SOAP note exercise

Sample Case 1:

CC: Sudden onset substernal chest pain that “woke me up” and lasted until now (about 45 mins) 

HPI: 70 y/o man with h/o hypertension, hyperlipidemia, 40 pack-years smoking history, and brother who died of MI at 60y/o brought in by ambulance to the ED with c/o substernal chest pain.  The pain is described as pressure-like and radiating to the left arm and jaw, accompanied by nausea, diaphoresis, and shortness of breath.  Nitroglycerin was administered sublingually, but only provided temporary relief.  Aspirin was given to the patient to chew in the ambulance.

PE:

VS: BP 150/70, HR 110, Temp 37.1 ͦC, R 30  Pulse oximetry: 96% on room air

Gen: obese, pale, diaphoretic patient

Lungs: clear to Auscultation and Percussion

Heart: RRR, S4 gallop noted

Ext: No cyanosis or edema

Labs:

CBC: Hemoglobin & hematocrit normal, WBC 11,000 (slightly high)

Electrolytes: Normal

Troponins: Troponin T and I are elevated

CK-MB: normal

EKG: sinus tachycardia, elevated ST segments in leads II, III, and AVF

Assessment: Acute Inferior wall MI

Plan:  Start Morphine drip IV, O2 via nasal cannula, Metoprolol, urgent transfer to interventional cardiology lab

The patient has a balloon angioplasty and stent placement and is transferred to the telemetry unit for monitoring.  You see the patient the next day and need to document your visit in a progress note in the SOAP format. [See next page for information you need to write it]

The next day you visit the patient and must write a progress note to include the following:

A very brief synopsis of what occurred the day previously

His current medications:

Aspirin 81 mg orally, once a day

Plavix 75 mg orally, once a day

Lopressor 25 mg orally every 12 hours

His report of his condition today:  much more comfortable.  No pain, no shortness of breath.  Some mild fatigue when walking from room to nursing station

The EKG this morning shows normal sinus rhythm with no ST elevations and no Qwaves

The physical exam which includes: HR 72, BP 130/70, R 24, Temp 37.4   ͦC

General: appears comfortable. 

Extremities: peripheral pulses are slightly diminished and 1+

Heart: Regular rate and rhythm, no gallops or murmurs

Lungs: clear

Groin: femoral pulses intact and 2+ .  No hematoma

You believe he is doing well and that the same plan should be continued for now.  You would like the nurse to check his vital signs every 4 hours for one more day and then every 8 hours. 

If all goes well, patient is without chest pain and VS are stable, he can be discharged to home in 3 days.

SOAP note for this most recent visit:

S: 70 y/o male brought in yesterday for sudden onset substernal chest pain, found to have acute inferior wall MI and taken to cath lab for PCI. Much more comfortable today. No CP or SOB. Does c/o mild fatigue with ambulation from room to nursing station.

Meds – aspirin 81mg PO, once a day.

            Plavix 75mg PO, once a day.

            Lopressor 25mg PO, once every 12hrs.

O: VS – HR 72, BP 130/70, R 24, Temp 37.4

EKG – NSR, no ST elevations, no Q waves.

General: appears comfortable. Obese.

Extremities: peripheral pulses slightly diminished and 1+.

Heart: RRR, no gallops or murmurs.

Lungs: clear

Groin: femoral pulses intact and 2+. No hematoma.

A: 70 y/o male w Hx of HTN, HLD, 40-pack year smoking Hx, and family Hx of sudden cardiac death, admitted after PCI for acute inferior wall MI. Doing well. Has mild fatigue on exertion but is comfortable.

P: Continue monitoring. Continue meds.

Repeat VS every 4 hours x1 day, then every 8 hours the next day.

Plan to discharge in 3 days if still appears well, VS stable, and is without chest pain.

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