Page 1

Soap Note #4                                                                                                                Monday, March 8, 2010  3/2/10   1500   K.C. is an 18 year‐old white female  Referral:  None  Source and Reliability: Self‐referred; seems reliable   

S‐Subjective:   Chief Complaint:  “Fast heart rate at times for past 3 weeks with chest pain level of 4‐5/10. The pain is  right over my heart Sometimes I have shortness of breath.”    Present Illness:  Episodic increase HR with SOB, CP, and dizziness noted at times with the increased HR.  Mom reports that she also seems  more tired. Denies any current or recent stressors. She in enjoying  school and is active in choir.  Denies consumption of caffeine or coffee.  States that she “gave up  chocolate for Lent”.  Does not note any aggravating or alleviating factors for her symptoms. “ The  symptoms just come and I have to just relax for 2‐3 minutes and my heart slows down.” Reports only  one night of difficulty sleeping since this began.  Has noted one episode of tingling in her left  arm with  symptoms. C/O dizziness only with positional changes and denies syncope. Denies belching or heart  burn. Has struggled with recurrent URI, strep pharyngitis, and conjunctivitis in the past six months.  Tested negative for mononucleosis in 12/09.   9/29/09 Strep pharyngitis ‐ Amoxicillin/Medrol dose pack                                                                                   10/1/09 Strep pharyngitis ‐ continue abx therapy                                                                                                12/3/09 Pharyngitis, early tonsillitis ‐ Treated with Keflex                                                                                     12/14/09 Questionable MONO, Pharyngitis, Conjunctivitis, URI – Polytrim for conjunctivitis   Past History:  Childhood Illnesses: Tympanic membrane dysfunction                                                                              Allergies: None                                                                                                                                                          Adult Illnesses.   Medical:  No asthma or recurrent bronchitis.  Surgical: Myringotomy with tubes placed  in 2006. Psychiatric:  None.   Hospitalizations:  See surgical history.                                                          Health Maintenance:  Immunizations up to date; Encouraged to schedule complete physical; Encouraged  consistent exercise regimen.  Medications:   Zyrtec  Family History:  Sister has allergies  Social History:  Senior in high school.  Denies ETOH, tobacco or drug use.   Exercise:  Aerobics three times a week; Cheerleader at school  Safety measures: Did not assess     


Review of Systems  General: Pleasant and cooperative. Skin: Denies any rashes or skin changes. Head, Ears, Eyes, Nose, Throat (HEENT): Head: No history of head injury. Ears: Hearing appropriate to whispered voice; Denies vertigo, tinnitus. Eyes: Denies diplopia or blurred vision. Did not assess for last eye exam. Nose: Denies allergies or sinus problems. Throat: Did not assess for last dental exam. Neck: Denies thyroid or lymph node enlargement. Thorax and Lungs: Denies cough. SOB only when HR is increased. No hemoptysis. Cardiovascular: Denies orthopnea. Chest pain only when HR is increased. Denies family history of cardiovascular disease or arrhythmias. Gastrointestinal: Appetite good. Denies NV/D. No jaundice, gallbladder or liver problems. No recent changes in bowel habits. Genitourinary: Denies frequency, dysuria, hematuria or flank pain. Genital: Denies discharge, itching or burning. Did not discuss sexual history. Peripheral Vascular: Denies any calf tenderness or varicosities. Denies any numbness or tingling in lower extremities. Musculoskeletal: Denies any current swelling or deformity. Neurologic/Psychiatric: No history of depression or psychiatric conditions. Hematologic: Denies easy bleeding. No history of anemia Endocrine: Denies history of thyroid disease and diabetes. Sweating appropriate. Allergic/Immunologic: None


O-Objective: Physical Assessment: K.C. is a well nourished adolescent in no apparent distress. Smiling and interactive in conversation. Vital Signs: Wt: 138; HR 98; T 98.1; BP 102/54; 100% on RA; BMI 23 Skin: Pink, warm and dry. Nails without clubbing or cyanosis. No rashes or suspicious nevi. No petechiae, or ecchymosis. Head, Eyes, Ears, Nose, Throat (HEENT): Head: Skull is normocephalic, without injury. Hair with average texture. Scalp without lesions. Ears: Hearing appropriate to whispered voice; no vertigo, tinnitus. Tympanic membrane intact with cone of light noted. Eyes: Sclera white with conjunctiva pink and moist; PERRLA at 2mm; Did not assess optic disc. Nose: Nasal mucosa pink and moist, no obstruction; septum midline, no sinus tenderness. Throat: Oral mucosa pink and moist. Tongue midline. Pharynx without exudate. Good dentition. Neck: Trachea midline. No tenderness or masses. No thyromegaly or lymphadenopathy. Thorax and Lungs: Thorax symmetric with good expansion. Lungs resonant. No fremitus. Breath sounds vesicular. No adventitious sounds. No hemoptysis. Did not measure diaphragm excursion. Cardiovascular: No JVD. No thrills or bruits. Heart sounds S1, S2 with no murmurs, rubs or gallops. Irregular rhythm noted on auscultation at PMI and radial pulse palpation for one minute. Carotid, radial, and pedal pulses palpable 2+. Capillary refill <3 seconds throughout. Gastrointestinal: BS normoactive times 4 quadrants. No tenderness or masses. No palpable liver, kidney or spleen. Genitourinary: No frequency, dysuria, or flank pain. No costovertebral angle tenderness. Genital: Not assessed. LMP 2/25/2010 Musculoskeletal: Steady gait. Active ROM. No swelling or deformities. Peripheral vascular: No varicosities or peripheral edema. Neurologic/Psychiatric: Alert and oriented to person, place and time. Cooperative and pleasant. Interacts in visit. Cranial nerves II-X11 intact. No gross focal, motor or sensory deficits. Endocrine: None Hematologic/Lymphatic/Immunologic: No anemia. No lymphadenopathy. No joint deformity or swelling. Lab work obtained: CMP, CDP, TSH, Free T4

Procedures: EKG


A-Assessment/Diagnoses 1. Health Maintenance: a. Complete physical (V70.0) b. Exercise (V65.41) 2. Self-limiting problems: a. Palpitations (785.1) DD: Wolfe-Parkinson-White Syndrome (426.7); Anxiety (300.00); Hyperthyroidism (242.9) b. Atypical CP (786.50) DD: Chest wall injury (959.11); Esophagitis (530.1); Anxiety (300.00) c. Dyspnea (786.00) DD: Anxiety (300.00); Hyperthyroidism (242.9); Chest wall injury (959.11) 3. Chronic Health Problems: None

P-Plan 1. Health Maintenance: 1a – Schedule complete physical prior to college in the fall. 1b – Encouraged to continue exercise as tolerated but to stop if increased HR noted. 2. Self-limiting problems: 2a-2c: 1. EKG 2. Cardiology referral for Halter Monitor 3. CBC, CMP, TSH, Free T4 4. Keep a journal of HR along with symptoms (aggravating or alleviating factors, locations, duration, character, radiating, timing) 5. Taught how to assess pulse 6. Instructed to seek medical attention if HR increase is sustained.s 3. Chronic Health Problems: None

Christy Holshouser RN, FNP student Sources: McPhee, Stephen J. and Papadakis, Maxine A (2010). Current medical diagnosis and treatment. New York, NY: McGraw Hill. Ferri, F. (2010). Ferri’s Clinical Advisor 5 Books in 1. Philadelphia, PA: Mosby/Elsevier Epocrates Essentials Deluxe        


SOAP palpitations  

physical exam and SOAP

Advertisement
Read more
Read more
Similar to
Popular now
Just for you