Rw 2 soaps

SOAP Note _______

NU___:_________

Herzing University

Name:_________________________

Typhon Encounter #: _____________________

Comprehensive:____Focused:____

S: SUBJECTIVE DATA

CC:

“I experience chest pain on walking which disappears when I rest.

HPI:

77 years of age white male with a history of CAD with complaints of a chest discomfort during exertion. O: Gradual onset over weeks. L: Substernal. D: Exertional in nature, lasts 5-10 minutes. C: Pressure-like discomfort. A: Occupying because of walking uphill. R: Relieved by rest. T: No nitroglycerin in the house. S: Stable angina symptoms.

PMH:

Coronary artery disease.

ALLERGIES

NKDA

MEDICATIONS

Aspirin 81mg daily (per history).

SH

Former smoker. Lives with spouse.

FH

Father deceased from MI at 70.

HEALTH PROMOTION & MAINTENANCE

Cardiac diet advised, frequent cardiology follow-up prescribed.

ROS

(put N/A in sections not completed day of exam)

Constitutional

N/A

Head

N/A

Eyes

N/A

Ears, Nose, Mouth, Throat

N/A

Neck

N/A

Cardiovascular/Peripheral Vascular

Affirmative of exertional chest pain.

Respiratory

Denies SOB at rest.

Breast

N/A

Gastrointestinal

N/A

Genitourinary

N/A

Musculoskeletal

N/A

Integumentary

N/A

Neurological

N/A

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: 138/84

Temp: 98.6 o C

SpO2%: 97

Ht:

Wt:

BMI: 27

Age: 77

LMP:

PAIN:5/10

PHYSICAL EXAM

General Appearance

No distress during rest, alert.

Head

N/A

Eyes

N/A

ENT, Mouth

N/A

Neck

N/A

Cardiovascular/Peripheral Vascular

Normally fast/regular, no murmurs.

Respiratory

Clear bilaterally.

Breast

N/A

Gastrointestinal

N/A

Genitourinary Male

· External Exam

N/A

· Internal Exam

N/A

Genitourinary Female

· External Exam

N/A

· Internal Exam

N/A

Musculoskeletal

N/A

Integumentary

N/A

Neurological

N/A

Psychiatric

N/A

Endocrine

N/A

Hematologic/Lymphatic

N/A

Allergic/Immunologic

N/A

Other

N/A

A: ASSESSMENT AND DIAGNOSIS

DIAGNOSIS

ICD-10 CODES

PRIORITIZE DIAGNOSIS

1. Angina pectoris

ICD-10: I20.9 (ICD-9: 413.9)

2.

3.

VISIT CODES

CPT BILLING CODES

99214 (established);

CPT 99204 (new).

DIAGNOSTICS

POC TESTING

TESTS REVIEWED

P: PLAN

ACTIONS

1.

Diagnosis: Stable Angina

Diagnostics Order: EKG now; referral to stress test.

Therapeutic: Nitroglycerin 0.4 mg SL tablet, 1 tablet at a time every 5 minutes PRN chest pain up to 3 doses, #25, 1 refill.

Education: Take nitroglycerin when the pain occurs; call 911 when pain does not lessen after 3 doses. Examined heart warning signs.

Consultation/Collaboration: Cardiology referral.

2.

Diagnosis:

Diagnostics Order:

Therapeutic:

Education:

Consultation/Collaboration:

3.

Diagnosis:

Diagnostics Order:

Therapeutic:

Education:

Consultation/Collaboration:

PREVENTITIVE

FOLLOW UP

1 month or earlier in case of increasing symptoms.