Episodic/Focused SOAP Note Week 7
Patient Information:
Initials
Mr. H. Age 57, Sex: Male, Race Caucasian
S.
CC
“Chest pain”
HPI
: 57-year-old Caucasian male who developed sudden onset of chest pain which began 3 days
ago. The pain is described as “sharp” and is rated a 9 out of 10 in terms of intensity.
The pain is
located in the middle of the chest and is accompanied with shortness of breath and coughing up
blood.
He also has right calf pain and swelling with no reports of injury. Also reports long 8hr
plane ride. The patient has not tried anything to relieve the pain.
Location: Middle Chest
Onset: 3 days ago
Character: constant sharp Pain
Associated signs and symptoms: Shortness of breath and coughing
Timing: started a few days ago
Exacerbating/ relieving factors: deep breathing makes pain worse, alleviated by nothing.
Severity: 9/10.
Current Medications
: Reports not taking any medication
Allergies:
NKDA
PMHx
: Reports no past medical history
Soc Hx
: positive for smoking 3 cigarettes per day. Married and retired.
Fam Hx
: Not disclosed by patient
ROS
:
GENERAL--Positive for fatigue and negative for fevers, chills or weight loss
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HEENT-- Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose,
Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN—intact, cool and sweaty
CARDIOVASCULAR—Positive for orthopnea, PND, positive for erythema and edema to R.
lower extremity
GASTROINTESTINAL--Negative for nausea and vomiting; negative for diarrhea or abdominal
pain
PULMONARY--Positive for dyspnea on exertion, positive for cough and hemoptysis
GENITOURINARY: Reports no burning on urination and no enlarged prostate.
NEUROLOGICAL: Reports no headache, dizziness, syncope, paralysis, ataxia, numbness or
tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: Reports No muscle, back pain, joint pain or stiffness.
