Cardiac SOAP Note – nursing notebooks

Identifying Information:

Patient: J.D. 40 y/o BF.

DOB: 01/13/1973

Visit: 3/12/2013, 0900

Medical HX: Pt. was diagnosed with HTN, hyperlipidemia, and type II DM 10 years ago, all three are well controlled with medication, diet and exercise. Pt. was diagnosed with systemic lupus erythematosus two years ago and is currently not experiencing complications related to her disorder. She was taken off steroids six months ago and takes NSAIDS as needed. No other childhood or adult diseases, and immunizations UTD. She received the flu vaccination 12/2012. No psychiatric history.

Surgical HX: Pt. reports uncomplicated TVH (total vaginal hysterectomy) in 2011 due to symptomatic uterine fibroid tumors. Pt. denies any negative effects from this procedure.

OBGYN: G-1 T-1 P-0 A-0 L-1, TVH 2011

Medications: Lisinopril/HCTZ 20-12.5 mg PO daily

Metformin 500 mg PO twice daily

Lipitor 20 mg PO daily

Ibuprofen 600 mg every 6 hours as needed

Tylenol 1,000 mg every 6 hours as needed

Allergies: None.

Personal/social HX: Pt. works as a nurse at a local hospital 40-50 hrs/week. She has been divorced one year and lives at home with her 11-year-old daughter who is in good health. She is an active member in her church and has a good support system. She and her daughter joined a gym near their home about three months ago. She enjoys doing yoga and eating healthy. She is compliant with her recommended and prescribed diet, exercise and medication regimen.

Drugs, Alcohol, or Smoking HX: No illegal drug use, no alcohol or tobacco use.

Family HX: Father HTN, doing well, Mother hypothyroidism, doing well, Siblings unremarkable

Source of information: Patient, seems reliable.

Subjective

CC: I have a sharp pain, that feels like a knife is stabbing me on the left side of my chest.

HPI: A 40-year-old black female presents with complaints of sharp, knifelike pain on the left side of her chest for the last two days. She rates her pain a 7 on the 0-10 pain scale, and she describes her pain as constant. Breathing and lying down make the pain worse, while sitting forward helps her pain. She denies any upper respiratory or GI symptoms, and also denies injury to the painful site. Tylenol and Ibuprofen have been unsuccessful in relieving her pain.

Review of systems:

General: Reports being as healthy as she can be. Denies fever, chills, recent weight gain or loss, weakness, or fatigue. States her last physical exam was in 2012, and first mammogram was in January of this year with normal results.

Skin, hair, & nails: Denies any changes in skin, hair and nails.

HEENT: head denies injury or headaches, eyes denies vision problems, last eye exam one year, ears hearing good, no ear problems, nose denies abnormal nasal conditions,

throat denies any throat problems, last dental exam 1 year.

Thorax/lungs: Reports sharp, knifelike pain to the left side of chest, see HPI. Denies injury, lung disease, allergies, or asthma. Last chest x-ray 2012

Cardiovascular: Reports sharp, knifelike pain to the left side of chest, see HPI. Denies irregular heartbeat, palpitations, or murmurs. Reports HTN and hyperlipidemia. Last EKG 2012. No prior stress test. PVS: Denies extremity edema, coldness, leg cramps, or ulcers.

Abdomen: Diabetic diet, denies N/V, bowel problems or pain. Denies history of jaundice, gallbladder, or liver disease.

GU: Denies urinary frequency, hesitancy, incontinence, nocturia, flank pain, burning, or bleeding with urination.

Metabolic/Hematologic: Reports type II DM, denies thyroid problems, heat/cold intolerance, bruising, ease of bleeding. No history of blood transfusions.

Musculoskeletal: Denies trauma or injury.

Psychiatric: Denies trouble concentrating, nervousness, anxiety, panic attacks, mood changes, hearing voices, frequent unhappiness, or desire to harm self/others. Sleep trouble related to nighttime coughing, no nightmares, memory loss, or excessive life stresses. No recent deaths in family or close friends.

Neurologic: Denies history of stroke, seizures, frequent/incapacitating headache, and tremors.

Objective:

Vital Signs: B/P-130/70, P-90, R-12, T-98.9, O2-99% Ht: 55, Wt: 150 lbs., BMI: 25

General: Black female, well kept, AAOX3, good eye contact and speech. Appears to be in distress, leaning over holding her left arm and hand to her chest.

Hair: WNL, thick and evenly distributed with no breakage, alopecia, dryness, or infestations

noted. Hair appears shiny and red in color. Eyebrows and eyelashes present and evenly distributed.

Skin: Warm, dry, supple, no bruises, rashes, or suspicious nevi to exposed skin.

Nails: Smooth and well manicured without clubbing or cyanosis. Capillary refill to finger pad is brisk.

Head/Neck: Normocephalic/atraumatic, no bumps, bruises, lesions. Scalp pink and moist. No sinus tenderness, and no palpable lymph node enlargement or tenderness. Neck supple; thyroid isthmus palpable, lobes not felt. Trachea midline.

Eyes: Pupils 4mm constricting to 2mm, PERRLA, EOMI, negative strabismus and nystagmus, conjunctiva pink and moist.

Ears: Acuity good, no tenderness or abnormalities to tragus & pinna, ear canal without inflammation or cerumen noted bilaterally. TM pearly white and intact with no redness or bulging. Cone of light visible bilaterally (5 oclock right, 7 oclock left).

Nose: Turbinates intact, nares patent, no septal deviation, nasal flaring or discharge.

Throat/mouth: Membranes pink and moist. Uvula is midline, tonsils at pillars, no redness or exudates. Good dentition noted.

Lungs: Respirations 12 breaths/min, breath sounds vesicular, no rhonchi, wheezes, or crackles present. Lungs resonant. Thorax is symmetric, and the diaphragms descend 4 cm bilaterally.

Heart: Scratching noise heard at lower left sternal border, coincident with systole. Apical pulse 90 bpm on auscultation. S1 and S2 regular rate and rhythm with no splitting, S1 best at apex, S2 best at base, with no S3 or S4. Carotid upstrokes brisk with no bruits. No JVD. PMI palpable at 5th ICS 7cm lateral to the midsternal line, discrete and tapping. No heaves, lifts, or thrills. No rubs, gallops, murmurs, or opening snaps. Pain not elicited with chest wall palpation.

Breasts: Symmetric and smooth without masses. Nipples without discharge.

Abdomen: Normoactive BS x 4 quadrants. No abdominal bruits. Soft, flat, and non-distended with no scars or striae. No abdominal tenderness to palpation. No palpable masses or hepatosplenomegaly. Kidneys not felt, no CVA tenderness.

Lymph Nodes: Head, neck, axilla, epitrochlear, and inguinal lymph nodes nonpalpable.

Extremities: Extremities are warm without edema. No varicosities or stasis. Calves are supple and non-tender. No femoral bruits. Brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial pulse are all 2+ and symmetric. Full range of motion to all extremities.

Genitals: Deferred

Rectum/Anus: Deferred

Neurologic: AAOX3, and cooperative. Anxious d/t acute distress. Cranial nerves II-XII intact. Normal gait. Maintains balance with eyes closed. Good, even strength and muscle tone. Reflexes are 2+ and symmetric with plantar reflexes. Rapid alternating movements intact. Pinprick, light touch, position, and vibration intact.

Assessment:

Plan:

References

Bickley, L. S. (2009). Bates Guide to Physical Examination and History Taking (10th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2011). Primary Care: The Art and Science of Advanced Practice Nursing (3rd ed.). Philadelphia, PA: F.A. Davis.

McCance, K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. (2010). Pathophysiology The Biological Basis for Disease in Adults and Children (6th ed.). Maryland Heights, MO: Mosby Elsevier.

Spangler, S. J. (2012). Acute Pericarditis. Retrieved March 10, 2013, from http://emedicine.medscape.com/ article/156951

Link:

Cardiac SOAP Note - nursing notebooks