Samuel Merritt University Soap Note of Chest Pain in A Primary Care Visit Analysis

1. Write a SOAP note of chest pain in a primary care visit.

CC: 56-year-old Asian male c/o of chest pain for 2 days. He has a blood pressure of 160/90. His Total Cholesterol is 220, HDL 45 & LDL is 175mg/dL. He is diabetic with an A1C of 7.9%. He is a former smoker with a 10pk/d smoking history, quit 2 years ago.

His current medications:

Metoprolol Succinate 25 mg one tab po qd

Metoprolol Tartrate 25 mg one tab po twice a day

Lisinopril 10 mg one tab po qd

Metformin 500 mg one tab po BID

Start by calculating his ASCVD Risk using this tool from the American College of Cardiology http://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/.

Your information in the subjective and objective data can be based on a hypothetical case.

2. Document detailed PE findings of Respiratory and Cardiac system in your SOAP note.

3. Write a substantive response to a minimum of two different students. Is objective and subjective data included in the right format? Please be specific to information related to the SOAP note format.

1. Would you agree with your peers differentials listed? Are there any diffs you would add/remove, if so explain your rationale.
2. Does HPI have relevant information related to CC?
3. Medication listed with right timing, dosing, and number of tablets specified? Any red flags with medication list?
4. PMH, FH, and SH has all the appropriate information?
5. Does information in ROS correlate to CC?
6. Is there any information lacking in physical exam documentation of CC (Students often get confused between ROS and objective findings)?
7. Includes assessment, plan, follow up information, and patient education?

See attached sample SOAP Note: Sample_ SOAP_ Note

20 points will be deducted for combining subjective and objective information. Please see example below:

ROS:

Example 1.

General: Alert and oriented, denies fatigue and chills.

( subjective and objective information is combined above. ” Alert and oriented” is part of PE general and not ROS.

Example 2.

ROS:

Resp: denies cough, wheezing, lungs sounds CTA bilaterally.

( subjective and objective is combined above;” lungs sounds CTA bilaterally” is part of PE

PE:

Example 1:

PE: Denies fatigue and chills. Alert and oriented.

” Denies fatigue and chills” is part of ROS and not PE.

Example 2:

PE: Bowel sounds present all quadrants. Denies abdominal pain.

” Denies abdominal pain” is part of ROS and not PE