Mr 2 soaps

SOAP Note NU :

Herzing University

Name: Typhon Encounter #:

Comprehensive: Focused:

S: SUBJECTIVE DATA CC: I experience chest pressure on walking or by physical activity.

HPI: Onset: Several weeks ago, the patient started having symptoms.

Location: Central chest area.

Duration: Happens occasionally when exercising.

Characteristics: is characterized by pressure or tightness.

related Factors: Episodes of mild shortness of breath.

Relievers: Factors Factors are relieved by a Rest.

Treatment: No known past medications before visit.

History: 74-year-old man with pressure in the chest on exertion alleviated by rest.

PMH: Hyperlipidemia and hypertension.

ALLERGIES NKDA.

MEDICATIONS Nitroglycerin PRN sublingual in case of discomfort in the chest.

SH Former smoker (quit 10 years ago). Occasional alcohol use. Retired mechanic.

FH Father was 70 years of age and died due to coronary artery disease. Mother with

hypertension.

HEALTH

PROMOTION &

MAINTENANCE

Patient denies excessive activity but has been limited in the recent past because of

the symptoms. Diet moderate in fat.

ROS

(put N/A in sections

not completed day of

exam)

Constitutional Denies fever.

Head N/A.

Eyes N/A.

Ears, Nose, Mouth, Throat N/A.

Neck N/A.

Cardiovascular/Peripheral

Vascular

Denies dyspnea.

Respiratory Mild dyspnea on episodes.

Breast

Gastrointestinal Negative of nausea/vomiting.

SOAP Note NU :

Herzing University

Name: Typhon Encounter #:

Comprehensive: Focused:

Genitourinary N/A.

Musculoskeletal N/A.

Integumentary N/A.

Neurological No syncope and dizziness.

Psychiatric (screening tools: Ex:

PHQ-9, MMSE, GAD-7)

N/A.

Endocrine N/A.

Hematologic/Lymphatic N/A.

Allergic/Immunologic N/A.

Other N/A.

O: OBJECTIVE DATA VITALS: HR: 82 RR:18 BP: 140/84 Temp: 98.2°F

SpO2%: 97% Ht: 5’9’ Wt: 185 lb BMI: 27.3

Age: 74 LMP: PAIN: 3/10

during exertion

PHYSICAL

EXAM

(Pertinent data

related to

presenting

problem or

visit type. Put

N/A in sections

not completed

day of exam)

General Appearance Security, obedient.

Head Normocephalic.

Eyes PERRLA.

ENT, Mouth N/A

Neck No JVD.

Cardiovascular/Peripheral Vascular Normally timed heartbeat, no murmur.

Respiratory lungs clear bilaterally.

Breast N/A

Gastrointestinal Soft abdomen

Genitourinary Male

• External Exam N/A

• Internal Exam N/A

Genitourinary Female

• External Exam N/A

• Internal Exam N/A

Musculoskeletal Range of motion normal.

Integumentary N/A

Neurological Aware and oriented.

Psychiatric Appropriate mood.

Endocrine N/A

Hematologic/Lymphatic N/A

SOAP Note NU :

Herzing University

Name: Typhon Encounter #:

Comprehensive: Focused:

Allergic/Immunologic N/A

Other N/A

A: ASSESSMENT AND DIAGNOSIS DIAGNOSIS ICD-10 CODES

PRIORITIZE DIAGNOSIS

1. Angina pectoris ICD-10: I20.9

2.

3.

VISIT CODES CPT BILLING CODES CPT-9: 99214

CPT-10: 99204

DIAGNOSTICS POC TESTING ECG, cardiac stress test ordered.

TESTS REVIEWED

P: PLAN ACTIONS 1.

Diagnosis: Stable Angina

Diagnostics Order:

Cardiac stress test and electrocardiogram.

Therapeutic:

Nifedipine 0.4 mg SL tablet-at-onset of-chest-pain, #25 pills, 1 renewal.

Education:

Patient instructed to take a rest in between periods and take medicine as

advised. Directed to get emergency treatment in case of continuing chest

pain despite taking medication. Change in lifestyle was talked about such as

diet and exercise.

Consultation/Collaboration:

Further examination in cardiology.

SOAP Note NU :

Herzing University

Name: Typhon Encounter #:

Comprehensive: Focused:

2. Diagnosis:

Diagnostics Order:

Therapeutic:

Education:

Consultation/Collaboration:

3. Diagnosis:

Diagnostics Order:

Therapeutic:

Education:

Consultation/Collaboration:

PREVENTITIVE

(Used for

comprehensive exams)

FOLLOW UP In 1-2 weeks, cardiology appointment. Emergency treatment in case of

aggravation of symptoms.