Episodic/Focused SOAP Note Chest Pain

Health Assessment

Student’s Name
Institutional Affiliation
Professor’s Name

Health Assessment
Episodic/Focused SOAP Note Chest Pain
CC: “Chest pain”

HPI: Mr. Foster is a 55-year-old Caucasian male that appears relatively healthy and active. He is seen today for new onset of chest pain. The chest pain began about a month ago and its non-radiating. The pain is localized to the center of his chest. He denies pain in the arms, legs and jowl pain. The patient denies symptoms of nausea, vomiting, dizziness and shortness of breath. Mr. Foster denies numbness or tingling of the extremities and denies abdominal pain during the episodes. The chest pain is “uncomfortable” and hurts in the center of his chest. The pain is described as “tight, tightness” that gives him “anxiety when it does not subside.” Mr. Foster rates the chest pain a five out 10 intensity on a 1-10 pain scale. The patient states the chest pain episodes have occurred about three times in the last month. The pain is triggered by physical activity like climbing stairs or yard work and seems to last for a few minutes. The chest pain subsides after a period of rest. Mr. Foster states he had a normal EKG performed about three months ago.

PMx: Positive for hypertension and hyperlipidemia diagnosed 1 year ago.

General: Patient appears healthy, presents with no pain or symptoms at this time.
AAOx4, denies headaches or facial pain, seizures, dizziness, numbness or tingling of extremities and denies loss of sensation.
HEENT: Denies visual or hearing deficit, Denies snoring, insomnia, or sleep apnea, Denies difficulty of swallowing
RESP: Denies shortness of breath, Asthma and denies COPD
CV: Denies murmur, previous chest pain, denies diaphoresis,
GI: Denies heart burn or gastrointestinal issues, denies changes or abnormal bowel movements
DIET: Negative for heart healthy diet (steak, red meats)
GU: Denies difficulty with urination, denies prostate problems and is sexually active
MUS/SKE: Denies joint, muscle, leg, feet or hip pain
SKIN: Denies skin deformities or skin diseases

PSx: Denies surgery of any kind.

ILLNESS: Denies hospitalization, broken bones or any adult illness. Denies infections, flu, pneumonia or having shingles. Positive for childhood chicken pox.
IMMUNIZATION: Up to date, needs annual flu shot

ALLERGIES: Codeine: Causes nausea and vomiting
MEDICATIONS: *Lisinopril (Prinivil) 20 mg, PO Daily, taken today
*Atorvastatin (Lipitor) 20 mg, PO Daily at bedtime, last dose yesterday (hyperlipidemia)
*Omega 3 Fish Oil 1200 mg PO BID, last dose at 8am (OTC Supplement).

FHx: Mother; type 2 diabetes, hypertension, age 80.
Father: hypertension, hyperlipidemia, obesity, died at 75 of colon cancer.
Brother: died at 24 MVA.
Sister: type 2 diabetes, hypertension, at 52.
Maternal grandmother: died of heart attack.
No history of premature cardiovascular disease in first degree relatives.
SHx : Negative for current or previous tobacco use; consumes 2-3 alcohol beverages a week; denies use of marijuana, cocaine, heroin or other illicit drugs in the past thirty years. College graduate and employed full time as civil engineer and comfortable with financial situation. Patient reports being married for 27 years and has two children. He lives at home with his wife and daughter. He enjoys spending time with family and is physically active with chores and daily task like yard work. He does not have a routine exercise regimen.
General– Patient appears healthy and neurological intact. The patient is AAOx4 and moves all extremities. The patient performs ADL independently. The patient presents with no chest pain or symptoms of chest pain at this time. Face is symmetrical, skin is dusky to pale on his face and hair is plentiful throughout head. The patient is not wearing any visual aids such as glasses or hearing aids. The patient is negative for dyspnea at rest, chills, fatigue, and is afebrile.
Pulmonary: No abnormal visual findings. No cough or hemoptysis. Chest is symmetrical, no intercostal breathing visible. Trachea is midline. Inspected bilaterally hands and feet with no visual cyanosis, no clubbing of nails, no abnormal color noted of extremities on inspection. No apparent signs of shortness of breath. Chest rise is equal upon inhale and exhale.
CV: Inspected neck for jugular venous distention. JVP 3 cm above sternal angle. Chest is symmetrical and no abnormalities observed. Patient is afebrile, with no generalized edema. Upper and lower extremities are pink, toenails are not thickened and appear healthy. Upon inspection of lower extremities, the left and right legs appear to have no hair present. Lower extremities are without edema and skin color is pink.
GI: Abdomen is slightly rounded with no abnormal skin deformities upon examination. Inspected front, right and left sides of abdomen and no abnormal findings upon visual examination. Negative for nausea, vomiting, heart burn or gastrointestinal issues.
GU: No abnormalities in urination and continence.

VS: BP (Rt Arm), Sitting 146/90; P (Monitor) 104; R 19; T 37.4; 02. 98%
Wt. 197 lbs.; Ht 5 ft 11 inches

Physical Examination
GENERAL: Patient is not currently having chest pains and is asymptomatic. Patient is neurologically intact, AAOx4, with no apparent physical deficit.
HEENT: Face is symmetrical with no facial droop. No glasses, hearing aids and breaths well through his nose. Speech is clear.
Trachea is midline. No masses palpated. Carotid arteries: Auscultated left and right carotid pulse with bell of stethoscope. Left bruit present, Right Bruit present. Palpated left and right carotid pulse; BL No thrill, +2 left, +3 Right. Inspected neck for jugular venous distention, JVP 3 cm above sternal angle.

HEART: Auscultated pulmonic, aortic, Erbs point and tricuspid area with diaphragm first then used the bell on each area listed. S1, S2 heard at the apex and base of the heart. S3, gallop auscultated with the bell and heard at cardiac apex. No other advinticous sounds upon auscultation.
PMI: Palpated PMI, Displaced laterally; brisk and tapping less than 3 cm
LUNGS: Breath sounds in all areas of lungs posterior and anterior. Anterior RUL, RLL clear. Anterior LLL, LUL all clear. Posterior RUL, LUL clear upon auscultations. Fine crackles posterior LLL and posterior RLL upon auscultation.
ABDOMEN: Negative bruit upon of abdominal aorta upon auscultation. The right and left abdominal arteries are negative for bruits with bilaterally equal pulses upon auscultation. Iliac pulse bilaterally with no bruits found upon auscultation. Bilaterally femoral pulses audible with no bruits heard upon auscultation.
Abdominal bowel sounds audible in all four quadrants upon auscultation. Tympany over the abdomen as percussed.
Abdomen palpation with light and deep pressure in LLQ, RLQ, URQ, ULQ. No abnormal findings. No masses, guarding, tenderness or distention upon palpation.
LIVER: Negative for friction rub as auscultated over liver. Palpable 1 cm below right costal margin. Liver span 7cm in the midclavicular line with dullness present upon percussion.
SPLEEN: Auscultation over spleen and no friction rub found upon exam. Not palpable, no masses or splenomegaly are noted. Percussion remains tympanic as percussed.
KIDNEYS: Left kidney, not palpable, right kidney, not palpable.
SKIN: Warm, dry, non-tenting and normal for ethnicity. .
Brachial pulse palpable bilaterally. Brachial pulse left; No thrill +2, Brachial pulse right: No thrill +2. Radial Pulses: Bilaterally, No thrill +2 left and right upon palpation.
Femoral Pulses: Bilaterally equal with no thrill +2, left and right upon palpation.
Popliteal Pulses: Bilaterally palpable with differences noted: Right, No thrill +2, LEFT No thrill, +1 diminished and barely palpable.
Tibial Pulses: Bilaterally equal palpable with no thrill and +1 diminished on left and right.
Dorsalis pedis pulse: Bilaterally equal upon palpation. No thrill, +1 diminished and barely palpable left and right.
Diagnostic results: EKG, CXR, CK-MB. EKG displays QRS changes. The abnormalities in the heart rhythm suggest some portions of the heart are not getting sufficient blood (Joloudari et al., 2020). CXR shows the shape and size of the heart to determine if heart is enlarged due to a condition (Cagle Jr & Cooperstein, 2018). CK–MB isoenzyme test values shows presence of abnormalities.
Blood test to check cholesterol levels, coronary calcium scan, CT Cornary angiogram or catherization lab to see the level of potential blockage, echocardiogram stress test to determine blood flow (Alizadehsani et al., 2019).
Differential Diagnosis:
1) CAD – CAD symptoms and Mr. Foster symptoms extremely similar. CAD is common and he has hyperlipidemia and hypertension (Alizadehsani et al., 2019). The most common symptom of CAD is chest pain described in Mr. Fosters’ interview. CAD could be a player in Mr. Fosters’ symptoms. Other evidence that leads to CAD is the S3 gallop heard during the exam as well as a rapid heart rate of 104. Angina pain, pulses in his extremities are not all equal and many are faint to barely palpable. He also is missing hair on his legs which leads toward peripheral vascular issues r/t CAD.
2) Angina – Is common and is relieved with nitro or rest. We can perform a stress test to see the actually stress on the heart and try nitro when the pain occurs since we know rest relieves the pain (Hu et al., 2018).
3) CHF – His blood pressure is high systolic and diastolic as well as pulse is high. His heart is working hard and he has fine crackles in the bases of his lungs LLL LRL bilaterally which could indicate fluid buildup r/t CHF (Hu et al., 2018). I feel strongly he is in this category based on the evidence presented in his exam
Need more test like stress test to determine how hard his heart is working while he is physically active. We need a possible echocardiogram to measure his cardiac output or ejection fraction. We need a troponin and CK enzymes drawn even if the last attack was more than 24 hours. These test can decide if he has heart muscle damage, MI or underlying heart issues.
Primary Diagnosis/Presumptive Diagnosis:
Coronary Artery Disease
Treatment plan involves taking medication since it is the first line of treatment of CAD. Nitroglycerin tablets controls the pain and dilating the coronary arteries. The medication reduces the heart’s demand for blood (Chandra et al., 2017). The patient should make lifestyle changes including avoid smoking, drinking alcohol, start exercising, and eat healthy meals. A regular evaluation is essential to determine the level of risk.

Alizadehsani, R., Roshanzamir, M., Abdar, M., Beykikhoshk, A., Khosravi, A., Panahiazar, M., … & Sarrafzadegan, N. (2019). A database for using machine learning and data mining techniques for coronary artery disease diagnosis. Scientific Data, 6(1), 1-13.
Cagle Jr, S. D., & Cooperstein, N. (2018). Coronary Artery Disease: Diagnosis and Management. Primary Care, 45(1), 45.
Chandra, D., Gupta, A., Leader, J. K., Fitzpatrick, M., Kingsley, L. A., Kleerup, E., … & Sciurba, F. C. (2017). Assessment of coronary artery calcium by chest CT compared with EKG-gated cardiac CT in the multicenter AIDS cohort study. PloS One, 12(4), 0176557.
Hu, T., Yang, C., Lin, S., Yu, Q., & Wang, G. (2018). Biodegradable stents for coronary artery disease treatment: Recent advances and future perspectives. Materials Science and Engineering: C, 91, 163-178.
Joloudari, J. H., Hassannataj Joloudari, E., Saadatfar, H., GhasemiGol, M., Razavi, S. M., Mosavi, A., … & Nadai, L. (2020). Coronary artery disease diagnosis; ranking the significant features using a random trees model. International Journal of Environmental Research And Public Health, 17(3), 731.

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