SOAP Note TemplateSubjective – The history” sectionHPI inc.docx

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

involving left 5th LS nerve root.”
Provide at least 2 differential diagnoses for the major new
problem identified in your note.
Plan – Your plan for the patient based on the problems you’ve
identified
Develop a diagnostic and treatment plan for each differential
diagnosis.
Your diagnostic plan may include tests, procedures, other
laboratory studies, consultations, etc.
Your treatment plan should include: patient education,
pharmacotherapy if any, other therapeutic procedures. You must
also address plans for follow-up (next scheduled visit, etc.).
Also see your Bates Guide to Physical Examination for
excellent examples of complete H & P and SOAP note formats.
Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserv
ed. Page 1
BATES’ VISUAL GUIDE TO PHYSICAL EXAMINATION
OSCE 1: Chest Pain
This video format is designed to help you prepare for objective
structured clinical examinations, or
OSCEs.

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.

Respiratory rate.
Two weeks ago I was reading a story in the paper about a car cr
ash, when I noticed sharp pains in my
left chest. I was sweating and short of breath for about 5 minute
s. And my heart felt like it was racing.
What possible causes of chest pain are you considering?
Angina.
GERD.
Panic attack.
Musculoskeletal chest wall pain.
Can you tell me how severe the pain was, on a scale from 1 to 1
0, with 1 being very faint and 10 being
severe?
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I was 5 over 10.

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.

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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When I was in my 20s I smoked about a pack a day for about 4
years.
Do you drink any alcohol?
I have 1…or 2 glasses of wine maybe 3 nights a week, more rec
ently to help me relax.
Is there any heart disease in your family?
Yes, my brother had bypass surgery when he was 48, and my mo
m died of a heart attack when she was
62.
What about high cholesterol, or is there any diabetes in the fami
ly?
No, I’ve never had trouble with my cholesterol and we don’t ha
ve diabetes in my family.
You’ve given me a good picture of your symptoms, and I can se
e why you’re concerned. Is there
anything you think we may have missed?
No, but I can’t get away from these flashbacks about my father’
s accident.
It’s common to visualize scenes like a crash with a loved one. L
et’s do your physical examination, and

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.

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Find the highest point of oscillation in the internal jugular vein
…
…and measure the vertical distance from the sternal angle.
Palpate carotid upstroke.
The normal upstroke is brisk, smooth, and rapid, and follows S1
almost immediately.
Large bounding upstrokes indicate aortic insufficiency.
Listen for a bruit, which is a whooshing, murmur‐like sound oft
en from atherosclerotic narrowing of the
carotid artery. A bruit sounds like this:
[BRUIT, WHOOSHING MURMUR]
Okay, I’m going to check the tapping impulse point of your hear
t.
Palpate the point of maximal impulse. You can do this and liste
n to the heart sounds by listening under
the gown without exposing the chest.

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

esent during ischemia or in the setting of
hypertension.
Identify these heart sounds.
[HEARTBEAT]
Mitral regurgitation is a holosystolic murmur reflecting mitral v
alve dilatation, best heard at the apex
that may radiate to the axilla and lower left sternal border. It ma
y occur with transient ischemia.
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Assess congestive heart failure (CHF) in patients with extensive
myocardial infarction that compromises
cardiac output due to decreased stroke volume or heart rate. Wh
ich findings on the cardiac exam have
the best evidence for congestive heart failure?
Rales, an elevated JVP, and an S3 consistently predict heart fail
ure.
[HEARTBEAT]

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

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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Consider a trial of a proton pump inhibitor for 4‐6 weeks for po
ssible GERD.
Chest x‐ray may be helpful to look for widened mediastinum, w
hich can be evidence of aortic dissection.
Behavioral therapy—
to learn management strategies for anxiety and panic disorder.
Summary
In sum, this is a 50‐year old school counselor with three episode
s of left substernal chest pain over the
prior two weeks, rated 5 to 10 in intensity, with associated swea
ting and shortness of breath.
The first episode was precipitated by reading about a car crash,
the cause of her father’s recent death.
The patient had hypertension during pregnancy and a brief smok
ing history in her 20s.
There is a strong family history of coronary artery disease. Her
mother died of a myocardial infarction at
age 62 and her brother had a coronary bypass at age 48.

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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SOAP Note TemplateSubjective – The history” sectionHPI inc.docx

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