Comprehensive SOAP: Brian Foster
Documentation Notes
Name
Walden University
NURS 6512, Advanced Health Assessment and Diagnostic Reasoning
2022
Brian Foster
Episodic Visit
Chief Complaint: Patient complains of chest pain that recurs for the last one month
History of Present Illness: Patient complains of chest pain experienced during physical activity
on three occasions in the last month which he originally thought to be heartburn. Specifically chest
pain was felt doing yard on two occasions and once climbing stairs to his office at work. Pain is felt
in the “middle of chest, over the heart”, does not radiate, and has duration of a couple of minutes.
Pain is described as tight, uncomfortable, and anxiety inducing, with the most severe pain felt as a 5
out of 10. Patient has not used any medications for relief.
PAST MEDICAL HISTORY
General: Unremarkable
Childhood Diseases: None
Adult Illnesses/Diagnoses:
2017 Hypertension (Stage II)
2017 Hyperlipidemia
Accident/Injuries: Denies any accidents or injuries
Hospitalizations: Denies any hospitalizations.
Immunizations: Up to date (Influenza)
Screenings:
2000 Colonoscopy
2017 Annual eye exam
Nutrition: Cautious about fat and sodium intake
Coping/Mental Health: Reports low stress in daily life; engages in fishing for relaxation
Surgeries: No surgical history.
Transfusions: No past transfusions.
FAMILY HISTORY
Paternal grandmother died at 78 years of pneumonia.
Maternal grandfather died at 54 years of a heart attack.
Father died at 75 years of colon cancer. Diagnosed with hypertension, hyperlidemia, and obesity.
SOCIAL HISTORY
