A SOAP note is a form of written documentation many healthcare professions use.Submit a SOAP note as an ARNP.
Part 1.As a Family Nurse Practitioner this client is seeking medical care and complain of chest pain.A SOAP note is a form of written documentation many healthcare professions use to record a patient or client interaction. … However, all SOAP notes must include Subjective, Objective, Assessment, and Plan sections, hence the acronym SOAP.
Submit a SOAP note.APA format Attached are samples.Please use as reference ONLYPlagiarism is never acceptable – give credit when credit is due – cite your sources
The Topic to address: Chest Pain
What questions will you ask for a client complaining of chest pain? Give the rationale for each (articles, books, abstracts, etc.). What are 2 normal findings and 2 abnormal findings that can be identified from one of your questions?Use in-text citations citations and References.
Part2.Respond to classmates Soap notes. below Use APA format.
- Respond to each student’s postings separately with substantive comments. Substantive comments add to the discussion and provide your fellow students with information that will enhance the learning environment.The postings should be at least one paragraph (approximately 100 words) and include references
- References and citations should conform to the APA 6th edition.
- Remember: Please respect the opinions of others, even if their views differ. In other words, disagree professionally and respectfully.
Student1
Brooke
U2D1-Chest pain
Pt presenting with chest pain should have the following questions asked:
- When did the pain start? What were you doing when the pain first occurred?
Rationale: Ischemic pain tends to come on gradually and get worse over time; it generally lasts from two to five minutes after resting if it is related to exertion (Aroesty & Kannam, 2016).
- Describe the pain and where exactly it is located?
Rationale: Pain in the area of the chest can occur for several reasons and be related to GI concerns, musculoskeletal issues, or cardiac concerns. For this reason, all complaints of chest pain should be taken seriously and further investigated. If the patient is able to point with a finger to one area of pain, it is unlikely to be caused by cardiac ischemia (Aroesty & Kannam, 2016).
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- Two normal findings in this category would be localized skin pain from a bruise after mild trauma and reproducible muscle pain from muscle strain after heavy lifting. Although, chest pain of any kind should not be viewed as “normal.”
- Two abnormal findings in this category would be the abrupt tearing pain in the anterior chest wall as well as decreased femoral pulses indicating an aortic dissection, and crushing midsternal chest pain that radiates into the jaw and left arm indicating acute coronary syndrome.
- How long does the pain last? Is it constant or intermittent?
Rationale: Pain that presents with physical activity or exertion but is relieved within minutes of resting is typically angina (Aroesty &Kannam, 2016).
- Is there anything that makes the pain better or worse?
Rationale: Pain that is aggravated by chest wall movement is often due to inflammation of chest wall cartilage or costochondritis (Dains, Baumann, & Scheibel, 2016).
- Do you have any other symptoms related to the pain?
Rationale: Associated symptoms such as shortness of breath, lightheadedness, dizziness, palpitations, or diaphoresis can be an indication of a serious cardiac concern.
SOAP NOTE:
S:
Pt is a 50yr old male who presents today with a complaint of “I have chest pain and it’s been going on for a weeks now.” He describes the pain as a dull, intermittent pain located in the upper left portion of his chest. Pt states the pain comes and goes and is worse with activity. Rates pain 4/10. Denies radiation of pain. Denies SOB, N/V, lightheadedness. Pt states that he tries sitting down and resting when it starts and that seems to provide some relief.
PMH: Significant for MI in 2010 with stents placed x2. Pt also has hyperlipidemia and htn.
Medications: ASA, Lipitor, and Metoprolol
Allergies: NKA
Family Hx: Mother currently alive and healthy. Father died of a heart attack 2 yrs ago.
Social Hx: Pt is going through a divorce after 17 yrs of marriage. States he has a lot of stress in his life right now. Pt works as a taxi driver and says he doesn’t get much exercise because he spend most of the day in his car. Denies alcohol or tobacco use.
O:
Middle aged, uncomfortable appearing male sitting up in bed. A&Ox4, appears well cared for and is a reliable historian.
VS: T-97.8 P-104 R-20 BP 152/98 Pox 98% room air
Ht 69in, Wt 186 lbs
Resp: Lungs clear to auscultation bilaterally on anterior and posterior chest. Respirations even and unlabored.
CV: S1, S2 WNL. Heart rate- slight tachycardia at a rate of 104 with regular rhythm noted. No murmurs or gallops heard.
Extremities: Skin warm, dry, and intact. Palpable pulses noted to all 4 extremities. No edema noted.
A:
- Chest pain-R/O MI vs angina vs stress/anxiety
- HTN
P:
- EKG
- Labs including CMP, CBC, Lipid profile, and cardiac enzymes.
- CXR
- Increase metoprolol
- Educate on stress relieving techniques
References
Aroesty, J., & Kannam, J. (2016). Chest pain: Beyond the basics. Retrieved from
https://www.uptodate.com/contents/chest-pain-beyon…
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical
diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier.
Student2
Chest pain can arise from several different organ systems, including the cardiovascular system, pulmonary system, musculoskeletal system, and gastrointestinal system (Fass & Achem, 2011). Chest pain can also be involved in anxiety or panic disorders (Bickley, 2016). According to Fass and Achem, “noncardiac chest pain is defined as recurrent chest pain that is indistinguishable from ischemic heart pain after a reasonable workup has excluded a cardiac cause” (p. 110). Since cardiac chest pain is often a serious condition, it is important that these conditions be ruled out first, before investigating the other possible causes (Fass & Achem, 2011). A series of appropriate questions can help the provider key in on the source of the patient’s chest pain. Questions to ask regarding chest pain include: location of pain, description of pain, severity, factors that aggravate, factors that relieve, timing, and other noticeable symptoms (Bickley, 2016). From the question regarding relieving factors, there can be some “normal” findings and some “abnormal” findings. While any type of chest pain is not “normal,” chest pain that is relieved by rest may be considered normal, whereas chest pain not relieved by rest can be a sign of a myocardial infarction (Bickley, 2016). Also, chest pain that is triggered by exertion is often more normal than chest pain that arises suddenly in the absence of exertion (Bickley, 2016).
SOAP note:
S- Mr. T is a 40 year old man visiting the clinic today with the chief complaint of chest pain. He states that he has been experiencing chest pain on and off for the last week.. He describes the pain as burning and squeezing, that can become severe at times. The pain can also be felt in his back. He has been under a lot of stress lately and is worries about his heart. He states he has been working until late in the evening and then coming home to eat dinner and go to bed. He has noticed the chest pain to be worse at the end of the day when his body “is supposed to be relaxing.” He states he has to sit up in bed and take deep breathes in order to make the pain subside. He also notices he coughs more when his chest hurts. The patient maintains a healthy body weight and exercises 2-3 times per week. He does not notice any chest pain with exertion. He has no family history of heart disease. He takes no medications and is on a daily multivitamin.
O- Temperature 98.4 F; HR 80 bpm; 18 breaths per minute; BP 122/88. Patient alert and oriented. CV: Regular rate and rhythm; no murmurs noted; pulses 2+; no peripheral edema. Lungs: clear auscultation and percussion bilaterally. Abdomen: active bowel sounds, no tenderness to the touch. Skin: warm to touch, no redness or diaphoresis. EKG normal. Blood tests normal.
A-Non-cardiac chest pain; GERD
P-Refer to a gastroenterologist for diagnosis and treatment of GERD. Educate patient on how to keep a food diary to identify aggravating foods. Encourage patient to eat at least 2-3 hours before going to sleep.
References
Bickley, L. S. (2016). Bates’ Guide to Physical Examination and History Taking, 12th Edition [VitalSource Bookshelf version]. Retrieved from https://bookshelf.vitalsource.com/books/9781496354…
Fass, R., & Achem, S. R. (2011). Noncardiac chest pain: Epidemiology, natural course and pathogenesis. Journal of Neurogastroenterology and Motility, 17(2), 110–123. http://doi.org/10.5056/jnm.2011.17.2.110