Soap Note 3 Dominguez

Christine Dominguez
SOAP Note # 3
ID
11/4/15, Mr. S, Caucasian male, marital status, religion, advanced directives, insurance unknown.
Patient works stocking shelves at a grocery store.
CC
chest pain
HPI
Patient states he has had the development of pain in the mid sternal chest region that has been
intermittent over the past two weeks. He states that the pain would last for a few minutes to a
couple of hours, with an aching quality. Since 9:00 pm last evening, pain is now constant and is
localized to the left chest, rating it 8/10 on a 0-10 pain scale. He states that walking seems to
worsen or bring on the chest pain, and it is relieved when he sits down and rests. Lifting boxes at
his employment as a shelf stocker does not seem to worsen or initiate chest pain. Coughing
makes chest pain worse, and oxygen improves his pain.
PMH
Patient is a smoker of unknown amount or duration. He has a history of hypertension, and states
no documentation of hypercholesteremia or diabetes mellitus. Patient presently is not on any
medications, denies drug allergies. He states he is in an overall good state of health, denies any
history of severe illnesses or hospitalizations.
PERSONAL HISTORY
Patient is single, lives by himself, makes just above minimum wage working full time at a local
grocery store. Patient does not admit to high impact sports, or dangerous activities. He denies
any recent trips or periods of long travel.
HEALTH HABITS
Patient smokes cigarettes, consumes 2 alcoholic beverages per week. Patient does not participate
in a formal exercise program
HEALTH MAINTENANCE
Last physical exam and past diagnostic testing unknown
FAMILY HISTORY
Father suffered MI at age 65, Mother has history of DVT
REVIEW OF SYSTEMS
GENERAL
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Christine Dominguez
SOAP Note # 3
Patient states he has not experienced fever, chills, malaise or night sweats. He has experienced no
diaphoresis with chest pain.
DIET
Patient states no change in appetite, denies use of vitamins or supplements
SKIN, HAIR, NAILS
Patient states he has not noticed any rash, pruritis or changes in skin pigment
HEAD AND NECK
Patient states no headaches, dizziness or lightheadedness
EYES
Patient does not wear corrective lenses, denies blurred vision, diplopia, or visual changes.
EARS
Patient states no loss of hearing, ear pain, vertigo or tinnitus
NOSE
Patient states no nasal congestion, nosebleed, or postnasal drip
THROAT AND MOUTH
Patient denies sore throat, hoarseness, tooth problems or mouth sores
GASTROINTESTINAL
Patient has no complaints of nausea, abdominal pain, or diarrhea. He denies heartburn or any
changes in bowel habits.
LYMPH
Patient states no lymph node tenderness or swelling.
ENDOCRINE
Patient states he has not experienced changes in weight, heat/cold intolerance, increased thirst or
urination. He also states no changes in hair growth or loss, or swelling of hands or feet.
MALE
Patient denies any sexual changes at this time, denies testicular pain, priapism. Patient states he
has no history of using medications for erectile dysfunction.
BREASTS
Patient states he has not had any lumps, swelling or discomfort in breast tissue.
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Christine Dominguez
SOAP Note # 3
CHEST AND LUNGS

Cough, sputum, shortness of breath, dyspnea on exertion, night sweats, and exposure to TB
States he experiences an occasional cough, that is nonproductive, and causes worsening of his
chest pain. Patient states he has experienced mild shortness of breath since yesterday evening. He
has no known exposure to TB, and is not aware of any recent TB screening test.
CARDIOVASCULAR
Patient has had a two week history of generalized, intermittent chest pressure. He has now
developed left sided chest pressure since 9pm yesterday evening, radiating to left shoulder and
into his neck. Patient denies radiation to the back, palpitations or orthopnea. He has not noted
any claudication or edema.
HEMATOLOGY
Patient states he has no unexplained bruising, no history of anemia
GENITOURINARY
Patient denies trouble with urination, frequency, burning or nocturia.
MUSCULOSKELETAL
Patient states he has been experiencing left clavicular and shoulder pain since yesterday evening,
which is neither worsened nor ameliorated with movement.
NEUROLOGIC
Pt states he has not experienced weakness, altered level of consciousness, or loss of coordination.
MENTAL STATUS
Patient denies any problems with sleeping, concentration, eating or changes in mood.
Physical Examination
VS
T: 97.8, BP: 142/86, P: 86, R: 24, Ht: 511, Wt: 168, BMI: 23.4
O2 sat: 98% on room air
GENERAL APPEARANCE
Patient presents as a 38 year old Caucasian male, standing erect, with alignment of extremities.
No evidence of kyphosis or lordosis.
MENTAL STATUS
3
Christine Dominguez
SOAP Note # 3
Patient is awake and alert with a clear and concise speech pattern noted. Oriented to person,
place and time, and is able to provide a detailed recollection of the events surrounding his chief
complaint.
SKIN
Patient notably has even skin tone, integrity intact. No visible edema, lesions or rash noted.
Patient has no crusting, ulcerations or excoriation. Skin is clean and dry, no decrease in skin
turgor. No patchy loss of hair noted, skin smooth. His nails are clean and trimmed, nail base
angle 160 degrees, with no clubbing noted.
HEAD
Scalp clean and dry, with no lesions or deformities noted
NECK
Trachea midline in position, with bilateral symmetry of the sternocleidomastoid and trapezius
muscles. Patient is able to flex, extend, rotate and turn his head in all directions. No jugular
venous distention noted. Thyroid gland rises freely with swallowing, no enlarged neck lymph
nodes appreciated.
EYES
Pupils equal and reactive to light, conjunctivae translucent, without erythema. Sclerae white and
clear. Light reflex and accommodation intact.
EARS
Ears are without lesions or discharge, otoscopic exam notes no bulging or perforation in
tympanic membrane, translucent.
NOSE
Turbinates without discharge or swelling, pink in color. No tenderness or swelling of sinuses.
MOUTH AND THROAT
Lips, teeth and gums, pink without lesions, bleeding or swelling. Tonsils symmetric without
exudate.
CHEST/LUNGS
No deformity to sternum, chest wall or spine, with symmetric expansion upon inspiration.
Respirations are regular and nonlabored. Chest is resonant to percussion, but notably dull over
left lower lobe base. Tactile fremitus present. Inspiratory wheezes and crackles noted in left
lower lobe base, all other lung fields clear to auscultation.
BREASTS
4
Christine Dominguez
SOAP Note # 3
No swelling or masses noted in breast tissue

HEART
PMI noted at the 5th intercostal space, palpable within less than 1 cm. Rhythm is regular rate,
increasing on inspiration, decreasing with expiration, with audible S1, S2. No S3 or S4 noted. No
splitting, rubs or murmurs present on auscultation. No lifts or thrills on palpation.
BLOOD VESSELS
No neck vein distention. 2 + pulses noted to bilateral dorsalis pedis, posterior tibial, popliteal,
carotid. 3 + pulses palpated to bilateral radial. No cyanosis, < 2 second capillary refill noted at
nail beds.
ABDOMEN
Abdomen symmetric, with slightly rounded contour. Bowel sounds active in all four quadrants,
no bruits noted at the aortic or renal arteries. Tympany noted in all four quadrants, no palpation
or percussion of liver or spleen noted. No withdrawal or facial grimaces noted with deep
palpation.
MALE GENITALIA
Not assessed
RECTUM/PROSTATE
Not assessed
MUSCULOSKELETAL
Bilateral symmetry noted. Active and full range of motion noted to bilateral shoulders and arms.
No swelling, redness or tenderness noted in bilateral lower extremities.
NEUROLOGIC
Patient able to participate in active alternating movements, with accuracy noted in both upper
and lower extremities with finger to nose test, heel to shin test. Positive plantar and abdominal
reflexes noted. Positive biceps, brachioradial, triceps, patellar and achilles deep tendon reflexes
noted.
CRANIAL NERVES
I: Not assessed
II: Not assessed
III, IV, VI: No eyelid droop. Eye movement intact through the six cardinal points of gaze
V: Corneal reflex intact, expected findings for facial sensation, Muscle tone over face symmetric
with uniform jaw opening and bite strength.
5
Christine Dominguez
SOAP Note # 3
VII: Patient able to raise eyebrows, close eyelids, puff cheeks, show teeth, blow out air through
pursed lips and smile upon command.
VIII: Rinne, Weber intact
IX, X: Positive gag reflex
XI: Trapezius and sternocleidomastoid muscle strength noted
XII: Tongue symmetrical in movement
Diagnosis:
Bronchitis
DIFFERENTIALS
Angina pectoris
Asthma
Chronic Bronchitis
Pneumonia
Pulmonary embolus
PLAN:
Electocardiogram to observe for ST abnormalities, possible pulmonary embolus
CK, CK-MB, Troponin, CBC with diff, chemistry panel
CXR
Nitroglycerin 0.4mg sl x 1 to assess for relief of pain.
Possible trial of GI cocktail (15cc Mylanta/15 cc viscous lidocaine) x 1 to assess for esophageal
reflux
Albuterol MDI 2 puffs q4 hours prn, shortness of breath, wheezing

Soap Note 3 Dominguez

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What is the patient's chief complaint?

What are the findings on physical examination of the chest?

Christine Dominguez

CHEST AND LUNGS

No swelling or masses noted in breast tissue

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