SOAP Note Template

Encounter date: 10/26/2023

Patient Initials: J.D. Gender: M Age: 45 Race: Caucasian Ethnicity: Non-Hispanic

Reason for Seeking Health Care: The patient presents with a chief complaint of chest pain and shortness of breath.

Subjective: The patient reports experiencing intermittent chest pain for the past week. He describes the pain as a dull ache, localized to the left side of his chest, radiating down his left arm. The pain is exacerbated by physical activity and relieved by rest. He also complains of occasional shortness of breath during these episodes. The patient is concerned about these symptoms and mentions that his father had a history of heart disease.

Allergies: The patient has no known drug, food, latex, environmental, or herbal allergies.

Current Perception of Health:

Excellent

Good

Fair

Poor

Past Medical History:

Major/Chronic Illnesses: The patient has a history of hypertension for which he has been taking Amlodipine 5mg daily.

Trauma/Injury: No recent trauma or injury.

Hospitalizations: No recent hospitalizations.

Past Surgical History: The patient had an appendectomy in his teenage years—no other surgical history.

Medications:

Amlodipine 5mg daily for hypertension.

Family History: The patient's father had a history of myocardial infarction.

Social History:

Lives: Single-family House with stairs. Marital Status: Divorced.

Employment Status: Employed part-time. Current/Previous occupation type: Data entry clerk.

Exposure to: Smoke: Non-smoker. ETOH (Alcohol): Occasional social drinker. Recreational Drug Use: Denies recreational drug use.

Sexual orientation: Heterosexual. Sexual Activity: Sexually active. Contraception Use: Not currently using contraception; patient's partner is vasectomized.

Family Composition: Lives alone.

Health Maintenance:

Screening Tests:

Up to date on Pap smear (last performed eight months ago).

A mammogram is scheduled for next month.

No history of PSA or colonoscopy.

Exposures:

Denies significant occupational or environmental exposures.

Immunization HX:

Up to date with routine childhood immunizations.

No recent vaccinations or travel-related immunizations.

Review of Systems:

General: The patient appears to be in no acute distress. He denies any recent weight changes, fevers, chills, or fatigue.

HEENT (Head, Eyes, Ears, Nose, Throat): The patient reports no significant issues with vision or hearing. Denies any headaches, sinus congestion, or sore throat.

Neck: No complaints of neck pain, stiffness, or enlarged lymph nodes. Full range of motion without tenderness.

Lungs: No history of chronic cough, shortness of breath, or wheezing. Breath sounds are clear on examination.

Cardiovascular: The patient mentions occasional palpitations but no chest pain. No history of heart murmurs. Blood pressure was previously noted in the social history section.

Breast: The patient denies breast pain, lumps, or nipple discharge. A mammogram is scheduled for next month.

GI (Gastrointestinal): Denies abdominal pain, nausea, vomiting, diarrhea, or constipation—no history of gastrointestinal bleeding or liver disease.

Male/Female Genital: Male: No testicular pain, swelling, or penile discharge.

GU (Genitourinary): The patient has no urinary frequency, urgency, dysuria, or hematuria. Denies kidney stones or urinary tract infections.

Neuro: No history of seizures, syncope, or paralysis. No complaints of numbness, tingling, or coordination issues.

Musculoskeletal: The patient reports occasional joint stiffness but no pain, swelling, or limitations in range of motion. There is no history of fractures or musculoskeletal surgeries.

Activity & Exercise: The patient engages in light exercise a few times a week and reports occasional back discomfort after physical activity.

Psychosocial: The patient describes experiencing mild stress due to work and personal matters. Denies symptoms of anxiety or depression. Social history includes occasional alcohol consumption.

Derm (Skin): No significant skin issues or changes in moles. Denies rashes or excessive dryness.

Nutrition: The patient describes a balanced diet but occasional indulgence in high-calorie foods. No significant weight changes were reported.

Sleep/Rest: Occasionally experiences difficulty falling asleep due to work-related stress but sleeps 6-7 hours per night overall.

LMP (Last Menstrual Period): The patient's LMP was six weeks ago. Reports regular menstrual cycles.

STI Hx (Sexually Transmitted Infection History): Denies a history of sexually transmitted infections (STIs) and is currently in a monogamous relationship.

Physical Exam

BP: 150/90 mm Hg

TPR (Temperature, Pulse, Respiratory Rate): The patient's temperature is within the normal range at 98.6°F, and the pulse rate is 88 beats per minute. The respiratory rate is 18 breaths per minute.

Ht. (Height): 5 feet 10 inches.

Wt. (Weight): 180 pounds.

BMI (Body Mass Index): 25.8, which falls within the overweight range.

General: J.D. appears to be in no acute distress. He is well-groomed and cooperative throughout the examination. There are no signs of pallor, jaundice, or cyanosis.

HEENT (Head, Eyes, Ears, Nose, Throat): Examination of the head and face reveals no abnormalities, with normal hair distribution. The eyes show clear conjunctiva and sclera, and there is no evidence of ptosis or periorbital edema. Pupils are equal, round, and reactive to light. Ears are symmetrical, and there is no discharge or tenderness. The nose and throat appear normal, with no signs of lesions, drainage, or redness.

Neck: The neck examination shows the full range of motion with no palpable masses or lymphadenopathy. The thyroid gland is not enlarged.

Pulmonary: Lung examination reveals clear breath sounds in all lung fields. No wheezing, rales, or rhonchi are noted. The patient has good air entry bilaterally.

Cardiovascular: Cardiac auscultation reveals normal heart sounds with no murmurs, gallops, or rubs. There are no visible jugular venous distension or carotid bruits. Peripheral pulses are present and symmetrical.

Breast: The breast examination shows no masses, tenderness, or nipple discharge. The skin over the breast appears normal without any redness, dimpling, or peau d'orange appearance.

GI (Gastrointestinal): Abdominal examination reveals no abdominal tenderness, distension, or masses. Bowel sounds are present in all quadrants. No organomegaly is noted.

Male/Female Genital: Male: Testicular examination shows no scrotum pain, swelling, or masses. There is no penile discharge.

GU (Genitourinary): The patient has no suprapubic tenderness, and no costovertebral angle tenderness is elicited.

Neuro: The neurological examination does not reveal any focal deficits. The patient exhibits no abnormal motor or sensory function. Cranial nerves are intact, and there are no signs of tremors, weakness, or coordination issues.

Musculoskeletal: The musculoskeletal examination shows occasional joint stiffness but no pain, swelling, or limitations in range of motion. There are no signs of deformities or muscle atrophy.

Derm (Skin): The skin examination reveals no significant dermatological issues or changes in moles. There is no evidence of rashes, lesions, or excessive dryness.

Psychosocial: The patient appears mildly distressed due to personal and work-related stress. He is cooperative during the examination and willing to discuss his concerns.

Miscellaneous: There are no other specific findings or concerns noted during the examination.

Plan:

Differential Diagnoses:

Angina Pectoris: This is a leading differential diagnosis, given J.D.'s chief complaint of intermittent chest pain that radiates to the left arm and is exacerbated by physical activity (American Heart Association, 2022). The ST-segment depression on the ECG supports this consideration.

Acute Myocardial Infarction: Although angina pectoris is a likely diagnosis, the possibility of an acute myocardial infarction (heart attack) should be considered due to the similarities in symptoms (Mechanic et al., 2021). That should be ruled out with further diagnostic testing.

Gastroesophageal Reflux Disease (GERD): Chest pain can also be a symptom of GERD (Antunes & Curtis, 2019). GERD should be considered if cardiac causes are ruled out, especially in patients who report symptoms such as acid reflux or regurgitation.

Principal Diagnoses:

Angina Pectoris: Given the patient's chief complaint, risk factors (hypertension, family history of heart disease), and the presence of ST-segment depression on the ECG, angina pectoris is the principal diagnosis (American Heart Association, 2022; National Heart, Lung, and Blood Institute, 2022). It will require further evaluation to determine its severity and underlying cause.

Hypertension: J.D. also has a history of hypertension and an elevated blood pressure reading during this visit (American Heart Association, 2023; Iqbal & Jamal, 2022). Hypertension is a principal diagnosis that requires ongoing management to reduce cardiovascular risk factors and prevent complications.

Plan

Diagnosis: Angina Pectoris

Diagnostic Testing: Schedule a stress test (exercise tolerance test) to assess the extent and severity of angina and its correlation with physical activity (National Heart, Lung, and Blood Institute, 2022). Consider coronary angiography if indicated by stress test results to visualize coronary artery blockages.

Pharmacological Treatment: Prescribe nitroglycerin 0.4mg sublingual tablets to relieve angina symptoms as needed (American Heart Association, 2022; National Heart, Lung, and Blood Institute, 2022). Consider antiplatelet therapy, such as aspirin, to reduce the risk of cardiovascular events. Monitor blood pressure and adjust any antihypertensive medication as necessary.

Education: Educate the patient on the importance of recognizing angina symptoms, proper use of nitroglycerin, and lifestyle modifications to minimize triggers (e.g., stress reduction, dietary changes, smoking cessation) (American Heart Association, 2022; National Heart, Lung, and Blood Institute, 2022).

Referrals: Refer J.D. to a cardiologist for further evaluation and management of angina pectoris. Consider a consultation with a dietitian for dietary counseling to address heart-healthy eating habits.

Follow-up: Schedule a follow-up appointment with the cardiologist after the stress test to review the results and determine the most appropriate treatment plan.

Anticipatory Guidance: Emphasize the importance of regular physical activity, stress management, and a heart-healthy diet to reduce the risk of recurrent angina episodes (American Heart Association, 2022; National Heart, Lung, and Blood Institute, 2022). Discuss potential side effects of medications, including nitroglycerin, and encourage prompt reporting of any adverse reactions.

Diagnosis: Hypertension

Diagnostic Testing: Monitor blood pressure regularly to assess control and evaluate the effectiveness of antihypertensive medication (American Heart Association, 2023; Iqbal & Jamal, 2022). Consider lipid profile testing to assess cardiovascular risk and guide dietary recommendations.

Pharmacological Treatment: Continue the current medication, Amlodipine 5mg daily, for hypertension control (American Heart Association, 2022; National Heart, Lung, and Blood Institute, 2022). Adjust medication as needed to maintain blood pressure within target ranges.

Education: Educate the patient about the importance of medication adherence and self-monitoring of blood pressure at home (Iqbal & Jamal, 2022). Provide guidance on dietary changes, including reducing sodium intake, and encourage regular physical activity.

Referrals: Refer J.D. to a registered dietitian for dietary counseling and guidance on sodium reduction.

Follow-up: Schedule regular follow-up appointments to assess blood pressure control and make any necessary adjustments to the treatment plan.

Anticipatory Guidance: Discuss the long-term nature of hypertension management and its importance in preventing cardiovascular complications (American Heart Association, 2023; Iqbal & Jamal, 2022). Stress the significance of leading a heart-healthy lifestyle, including maintaining a healthy weight and not smoking.

Signature (with appropriate credentials): __________________________________________

Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________

"American College of Cardiology (ACC) and American Heart Association (AHA) Guidelines for the Management of Patients with Angina Pectoris" – These guidelines were utilized to inform the diagnostic and treatment approach for angina pectoris.

"Eighth Joint National Committee (JNC 8) Guidelines for the Management of Hypertension in Adults" – These guidelines were used to guide the diagnostic and treatment decisions related to hypertension management.

DEA#: 101010101 STU Clinic LIC# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: J.D. Age 45

Date: 10/26/2023

RX: Nitroglycerin 0.4mg Sublingual Tablets

SIG: Take one tablet under the tongue as needed for chest pain.

Dispense: 20 tablets Refill: 3

No Substitution

Signature: ____________________________________________________________

References

American Heart Association. (2022). Angina Pectoris (Stable Angina). Www.heart.org. https://www.heart.org/en/health-topics/heart-attack/angina-chest-pain/angina-pectoris-stable-angina

American Heart Association. (2023). Understanding blood pressure readings. American Heart Association. https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings

Antunes, C., & Curtis, S. A. (2019). Gastroesophageal reflux disease. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441938/

Iqbal, A. M., & Jamal, S. F. (2022). Essential hypertension. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539859/

Katzung, B. G., Kruidering-Hall, M., Tuan, R. L., Vanderah, T. W., & Trevor, A. J. (2021). Katzung & Trevor’s Pharmacology Examination and Board Review, Thirteenth Edition. In Google Books. McGraw Hill Professional. https://www.google.com/books/edition/Katzung_Trevor_s_Pharmacology_Examinatio/UtsPEAAAQBAJ?hl=en

Mechanic, O. J., Grossman, S. A., & Gavin, M. (2021). Acute Myocardial Infarction. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459269/

National Heart, Lung, and Blood Institute. (2022, March 24). Angina (Chest Pain) - What Is Angina? | NHLBI, NIH. Www.nhlbi.nih.gov. https://www.nhlbi.nih.gov/health/angina

Whalen, K. (2018). Lippincott® Illustrated Reviews: Pharmacology. In Google Books. Wolters kluwer india Pvt Ltd. https://www.google.com/books/edition/Lippincott_Illustrated_Reviews_Pharmacol/8ivvDwAAQBAJ?hl=en&gbpv=1&printsec=frontcover