Question

this is a discussion that i would like you to respond to , i will post the discussion and sample answer to give you an idea how to formulate your own answer thank you

dicussion soap note

Subjective:

Chief concern: “I have had chest pain for 2 days.”

HPI: 56-year-old Asian male with history of untreated HTN and current every day smoker presents to the clinic today for chest pain that has increased gradually over the last 2 days. Patient describes chest pain as “pressure in the middle” of his chest, radiating to left shoulder and is worst when he is attempting strenuous activity at work. His pain is intermittent, lasting “a few minutes” when he must stop what he is doing because he “gets sweaty and dizzy until the attack goes away.” Patient reports his blood pressure "is OK" but admits he does not check it regularly. No heart palpitations or syncopal episodes.

Differential diagnosis:

1. Acute Myocardial Infarction
2. Acute Pericarditis

Assessment: Stable Angina

Plan:

1. Medication:
   1. propranolol hydrochloride 40 mg 1 tab PO BID
   2. verapamil 80 mg 1 tab PO TID
   3. Nitrostat 0.3 mg 1 tab SL q5min PRN for Angina, max: 3 doses w/in 15 minutes (store in original container)
2. Diagnostics:
   1. ECG
   2. Treadmill Stress Test
   3. Exercise myocardial perfusion testing
   4. CBC w/diff, ABGs, cardiac enzymes test (creatine kinase and cardiac troponin)
3. Patient education:
   1. Smoking cessation and alcohol cessation (unable to recommend Chantix d/t ETOH use).
   2. HTN and angina control with heart healthy diet and medication.
   3. Medications are potentiating, monitor for hypotension (BP journal).
   4. Measures to reduce stress (esp. during angina, rest immediately).
   5. ER if pain increases, persists for 30 minutes, or is unrelieved by rest/medication (unstable angina can be life threatening).
4. Follow-up: ER if symptoms worsen. RTC in 2 weeks, discuss effectiveness of medications. Depending on diagnostic results, alteration may need to be made in medications and treatments or follow up sooner if needed.

sample answer (formulate your own this is just a guide)

Fantastic job, you wrote a very well-organized and thorough SOAP note. Your HPI was fully pertinent to the chief concern, and the only other aspect that may be helpful to add is the severity of the patient's chest pain - how would he rate the pain at its worse and how would be rate it currently? Pain rating can also be included in the vital signs in addition to the HPI, since it is considered the fifth vital sign. I would also want to include timing in the HPI - has he experienced similar chest pain in the past? Otherwise, you did a great job addressing all of the other aspects of OLDCARTS. Your plan did an excellent job of addressing issues that are not only related to his current symptoms, but also his risk factors as well. Great work!

Answer 1

You have written a great SOAP note which is detailed but brief. Your have formulated an excellent HPI, describing the chief complaint in the best way. It would have been better if Pain Score and the present Blood Pressure of the Patient was included. It is more appropriate to include basic investigations with their results in the Assessment Part. You have made a wonderful plan, including the patient education, taking into consideration all the known information and details of the patient. Good Job.