Digital Clinic Experience SOAP note

Health History

Patient is Brian Foster, a 58 years old Caucasian Male whose chief complaint is chest pain near the sternum.  The paint also began 5 minutes before the assessment. The patient states the level of pain as being 6 out of 10. When he lays still slightly this relieves the pain.  When he moves around the pain becomes worse. The patient also complains that he feels pain in his left shoulder, however does not report any form of anxiety or stress. The patient also states pressure which he takes Lisinopril, has high cholesterol which he takes Atorvastatin. Patient does not have a regular exercise routine.

General Survey

Patient is an alert though very uncomfortable middle aged male, he looks pale, supine in hospital bed and appears to be mildly diaphoretic. 

He has an elevated respiratory rate which indicates distress. 

Cardiovascular:  there is no JVD, Heart Rate between 100-115, S1 and S2 + S4. 

There is no Murmur or rub. PVC is occasional.

Blood Pressure: is between 92-109/57-68. There is no thrill or carotid bruit.  

Peripheral Vascular: Capillary refill at <3 secs on toes and bilateral fingers. Radial Pulses 2>, dorsalis pedis pulse 1>

Edema-None, Varicosities-None, Focal Induration-None, Respiratory: able to speak full sentences, quiet and unlabored respirations. Lungs: RR 24-26/m, O2 saturation 97-99%, Neuro: patient is alert and oriented, moves all extremities and follows commands, Skin: diaphoresis and slight pallor, no purulence or redness or induration noted. EKG: Sinus tachycardia with occasional PVSs, ST segment elevation, none. 

Chief Complaint

Chest pain

History of Present Illness

The patient is a 58 years old Caucasian male that came to the clinic with the chief complaint of chest pain. Brian describes the pain as being tight and uncomfortable. According to Brian the pain began a month ago. The pain lasts for a few minutes.  Since the last one month he experienced three episodes. The pain becomes worse when he does various activities like Yard work and climbing stairs at his workplace.  Patient says that the pain gets better as he lays.  During the interview he was not having any pain. 

Medications

There is no reported allergies from the patient. 

The patient reports suffering from high blood pressure in the past, patient denies history of pulmonary embolism, patient denies angina, denies rheumatic fever, denies history of heart murmurs, patient reports taking annual stress tests, denies palpitations. 

 

Health Maintenance

Lives in clean environment. Does not exercise a lot, strives to maintains good weight and diet.  Patient reports that the family has a history of heart attacks, in particular is mother who died of a heart attack at a young age. However family does not have a history of stroke, family does not have history of pulmonary embolism. 

Social History

Patient is social, does not have sleeping issues. Patient’s typical dinner is typical dinner is grilled meat and vegetables, does not have control over salt intake, his typical lunch is turkey sub while his breakfast is granola bar and instant breakfast shake. 

When it comes to drinking, patient reports moderate drinking of 2-3 drinks in a single sitting, does not use tobacco, 

GENERAL:  Fever, chills, sweat, weakness or fatigue.

HEAD: No headache, no history of head injury

EENT:  Eyes:  No visual loss, blurred vision, double vision or yellow sclera. Ears, Nose, Throat:  No hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  No rash or itching, warm and moist