Focused SOAP Note For a Patient With Chest Pain Case Study Paper
Focused SOAP Note For a Patient With Chest Pain Case Study Paper
| Episodic/Focused SOAP Note Exemplar
Focused SOAP Note for a patient with chest pain S. HPI: The patient is a 65 year old AA male who developed sudden onset of chest pain, which began early this morning. The pain is described as “crushing” and is rated nine out of 10 in terms of intensity. The pain is located in the middle of the chest and is accompanied by shortness of breath. The patient reports feeling nauseous. The patient tried an antacid with minimal relief of his symptoms. Focused SOAP Note For a Patient With Chest Pain Case Study Paper ORDER HERE A PLAGIARISM-FREE PAPERMedications: Lisinopril 10mg, Omeprazole 20mg, Norvasc 5mg PMH: Positive history of GERD and hypertension is controlled FH: Mother died at 78 of breast cancer; Father at 75 of CVA. No history of premature cardiovascular disease in first degree relatives. SH : Negative for tobacco abuse, currently or previously; consumes moderate alcohol; married for 39 years
Allergies: PCN-rash; food-none; environmental- none
Immunizations: UTD on immunizations, covid vaccine #1 1/23/2021 Moderna; Covid vaccine #2 2/23/2021 Moderna ROS O. VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70”
General–Pt appears diaphoretic and anxious Cardiovascular–PMI is in the 5th inter-costal space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is heard best at the second right inter-costal space which radiates to the neck. A third heard sound is heard at the apex. No fourth heart sound or rub are heard. No cyanosis, clubbing, noted, positive for bilateral 2+ LE edema is noted. Gastrointestinal–The abdomen is symmetrical without distention; bowel sounds are normal in quality and intensity in all areas; a bruit is heard in the right para-umbilical area. No masses or splenomegaly are noted. Positive for mid-epigastric tenderness with deep palpation. Pulmonary— Lungs are clear to auscultation and percussion bilaterally
Diagnostic results: EKG, CXR, CK-MB (support with evidenced and guidelines) Focused SOAP Note For a Patient With Chest Pain Case Study Paper
A. Differential Diagnosis: 1) Myocardial Infarction (provide supportive documentation with evidence based guidelines). 2) Angina (provide supportive documentation with evidence based guidelines). 3) Costochondritis (provide supportive documentation with evidence based guidelines).
Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction
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A.
Differential Diagnosis:
1) Myocardial Infarction (provide supportive documentation with evidence based guidelines).
2) Angina (provide supportive documentation with evidence based guidelines).
3) Costochondritis (provide supportive documentation with evidence based guidelines).
Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction
- This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
Subjective Data Focused SOAP Note For a Patient With Chest Pain Case Study Paper
Chief complaint: fever and pain in the ears.
History of presenting illness: Amy is a three years old girl accompanied by her mother to the hospital due to fever and ear pain. The ear pain is of acute onset at the bilateral ears. The pain does not radiate and increases in frequency and intensity upon coughing and blowing the nose. The child reports having pain in the jaws, nasal congestion, yellowish nasal discharge, postnasal drip, fatigue, and a productive cough. She denies difficulties in breathing, ear discharge, and wheezing.
Past medical history: the child has a cold three days ago. She has a history of recurrent rhinitis. She denies hospitalization and blood transfusion. Her immunization schedule is up to date.
Surgical history: the patient denies having a minor and major surgical procedure.
Allergies: she denies food, environmental, and drug allergy,
Family history: she is the firstborn in a family of two. Her younger sister is six months and healthy. Her parents are alive with n record of chronic diseases. Her grandparents are healthy with no record of illness.
Social history: the child is jovial and playful. She follows instructions from her parents and playgroup friends.
Review Of Systems
Cardiovascular: the child denies palpitations, chest pain, syncope, and dyspnea.
Gastrointestinal system: the child denies abdominal pain, nausea, vomiting, diarrhea, and constipation.
Genital urinary system: the child denies hematuria, polyuria, dysuria, and flank pain.
Musculoskeletal system: the child denies joint pain, muscle pain, and muscle spasms.
Skin: she denies skin rash and itchiness,
Neurological: she denies paralysis, muscle weakness, and numbness of extremities.
Objective Data
General: the child is in fair general condition, calm, and oriented. She has no pallor, jaundice, or cyanosis.
Vitals: temperature is at 39.6 degrees Celcius, oxygen circulation at 99% room air, blood pressure at 90/68mmhg, and respiratory rate at 22 breaths per cycle.
HEENT: the child has purulent nasal and pharyngeal secretions, mucosa erythema, periorbital erythema, and facial erythema.
Diagnostic investigation: nasal cytology and nasal sinus biopsy are the recommended tests to rule out acute and recurrent sinusitis. Nasal cytology determines if the patient has nasal polyps, allergic rhinitis, and eosinophilia. Culture and sensitivity of the nasal secretions to rule out bacterial and viral sinusitis. CT scanning of the nose makes an accurate diagnosis of rhinosinusitis.
Assessment Focused SOAP Note For a Patient With Chest Pain Case Study Paper
Differential diagnoses
1. Rhinosinusitis
2. Allergic rhinitis
3. Otitis media
Rhinosinusitis is the inflammation of the nasal cavity and extends to the paranasal sinuses with concurrent rhinitis. The presenting symptoms are coughing, pharyngeal irritation, nasal blockage, post-nasal discharge, facial pain, hyposmia, post-nasal discharge, redness of the nose, dental pain, fever, and ear pressure (Bachert, et al, 2021). These symptoms may persist for up to 10 days and worsen at the onset of an upper respiratory infection. This is the patient’s primary diagnosis because she presents with similar symptoms, she had a cold three days ago and has a history of recurrent rhinitis.
Allergic rhinitis is the inflammation of the nasal membranes proceeding exposure to an allergen. It presents with sneezing, itching eyes, nose, and ears, post nasal drip, anosmia, headache, tearing, earache, fatigue, drowsiness, and eye swelling (Zhang, et al, 2021). The common cause of allergic rhinitis is exposure to cold air and environmental allergens such as fur, dust, and pollen. The patient presents with almost similar symptoms but this is not the actual diagnosis because she denies environmental allergens.
Otitis media is the inflammation of the middle ear due to bacterial or viral infections or trauma. The risk factors are weak immune system, smoking, and cold. The presenting symptoms are earache, fever, fluid draining from the ears, loss of balance, hearing difficulties, and pulling at both ears (De Corso, et al, 2021). This is not the patient’s diagnosis because she has a stable balance and denies ear discharge. Focused SOAP Note For a Patient With Chest Pain Case Study Paper
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References
Bachert, C., Bhattacharyya, N., Desrosiers, M., & Khan, A. H. (2021). Burden of disease in chronic rhinosinusitis with nasal polyps. Journal of asthma and allergy, 14, 127. https://doi.org/10.2147%2FJAA.S290424
De Corso, E., Cantone, E., Galli, J., Seccia, V., Lucidi, D., Di Cesare, T., … & Fetoni, A. R. (2021). Otitis media in children: Which phenotypes are most linked to allergy? A systematic review. Pediatric Allergy and Immunology, 32( 3), 524-534. https://doi.org/10.1111/pai.13431
Zhang, Y., Lan, F., & Zhang, L. (2021). Advances and highlights in allergic rhinitis. Allergy, 76(11), 3383-3389. https://doi.org/10.1111/all.150
Amy, a 3 year old girl is brought to your office by her mother because she has a fever and complains that her ear hurts. She has no significant medical history. The child is not pleased to be in the provider’s office and has been crying. Her mother explains that she developed a “cold†about 3 days ago with sniffles. As she cries she continues to cough and has yellowish nasal discharge.
Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each. Focused SOAP Note For a Patient With Chest Pain Case Study Paper
