication.
• Encourage Mr. Ravi to check his blood pressure continuously.
• Continue follow up if condition deteriorates.
• Avoid smoking,drinking alcohol etc.