SOAP Note TemplateSubjective – The history” sectionHPI inc.docx
1. SOAP Note Template
Subjective – The “history” section
HPI: include symptom dimensions, chronological narrative of
patient’s complains, information obtained from other sources
(always identify source if not the patient).
Pertinent past medical history.
Pertinent review of systems, for example, “Patient has not had
any stiffness or loss of motion of other joints.”
Current medications (list with daily dosages).
Objective – The physical exam and laboratory data section
Vital signs including oxygen saturation when indicated.
Focuses physical exam.
All pertinent labs, x-rays, etc. completed at the visit.
Assessment/Problem List – Your assessment of the patient’s
problems
Assessment: A one sentence description of the patient and major
problem
Problem list: A numerical list of problems identified
All listed problems need to be supported by findings in
subjective and objective areas above. Try to take the assessment
of the major problem to the highest level of diagnosis that you
can, for example, “low back sprain caused by radiculitis
3. You are going to observe and participate in a clinical encounter
of a patient who comes to the office
with a complaint of chest pain.
As you observe the encounter, you will be asked to answer quest
ions while the image on the screen
freezes. Such questions will allow you to practice history taking
and physical examination skills as well as
your clinical reasoning skills in developing an assessment or dif
ferential diagnosis and a plan—that is, an
appropriate next diagnostic workup.
You will have time to record your findings and receive feedback
.
Health History
Tell me your special concerns today.
I’m a little worried because I have been having sharp pains in m
y chest for the last two weeks.
What findings might be important to look for as you observe thi
s patient?
Level of distress.
Labored breathing.
Skin color: central and peripheral cyanosis.
5. Did it move into your neck or down your left arm?
No, no it was just in my chest.
How have you been since then?
I’ve had two other episodes, one of them was about 10 days ago
when I was lifting some books, the
other was about 5 days ago when I was talking with my sister ab
out our father’s death. He died 3
months ago in a car crash.
Did you have any other symptoms when you had these chest pai
ns?
Yes, I had the same sweating and shortness of breath, with some
light‐headedness during the most
recent one.
What was the level of pain?
The same, about 5 out of 10 for about 5 minutes. Then the pain j
ust went away while I was sitting there.
I keep feeling so lost and panicked since my father died.
How are you feeling today?
Today I’m feeling fine, but I haven’t been sleeping well. It’s str
ange, I never felt anxious or depressed
before.
6. What cardiovascular risk factors do you need to consider in this
patient? And which one has the highest
risk for coronary artery disease?
The risk factors are:
Family history of coronary artery disease.
Hyperlipidemia, hypertension, smoking, diabetes.
For women, preeclampsia and collagen vascular disease.
Family history conveys highest risk.
Do you have any problems with acid reflux? Or have you done a
ny heavy lifting or strenuous exercise?
No, I’ve never had any stomach problems and I don’t really exer
cise much.
Do you have a history of high blood pressure? I noticed today y
our blood pressure was 140 over 95.
Yes, well I did have high blood pressure during my three pregna
ncies, I think it was about 145 over 90,
but the deliveries were fine.
What about smoking?
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8. then we can talk more.
Physical Examination
I see your blood pressure is 150 over 95 and your heart rate is 9
5 today. These are both somewhat
elevated. I would like to begin by examining your lips and nails
for color and then listen to your lungs.
Okay.
Examine lips and nails for cyanosis.
Okay, looks good.
Percuss then auscultate posterior lungs in ladder pattern.
Take a deep breath.
Listen to the lungs making sure to listen to the right middle lobe
under axilla.
One more time.
[BREATHING IN AND OUT]
I’ll be examining the vessels in your neck, and then your heart.
So please lie back with your feet straight
out.
Examine the neck first.
Assess the jugular venous pressure.
10. You may notice “tapping” which is timed at the beginning of sy
stole. The point of maximal impulse may
be sustained or diffuse, meaning spread over more than one inte
rcostal space.
Listen for S1 and S2 in each of the six listening areas: in the aor
tic area in the right second interspace
close to the sternum; in the pulmonic area in the left second inte
rspace close to the sternum; in the left
third interspace; in the tricuspid area in the left fourth and left f
ifth interspaces; and in the mitral area at
the apex.
Use the diaphragm at the right upper sternal border and the lowe
r left sternal border.
Use the bell at the apex.
Listen to and palpate the abdomen.
The following findings may be heard in the cardiac auscultation
of this patient. Can you identify these
heart sounds?
[HEARTBEAT]
S4 is a low pitched diastolic sound reflecting changes in ventric
ular compliance, best heard with the bell
with the patient in a left lateral decubitus position. It may be pr
12. S3 is a low‐pitched diastolic sound reflecting changed ventricul
ar compliance, best heard with the bell
with the patient in a left lateral decubitus position.
Palpate the ankles for edema.
Diagnostic Considerations
List your diagnostic considerations in order of importance and e
xplain your rationale.
Press pause and list your answers. Resume when you are ready t
o receive feedback.
Angina. This woman has stress‐induced non‐exertional chest pai
n. Recent evidence shows that women
present with more subtle symptoms of cardiovascular disease. S
he has cardiac risk factors of
hypertension, past smoking, preeclampsia, and family history.
Panic attack. She had stress related symptoms and flashbacks to
the recent death of her father in a car
accident. She has suggestive anxiety, chest pain, and diaphoresi
s.
GERD. Her alcohol intake has recently increased. She has some
reflux symptoms but her symptoms are
not triggered by meals and she does not report heartburn.
Musculoskeletal chest wall pain. There is no history of chest pai
13. n triggered by movement of the upper
torso or related exercise, and no notation of chest wall tenderne
ss.
Dissecting aortic aneurysm. There is no asymmetry of blood pre
ssures noted and no history of pain
shooting into the neck, up the side of the head, or into the back.
Diagnostic Workup
List 5 next steps in your diagnostic workup.
Press pause and list your answers. Resume when you are ready t
o receive feedback.
EKG. About 80% of patients with an acute MI have an initial E
KG that shows evidence of new infraction
or ischemia, if read correctly. However, among patients mistake
nly discharged from the emergency
department, up to 50% have normal or non‐diagnostic EKG find
ings.
Stress echo. This is the test of choice for women with atypical c
hest pain. The echocardiography stress
test has a sensitivity of 90% and specificity of 79% for women,
and 85% and 96% for men.
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15. There is no history of diabetes. Her physical examination is unr
emarkable except for her blood pressure
of 150 over 95.
The differential diagnosis includes angina, especially suspect du
e to her symptoms, history of
hypertension during pregnancy, and family history. It also inclu
des panic attack, GERD, musculoskeletal
chest pain, and dissecting aortic aneurysm.
The diagnostic workup includes an EKG, stress echo, trial of a
PPI, chest x‐ray, and behavioral therapy.
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