Soap Note on Chest pain

Name xxx

United State University

Primary Healthcare if Chronic Client/Families Across the Lifespan-Clinical Practinum

xxxxxx

Professor xxxx

Date xxxxx

Subjective

ID: Mr.

Client’s initials: G.H, Age: 65, Gender: Male, Race: Caucasian, Date of Birth: January 01, 1962. Patient presents as a reliable historian.

CC: “I am experiencing chest pains.”

HPI: Mr. G.H, 65 years old, Caucasian man with a health history of high blood pressure, came to the clinic complaining of having chest discomfort for a span of about 2 months. In his description, the chest pain felt like an excruciating burning pain in the center of his chest. Mr. G.H described the rate of his pain as 5/10. Patient noted that the pain occurred slowly over a few minutes before going away. Most frequently while performing physically demanding tasks, such as climbing stairways; nevertheless, it might occur while seated as well as while standing up. On the other hand, Mr. G.H claims he has never felt dizzy or fainted before. The patient denied experiencing any discomfort in his neck or jaw. He attempted treating his chest pain with over-the-counter Advil 200 mg 2 tablet every 6 hours for 3 days, but the medication did not help. He denies using any herbal medications.

Past Health General: He was diagnosed with hypertension in 2017. He is currently on metoprolol 100 mg orally once daily for the treatment of high blood pressure. Patient stated that he is non compliant with his blood pressure medication. He has also had a history of the common flu in the past.

Social History: He has never smoked tobacco or any hard substances in his life. For numerous years he has abstained from the consumption of alcoholic beverages and strong drugs. He is a retired soldier. He is a married man with two grown sons. He is not a regular participant in physical activities. He acknowledged that a large portion of his diet consisted of fast food.

Family History: Father died at the age of 83 due to complications from ischemic heart disease. Mother, who is 84 years old, is in good health except for a vision problem and tinnitus, which are both common side effects of old age. His sister has hypertension and diabetes. He has two adult children who do not have any medical issues. His wife has had UTIs and stomach ulcers in the past.

Surgical History: No surgeries.

Allergies: He has no food or drug allergies.

Review of System

General: Patient has steadily gained weight over the previous ten years. In fact, he denied experiencing weariness, fevers, memory abnormalities, discomfort, or even suicidal thoughts.

Skin: No rashes, blisters, irritation, dryness, or discoloration. There were no wounds or bruises, as well as there was no extreme sweating; also, he does not experience high and low-temperature hypersensitivity. No hair loss and no nail alterations.

Head: Patient claims that he has no headache, dizziness, or a concussion.

Eyes: There are no adverse effects, such as blurred vision or excessive tearing, that need the use of corrective lenses.

Ears: Patient claims to experience no ringing in the ears, no infection, and no other form of ear discharge to be found.

Nose: No rhinitis, sneezing, a runny nose, or epistaxis were experienced.

Mouth: Patient has no bleeding gums, oral ulcer, as well as no cracked lips. A dental exam has not taken place in four months.

Throat: There was no painful throat or swelling in the throat.

Neck: Goiter, lymphoma, and other malignancies of the neck, as well as any other enlarged glands, are not present.

Neuro: No syncope or tremors are present in this patient. There are no aberrant movements in this patient’s extremities either.

Cardiac: In the two months prior, the patient had been experiencing pressure, and burning chest pain. In the midst of his chest, the agony felt like a scorching and tingling. He gave it a score of five out of ten, describing his discomfort.

Musculoskeletal: No muscle or joint discomfort or stiffness.

Gastrointestinal: He did not have any alterations in appetite, severe thirst or food desire, no swallowing problems, no heartburn, no stomach pains, and no changes in bowel patterns.

Genitourinary: No urgency or increased urination; no hesitancy or decreased stream; no incontinence; as well as no blood in urine, no renal pain, or cramping in the genitals were reported.

Objective

Vital Signs

Temperature: 37.5°F, His height: 5’5” ft, His weight: 199 lbs., BMI: 33.11, Blood Pressure: 154/88, RR: 19, SpO2: 98%

Physical Examination

Constitutional: He has a decent physique; however, he is a touch overweight.

HEENT: Head: Normocephalic, as well as no palpable masses. Eye: Extensive extraocular movements, large visual ranges to confrontation, and clean conjunctivae are present in both eyes. Icterus does not exist, pupil size and shape are equal, light sensitivity and correction are present, and the eyes have a chance of developing cataracts. Ears: His hearing accuracy is quite poor on both sides of the ears. The tympanic membrane’s markers were plainly visible on the slide. Nose: No abnormal discharge, obstruction, or deviation of the septum can be found in the nose. Mouth: A complete set of dentures, upper and lower. The pharynx has no exudates since nothing has been injected into it. The uvula, which is located in the center of the body, moves upward. Gag reflexes are quite natural.

Neck: No lumps. No thyroids, and the pressure in the jugular veins is 8 cm. No masses.

Lymph nodes: There are no enlarged lymph nodes.

Chest: It appears that the breasts have no lumps or discharges. Lung sound is reduced, but there is no reduction in percussion. The diaphragm’s breathing is effortless. No rhonchi, rubs, or wheezes.