SOAP Note Format – CHEST PAIN 1/24/18
Pre-Brief:
This assignment provides the opportunity to conduct a focused exam on a patient presenting with
recent episodes of chest pain in a non-emergency setting. Interview Mr.
...
SOAP Note Format – CHEST PAIN 1/24/18
Pre-Brief:
This assignment provides the opportunity to conduct a focused exam on a patient presenting with
recent episodes of chest pain in a non-emergency setting. Interview Mr. Foster and be sure to
thoroughly assess the cardiovascular system as well as related body systems in order to compile
a list of differential diagnoses. This case study offers you the opportunity to evaluate Mr. Foster's
personal and family history with heart disease and identify lifestyle risk factors. During the
physical examination, thoroughly examine the cardiovascular system and carefully evaluate and
document the patient's heart sounds.
Reason for visit: Patient presents complaining recurrent chest pain.
Patient Information:
Brian Foster, 58 yo Male. Presenting with recent episode of chest pain.
S.
CC:
Patient states intermittent chest pain that is tight and uncomfortable.
HPI:
Onset: Earlier in the month
Location: Middle of chest, does not radiate.
Duration: Pain lasts “several” minutes. Pain passes with rest. Has experienced CP 3x
this month. Last episode of CP last Friday per patient.
Characteristics: Denies sweating, nausea, vomiting, SOB or palpitations with pain. Has
never experienced this pain before. Describes pain as “tight” and “uncomfortable”. States
pain a 5/10 at worst. Currently no pain. Denies crushing, gnawing or burning pain.
Aggravating Factors: Physical activity. Fist occurrence when Mr. Foster was doing
yardwork, second occurrence when he had to use stairs at work to 5th floor office when
elevator was broken. Pain does not worsen when eating any type of food.
Relieving Factors: Rest, “lying still”, sitting down to rest.
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