Post Week 7.docx - Episodic\/Focused SOAP Note Week 7 Patient Information Initials Mr H Age 57 Sex Male Race Caucasian S CC \u201cChest pain\u201d HPI

Post Week 7.docx - Episodic/Focused SOAP Note Week 7...

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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 © 2014 Laureate Education, Inc. Page 1 of 5
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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.
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  • Summer '15
  • pleuritic chest pain

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