SOAP Note

Subjective

Chief complaint:

Patient presents with chest pain with an onset of 2 months ago

History of present illness:

Fred Maclntyre is a 62 yo male presenting with chest pain (mediastinum area) for the past two months.
The pain is in the mediastunim area. Pain began two months ago and happens about 3-4x/wk upon
exertion. Pt says pain occurs upon exertion and is alleviated by rest. Pt. noted he first felt the pain when
he was raking leaves. Pt. claims that pain feels more like a pressure rather than an injury. Pain is only
present upon exertion and is alleviated by rest and tried turns once with not relief. Pt says if he does not
rest immediately when the pain begins then he feels a squeezing sensation in his throat but rest
alleviates that also. Pt says pain is 5-6/10 when it happens

PMH

PT has a history of high blood pressure

Rx

HCTZ 25mg/day

NKDA

Fx

Both parents are deceased. Father was 68 and had multiple heart attacks. Mother was 71 with no health
issues; died because of stroke. Brother 59 has diabetes, sister 72 had a heart attack last year and had 3
stents put in.

Sx

Drinks a few drinks of alcohol 1-2x/wk with friends. Has smoked since he was 14, currently smokes a
pack a day. He works as a geologist and is stressed at work because there have been layoffs. He lives
with his wife and has two grown children

ROS

AOx3

Skin: normal

HEENT: normal

Cardiovascular: high bp

Respiratory: had SOB once with the chest pain

GU: normal
MSK: normal

Allergies: nkda

Heme: normal

Neuro: normal

Psych: stress due to layoffs at work

Objective

Pt is male 62 yo 6’1” 195lbs HR 72 wek, bp 140/94 RR 16

PE

Heart has ejection click

Labs

HbA1c normal

CBC normal

BMP low hdl 30 very high ldl 185

ECG shows cardiac hypertophy

Assesment

Patient has cardiac hypertphy

DD

Diabetes

Anemia

Hypertrophic Cardiomyopathy

Stable angina

GERD

Plan

Add Beta blockers or ace inhibitors

Have pt exercise 30 mins 3-5x/wk

Low sodium diet

Have patient go on a plan to quit smoking