Episodic/Focused SOAP Note Template Discussion

Patient Information:

B.F, 58, Male, Caucasian

S.

CC: chest pain

HPI: BF, age 58, is a Caucasian male who visited the clinic complaining of chest pain that had occurred in three separate bouts over the course of the previous month and is now occurring quite frequently. The patient characterized the pain as a tight and uncomfortable and rated its intensity of it as 5/10 at its worst. The discomfort is localized to the centre of the chest and lasts for a few of minutes at a time. According to the patient, the chest discomfort is made worse by physically demanding tasks like walking up stairs and gardening. He denies pain radiation to other body parts. To ease the pain, he mentions not using any medicine, instead stating that resting improved the pain. The patient states that he does not have a headache, nausea, chills, fever, or cough. Episodic/Focused SOAP Note Template Discussion

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Current Medications:

Omega-3fish oil 1200mg PO BID

Atorvastatin 20 mg PO QHS

Lisinopril 20mg PO QD

Allergies: Pt reports codeine allergy- nausea and vomiting are its symptoms.

PMHx: Reports history of hypertension and hyperlipidemia. Immunizations are current. Reports being heterosexual. Denies history of surgeries.

 Soc Hx: reports consuming between two and three beers on a weekly basis. He asserts that he has never used cigarettes or illegal substances. He does not adhere to any particular eating plan, but he does consume four to five portions of fruit per week in addition to drinking four glasses of water on a daily basis. Since his bicycle broke, he has not done any physical activity for almost two years. Reports that he has access to medical care and that he is able to afford his medicines without any issues. Episodic/Focused SOAP Note Template Discussion

Fam Hx:

Patient’s father passed away at the age of 75 from colon cancer; his medical history included obesity, hypertension, and hypercholesterolemia. Mother is now 80 years old and has a medical history that includes a diagnosis of hypertension and diabetes. Sister is 52 years old and has a history of  diabetes and hypertension. Accident involving a motor vehicle claimed the life of his brother when he was 24 years old. His son is now 26 years old and in good health. His daughter has been diagnosed with asthma. Maternal grandma passed away from breast cancer at the age of 65. The maternal grandpa passed away at the age of 54 as a result of a heart attack. His paternal grandma passed away at the age of 78 from complications related to pneumonia. Paternal grandpa died of “old age” at the age of 85.

ROS:

GENERAL:  Denies fatigue, weight loss, fever, chills, or loss of appetite. Episodic/Focused SOAP Note Template Discussion

CARDIOVASCULAR:  Reports midsternal chest pain. Denies chest pressure or chest discomfort. Denies palpitations or edema.

RESPIRATORY:  Denies shortness of breath, cough or wheezing.

GASTROINTESTINAL:  Denies constipation, nausea, vomiting, abdominal pain, or diarrhea..

MUSCULOSKELETAL:  Denies muscle, back pain, joint pain or stiffness.

PSYCHIATRIC:  Denies history of depression or anxiety.

O.

Physical exam:

Vital signs: Blood Pressure: 146/90; O2 Saturation: 98%; Pulse: 104; Resp Rate: 19; Temperature: 36.7C; Weight: 197 lbs.; Height: 5’11”; BMI: 27.5

General: pleasant, in no acute distress. Well-dressed, well-groomed, and well-nourished. appears cooperative, and alert and oriented x 3. Clear and coherent speech.

Cardiovascular: S1, S2, and S3 noted with gallops, no murmurs or rubs. Bruit noted the right carotid artery. Capillary refill less than three seconds. No edema noted on lower extremities.

Respiratory: symmetric chest without abnormalities. Breath sounds clear to auscultation.  Fine crackles noted on the left and left posterior lower lobe. Episodic/Focused SOAP Note Template Discussion

Gastrointestinal: soft, symmetric, round abdomen, no tenderness or abnormalities. No bruit auscultated in the arteries and the abdominal aorta. Normoactive bowel sounds. Liver is palpable while kidneys and spleen are not palpable. Tympany noted in all areas of the abdomen.

Skin: no skin tenting or lesions noted

Diagnostic Test/Labs:

EKG- Normal rate and rhythm. No ST elevation.

A.

Coronary Artery Disease: This is a disorder that occurs when cholesterol deposits in the arterial walls, resulting in plaque buildup. Plaques may either restrict the arteries and reduce the amount of blood that reaches the heart, or they can promote inflammation and hardening of the arteries’ walls. It is possible to have no symptoms of coronary artery disease, but it may also cause chest pain, shortness of breath, and even heart attacks (Malakar et al., 2019). Episodic/Focused SOAP Note Template Discussion

Stable Angina: Stable angina is characterized by pain, squeezing, pressure or tightness in the chest lasts for a short period of time and then subsides. Stable angina is caused by a blockage or restriction in the arteries that prevents new blood from reaching the heart. When a person has stable angina, they may have pain episodes that are triggered by physical activity (Gillen & Goyal, 2021).

Congestive Heart Failure:  Patients with this illness have an inability to pump blood adequately because the heart muscle is not strong enough. When this happens, the body’s blood flow typically reverses and fluid may build in the lungs, causing a feeling of being unable to breathe (Malik et al, 2021). Some cardiac problems, like heart artery obstruction or excessive blood pressure, may cause the heart to weaken or stiffen gradually, making it incapable of filling and pumping blood effectively. Some of the signs to watch out for include tiredness, breathing difficulty, edema of the legs, and an accelerated heart rate. Episodic/Focused SOAP Note Template Discussion

References

Gillen, C., & Goyal, A. (2021). Stable Angina. StatPearls.

Malakar, A. K., Choudhury, D., Halder, B., Paul, P., Uddin, A., & Chakraborty, S. (2019). A review on coronary artery disease, its risk factors, and therapeutics. Journal of cellular physiology, 234(10), 16812-16823.

Malik, A., Brito, D., Vaqar, S., & Chhabra, l. (2021). Congestive heart f

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Chapter 14, “Chest and Lungs”

This chapter explains the physical exam process for the chest and lungs. The authors also include descriptions of common abnormalities in the chest and lungs.

Chapter 15, “Heart”

The authors of this chapter explain the structure and function of the heart. The text also describes the steps used to conduct an exam of the heart.

Chapter 16, “Blood Vessels”

This chapter describes how to properly conduct a physical examination of the blood vessels. The chapter also supplies descriptions of common heart disorders.

Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.

Chapter 107, “X-Ray Interpretation: Chest (pp. 480–487) (specifically focus on pp. 480–481)

Chapter 107, “X-Ray Interpretation: Chest (pp. 480–487)

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.

Chapter 8, “Chest Pain”

This chapter focuses on diagnosing the cause of chest pain and highlights the importance of first determining whether the patient is in a life-threatening condition. It includes questions that can help pinpoint the type and severity of pain and then describes how to perform a physical examination. Finally, the authors outline potential laboratory and diagnostic studies.

Chapter 11, “Cough”

A cough is a very common symptom in patients and usually indicates a minor health problem. This chapter focuses on how to determine the cause of the cough by asking questions and performing a physical exam. Episodic/Focused SOAP Note Template Discussion

Chapter 14, “Dyspnea”

The focus of this chapter is dyspnea, or shortness of breath. The chapter includes strategies for determining the cause of the problem through evaluation of the patient’s history, through physical examination, and through additional laboratory and diagnostic tests.

Chapter 26, “Palpitations”

This chapter describes the different causes of heart palpitations and details how the specific cause in a patient can be determined.

Chapter 33, “Syncope”

This chapter focuses on syncope, or loss of consciousness. The authors describe the difficulty of ascertaining the cause, because the patient is usually seen after the loss of consciousness has happened. The chapter includes information on potential causes and the symptoms of each.

Note: Download the Student Checklists and Key Points to use during your practice cardiac and respiratory examination.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Chest and lungs: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Chest and lungs: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Heart: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

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Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Heart: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Bansal, M. (2020). Cardiovascular disease and COVID-19. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 14(3), 247–250. https://doi.org/10.1016/j.dsx.2020.03.013

Jolobe, O. M. (2021). Differential diagnosis of the association of gastrointestinal symptoms and ST segment elevation, in the absence of chest pain. The American Journal of Emergency Medicine, 49, 137–141. https://doi.org/10.1016/j.ajem.2021.05.067

Johnson K, & Ghassemzadeh S. (2021, July 21). Chest pain. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470557/

Zorzi, A., Vessella, T., de Lazzari, M., Cipriani, A., Menegon, V., Sarto, G., Spagnol, R., Merlo, L., Pegoraro, C., Marra, M. P., Corrado, D., & Sarto, P. (2019). Screening young athletes for diseases at risk of sudden cardiac death: Role of stress testing for ventricular arrhythmias. European Journal of Preventive Cardiology, 27(3), 311–320. https://doi.org/10.1177/2047487319890973

Please have someone who is familiar with Shadow health and NURS 6512. I need to have a high grade on it. Episodic/Focused SOAP Note Template Discussion