Task: Focused SOAP Note for a patient with chest pain.
Task: Focused SOAP Note for a patient with chest pain.
S. CC: “Chest pain” HPI: The patient is a 65 year old AA male who developed sudden onset of chest pain, which began early this morning. The pain is described as “crushing” and is rated nine out of 10 in terms of intensity. The pain is located in the middle of the chest and is accompanied by shortness of breath. The patient reports feeling nauseous. The patient tried an antacid with minimal relief of his symptoms. PMH: Positive history of GERD and hypertension is controlled FH: Mother died at 78 of breast cancer; Father at 75 of CVA. No history of premature cardiovascular disease in first degree relatives. SH : Negative for tobacco abuse, currently or previously; consumes moderate alcohol; married for 39 years ROS General–Negative for fevers, chills, fatigue Cardiovascular–Negative for orthopnea, PND, positive for intermittent lower extremity edema Gastrointestinal–Positive for nausea without vomiting; negative for diarrhea, abdominal pain Pulmonary–Positive for intermittent dyspnea on exertion, negative for cough or hemoptysis. Task Focused SOAP Note for a patient with chest pain
VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70”
General–Pt appears diaphoretic and anxious
Cardiovascular–PMI is in the 5th inter-costal space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is heard best at thesecond right inter-costal 2w7space which radiates to the neck.
A third heard sound is heard at the apex. No fourth heart sound or rub are heard. No cyanosis, clubbing, noted, positive for bilateral 2+ LE edema is noted. Task Focused SOAP Note for a patient with chest pain
Gastrointestinal–The abdomen is symmetrical without distention; bowel
sounds are normal in quality and intensity in all areas; a
bruit is heard in the right para-umbilical area. No masses or
splenomegaly are noted. Positive for mid-epigastric tenderness with deep palpation.
Pulmonary— Lungs are clear to auscultation and percussion bilaterally
Diagnostic results: EKG, CXR, CK-MB (support with evidenced and guidelines)
A.
Differential Diagnosis:
1) Myocardial Infarction (provide supportive documentation with evidence based guidelines).
2) Angina (provide supportive documentation with evidence based guidelines).
3) Costochondritis (provide supportive documentation with evidence based guidelines).
Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction
P. This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
Task Focused SOAP Note for a patient with chest pain
Week 7: Assessment of the Heart, Lungs, and Peripheral Vascular System
Cardiovascular disease (CVD) is the largest cause of death worldwide. Accounting for 610,000 deaths annually (CDC, 2017), CVD frequently goes unnoticed until it is too late. Early detection and prevention measures can save the lives of many patients who have CVD. Conducting an assessment of the heart, lungs, and peripheral vascular system is one of the first steps that can be taken to detect CVD and many more conditions that may occur in the thorax or chest area. Task Focused SOAP Note for a patient with chest pain
This week, you will evaluate abnormal findings in the area of the chest and lungs. In addition, you will appraise health assessment techniques and diagnoses for the heart, lungs, and peripheral vascular system. Task Focused SOAP Note for a patient with chest pain
Learning Objectives for Task Focused SOAP Note for a patient with chest pain
Students will:
- Evaluate abnormal cardiac and respiratory findings
- Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the heart, lungs, and peripheral vascular system
Learning Resources for Task Focused SOAP Note for a patient with chest pain
Required Readings (click to expand/reduce)
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
- Chapter 14, “Chest and Lungs”This chapter explains the physical exam process for the chest and lungs. The authors also include descriptions of common abnormalities in the chest and lungs. Task Focused SOAP Note for a patient with chest pain
- Chapter 15, “Heart”The authors of this chapter explain the structure and function of the heart. The text also describes the steps used to conduct an exam of the heart.
- Chapter 16, “Blood Vessels”This chapter describes how to properly conduct a physical examination of the blood vessels. The chapter also supplies descriptions of common heart disorders.
Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.
- Chapter 107, “X-Ray Interpretation: Chest (pp. 480–487) (previously read in Week 6; specifically focus on pp. 480–481)
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.
Note: Download the Student Checklists and Key Points to use during your practice cardiac and respiratory examination.
This study examines the medical decision making among Hispanics and non-Hispanic whites. The authors also analyze the preferred information sources used for making decisions in these populations.
This article describes the warning signs of impending deterioration of the respiratory system. The authors also explain the features of common respiratory conditions.
The authors of this article specify how to identify the major causes of acute breathlessness. Additionally, they explain how to interpret a variety of findings from respiratory investigations. Task Focused SOAP Note for a patient with chest pain
Shadow Health Support and Orientation Resources
Use the following resources to guide you through your Shadow Health orientation as well as other support resources:
Document: Shadow Health. (2014). Useful tips and tricks (Version 2) (PDF)
Document: Student Acknowledgement Form (Word document)
Document: DCE (Shadow Health) Documentation Template for Focused Exam: Chest Pain (Word document)
Use this template to complete your Assignment 1 for this week.
Optional Resource for Task Focused SOAP Note for a patient with chest pain
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.
- Chapter 8, “The Chest: Chest Wall, Pulmonary, and Cardiovascular Systems; The Breasts” (Section 1, “Chest Wall, Pulmonary, and Cardiovascular Systems,” pp. 302–433)
Note:Section 2 of this chapter will be addressed in Week 10.
This section of Chapter 8 describes the anatomy of the chest wall, pulmonary, and cardiovascular systems. Section 1 also explains how to properly conduct examinations of these areas. Task Focused SOAP Note for a patient with chest pain
Required Media (click to expand/reduce)
Advanced Health Assessment and Diagnostic Reasoning
Thoughtful, reasoned questioning leads from initial complaint to diagnosis in these three scenarios.
Note: Close the viewing window after the intro segment and after each diagnosis segment to view the menu. (12m) Task Focused SOAP Note for a patient with chest pain
Photo Credit:Provided courtesy of the Laureate International Network of Universities.
Online media for Seidel’s Guide to Physical Examination
In addition to this week’s media, it is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapters 13 and 14 that relate to the assessment of the chest, heart, and lungs. Refer to Week 4 for access instructions on https://evolve.elsevier.com/
Assignment 1: Digital Clinical Experience: Assessing the Heart, Lungs, and Peripheral Vascular System
Photo Credit: [Squaredpixels]/[E+]/Getty Images
Take a moment to observe your breathing. Notice the sensation of your chest expanding as air flows into your lungs. Feel your chest contract as you exhale. How might this experience be different for someone with chronic lung disease or someone experiencing an asthma attack?
In order to adequately assess the chest region of a patient, nurses need to be aware of a patient’s history, potential abnormal findings, and what physical exams and diagnostic tests should be conducted to determine the causes and severity of abnormalities. Task Focused SOAP Note for a patient with chest pain
In this DCE Assignment, you will conduct a focused exam related to chest pain using the simulation too, Shadow Health. Consider how a patient’s initial symptoms can result in very different diagnoses when further assessment is conducted. Task Focused SOAP Note for a patient with chest pain
To Prepare for Task Focused SOAP Note for a patient with chest pain
- Review this week’s Learning Resources and the Advanced Health Assessment and Diagnostic Reasoningmedia program and consider the insights they provide related to heart, lungs, and peripheral vascular system. Task Focused SOAP Note for a patient with chest pain
- Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation with the Shadow Health platform. Review the examples also provided. Task Focused SOAP Note for a patient with chest pain
- Review the DCE (Shadow Health) Documentation Template for Focused Exam: Chest Pain found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
- Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.
- Review the Week 7 DCE Focused Exam: Chest Pain Rubric provided in the Assignment submission area for details on completing the Assignment in Shadow Health.
- Consider what history would be necessary to collect from the patient.
- Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
DCE Focused Exam: Chest Pain Assignment: Task Focused SOAP Note for a patient with chest pain
Complete the following in Shadow Health:
- Cardiovascular Concept Lab (Recommended but not required)
- Abdominal Concept Lab (Recommended but not required)
- Episodic/Focused Note for Focused Exam: Chest Pain
Note: Each Shadow Health Assessment may be attempted and reopened as many times as necessary prior to the due date to achieve a total of 80% or better (this includes your DCE and your Documentation Notes), but you must take all attempts by the Week 7 Day 7 deadline. Task Focused SOAP Note for a patient with chest pain
Submission and Grading Information
By Day 7 of Week 7
- Complete your Focused Exam: Chest Pain DCE Assignment in Shadow Health via the Shadow Health link in Blackboard.
- Once you complete your Assignment in Shadow Health, you will need to download your lab pass and upload it to the corresponding Assignment in Blackboard for your faculty review.
- (Note:Please save your lab pass as “LastName_FirstName_AssignmentName”.) You can find instructions for downloading your lab pass here: https://link.shadowhealth.com/download-lab-pass
- Once you submit your Documentation Notes to Shadow Health, make sure to copy and paste the same Documentation Notes into your Assignment submission link below.
- Download, sign, date, and submityour Student Acknowledgement Form found in the Learning Resources for this week. Task Focused SOAP Note for a patient with chest pain
Grading Criteria
To access your rubric:
Week 7 Assignment 1 DCE Rubric
Submit Your Assignment by Day 7 of Week 7
To submit your Lab Pass:
Week 7 Lab Pass
To participate in this Assignment:
Week 7 Documentation Notes for Assignment 1
To Submit your Student Acknowledgement Form:
Submit your Week 7 Assignment 1 DCE Student Acknowledgement Form