Comprehensive SOAP Template
Name
Academic Institution
Comprehensive SOAP
Patient Initials: ___J.S____ Age: ___73____ Gender: ___M____
SUBJECTIVE DATA:
Chief Complaint (CC): Chest pain and difficulty in breathing.
History of Present Illness (HPI): J.S is a 73-year-old male who presents to the clinic with different symptoms including chest pain and difficulty in breathing. He indicates the symptoms have been persisting for the last one week. He is concerned that the condition may be due to the malfunction of the heart. He complains of mild difficulty in breathing. He states he did not take his medication for the last week. He denies any lifestyle changes. He has a family history of hypertension, myocardial infarction, and stroke. His mother died 20 years ago after succumbing to a stroke. The patient indicates the severity of the pain is 3 on normal days and 6-8 during some days.
Medications: Hydrocodone 5/325mg every 6 hours and as needed.
Allergies: NKDA
Past Medical History (PMH): He has suffered from diabetes since he was 50 years but the condition is well controlled. He has no history of child illness or hospitalization. He is not sexually active since his wife died 10 years ago.
Past Surgical History (PSH): He has been treated for a broken arm at age 43. He was admitted to Dr. Bakker, Grand Haven, MI. He has not experienced a heart condition in the past.
Sexual/Reproductive History: The patient is heterosexual but not sexually active.
Personal/Social History: He denies smoking or taking drugs including ETOH. He engages in regular exercise at a local sports club.
Immunization History: All immunizations are up to date. Recently, he received a flu vaccine. He received the two vaccines at Dr. Bakker, Grand Haven, MI.
Significant Family History: The two parents passed on 20 years ago. His father was suffering from hypertension while his mother died of cardiac arrest. His father was also diabetic. He has two healthy siblings. He lives in the same neighborhood with his sons who are aged 40 and 45. The two sons are healthy with no significant medical condition.
Lifestyle: The patient is a retired mechanic who is living off his pension. He attends a church service every Sunday at a local Pentecostal church. He hangs out with his friends at a local restaurant.
Review of Systems:
General: The patient is alert, cooperative, and in good health condition. He has a sharp memory and answers all questions correctly by narrating past events. He has unintentional weight changes, fever, or cold.
HEENT: The patient has no hearing problems, vision impairment. He wears eyeglasses. His last eye and ear examination were carried out 3 months ago. His hears have no discharge, infection, or abnormalities. His smell is unblemished. He has no running nose or nasal congestion. His oral mucosa is clean and intact. His last dental examination was 6 months ago. He has no dental problems. He swallows food with no difficulties.
Neck: Diffuse involvement of his scalp and preauricular cheek.
Breasts: He has no lesions or rashes.
Respiratory: No breathing problems. He has a symmetrical diaphragmatic excursion. No respiratory problems or a family history of asthma.
Cardiovascular/Peripheral Vascular: He reports mild discomfort in the chest, palpitations, dyspnea, orthopnea, edema as well as claudication.
Gastrointestinal: The patient reports no nausea, abdominal pain, or reflux. He has normal bladder patterns.
Genitourinary: He reports normal urine patterns and no history of incontinence.
Musculoskeletal: No history of gout or arthralgia.
Psychiatric: The patient has no history of depression or sleep disorders. He denies any suicidal thoughts.
Neurological: He has no history of seizures, dizziness, syncopal episodes. or poor coordination.
Skin: He has no rashes, bruises, or wounds. He has no itching or bleeding skin.
Hematologic: He has no history of blood disorder.
Endocrine: No endocrine problems.
Allergic/Immunologic: NKDA.
OBJECTIVE DATA
Physical Exam:
Vital signs: 134/76 18 97.3 97% O2 SAT HT 5’6 217 WT.
General: A&O *3 NAD, dressed decently, conscious about the environment, but appears slightly uncomfortable.
HEENT: Plaque involvement diffusely on the central face. Diffuse involvement of his scalp.
Neck: Carotids no bruit.
Chest/Lungs: CTA AP&L.
Heart/Peripheral Vascular: RRR without murmur, rub, gallop, pulses +2.
Abdomen: No organomegaly, diffuse, or rebound.
Genital/Rectal: Deferred.
Musculoskeletal: Symmetric muscle development, all muscle groups’ strength 5/5.
Neurological: CN I-IV grossly intact and DTR intact.
Skin: No bleeding, discoloration, discharge, or raised erythematous plaques.
ASSESSMENT:
Lab Tests and Results: SAO2 – 97%.
EKG: Irregular heart rate and rhythm.
Differential Diagnosis (DDX):
Myocardial infarction – The condition occurs when the blood flow decreases or stops causing damage to the heart muscles due to the formation of clots. It leads to chest pain and discomfort. The pain occurs on the shoulder, arm, neck, or jaw (Akbar et al., 2017). Myocardial infarction can occur in various types that can pose different risks to the health of a patient. It is one of the likely conditions due to the similarity of the symptoms.
Hypertension – It is a condition that involves high blood pressure. It occurs if the pressure is above 140/90 a patient is at greater risk (Anderson & Morrow, 2017). The symptoms involve chest pain and difficulty in breathing. Patients require medication to slow down the pressure. The patient is less likely to have hypertension since the blood pressure is 134/76. However, they continue taking medication since the risk of hypertension could still be high.
Heart failure – The condition is also known as congestive heart failure. It occurs when the muscles in the heart do not pump as they should (Reed et al., 2017). One of the major causes is narrowed arteries. The patient should continue taking regular assessments to ensure they are out of risk of heart failure.
Diagnosis:
Myocardial infarction is the most likely condition that the patient is suffering from.
Treatment Plan:
The patient should take Beta blockers 50mg twice a day (Kawamura et al., 2018). The patient should embrace more time to rest. He should come back for an assessment after three days.
Health Promotion:
The patient should take more rest and eat healthy meals. He should also avoid food with high amounts of salt or cholesterol. It is also advisable for the patient to reduce weight since patients can experience worse symptoms if they are overweight (Berliner et al., 2016). The patient also engages in regular exercises that will improve their body fitness. It is also appropriate to avoid alcohol and smoking since they can increase the risk of infection.
Disease Prevention:
The patient should avoid stressful situations or strenuous exercises that can trigger a rise in blood pressure. He should continue taking the medication as prescribed to avoid relapse. He should avoid stressful conditions that can cause the heart to overwork (Reed et al., 2017). The patient should get immediate medical help if they experience any abnormal symptoms.
REFLECTION:
The clinical experience provides a learning opportunity for carrying out a comprehensive examination of a patient with multiple conditions. The experience helped me to think of the relationships between various health conditions and their effect on the most likely condition. An analysis of the patient’s family and medical background was also informative. For example, identifying a link between family history and the present condition was interesting and informative. Additionally, it was interesting to examine other parts of the body their functionality including ears, nose, neck, and eyes. All the information was critical while carrying out the differential diagnosis and narrowing down on the specific conditions the patient could be suffering from.
In the future, I would like to study various health conditions of patients, especially among geriatric patients and their impact on general health. It is also important to study the risks that ambulating a patient’s experience that can lead to serious health conditions. I also desire to provide quality information to patients to help them make the appropriate decisions for their health. For example, lifestyle changes can lead to an increase in quality health among geriatric patients.
I uphold the findings of the preceptor since the information provided is similar to the symptoms the patient is suffering from. The symptoms indicate the likelihood of myocardial infarction. Evidence also suggests that the patient should make lifestyle changes to improve their health condition. For example, there is a need to improve on daily exercises while being careful about the food. The precautions will improve the health of the patient. Additionally, the patient should come back for further examination after three days. If the symptoms are worse, the patient can be admitted to receive close attention from the healthcare practitioners.
References
Akbar, N., Digby, J. E., Cahill, T. J., Tavare, A. N., Corbin, A. L., Saluja, S., … & McNeill, E. (2017). Endothelium-derived extracellular vesicles promote splenic monocyte mobilization in myocardial infarction. JCI Insight, 2(17).
Anderson, J. L., & Morrow, D. A. (2017). Acute myocardial infarction. New England Journal of Medicine, 376(21), 2053-2064.
Berliner, D., Schneider, N., Welte, T., & Bauersachs, J. (2016). The differential diagnosis of dyspnea. Deutsches Ärzteblatt International, 113(49), 834.
Kawamura, R., Saiki, H., Tada, H., & Hata, A. (2018). Acute myocardial infarction in a 25-year-old woman with sitosterolemia. Journal of Clinical Lipidology, 12(1), 246-249.
Reed, G. W., Rossi, J. E., & Cannon, C. P. (2017). Acute myocardial infarction. The Lancet, 389(10065), 197-210.
