Using the information from the examination of Brian Foster, Chest Pain in Shadow Health, Focused Exam, write a SOAP note and copy it into the Discussion for Module VI.  Your response discussion should be a review of one other student’s SOAP note, commenting on identifying areas that you did not include in your own SOAP note and discussing why inclusion of those areas may be important in reaching an appropriate assessment.Post your initial response and respond to one student. Scholarly written, APA formatted, and referenced.  A minimum of 2 references

Don't use plagiarized sources. Get Your Custom Essay on
Just from $13/Page
Order Essay


Pt. reports: “I have been having some troubling chest pain in my chest now and then for the past month.” Experiencing periodic chest pain with exertion such as yard work, as well as with overeating. Points to midsternal as location. Describes pain as “tight and uncomfortable” upon movement or exertion. Mentioned an episode upon going up the stairs to bed. Most recent episode was three days ago after eating a large restaurant dinner. Denies radiation. Pain lasts for “a few” minutes and goes away when he rests. States “It has never gotten ‘really bad'” so he didn’t think it was an emergency, but is concerned after three episodes in one month and wants his heart checked out. Last physical was 1 year ago but says he hadn’t been checked out for several years prior. His regular diet includes grilled meat, some sandwiches, and vegetables. Reports grilling between 4-5 times a week, usually red meat. Has fast food for lunch on busy days. 1-2 cups of coffee a day. Denies coughing, shortness of breath, indigestion, heartburn, jaw pain, fatigue, dizziness, weakness, nausea, vomiting, and diarrhea. Denies chest pain at time of interview. No history of anxiety or depression.

General Survey: Alert and oriented, with clear speech. Sitting comfortably in no acute distress. • Cardiac: S1, S2, without murmurs or rubs. S3 noted at mitral area. No swelling or fluid retention present. • Peripheral Vascular: No JVD present. JVP 3 cm above sternal angle. Left carotid no bruit. Right side carotid bruit. Right carotid pulse with thrill, 3+. Brachial, radial, femoral pulses without thrill, 2+. Popliteal, tibial, and dorsalis pedis pulses without thrill, 1+. Cap refill less than 3 seconds in all 4 extremities. • Respiratory: Breathing is quiet and unlabored. Breath sounds are clear to auscultation in upper lobes and RML. Fine crackles in posterior bases of L/R lungs. • Gastrointestinal: Round, soft, non-tender with normoactive bowel sounds in all quadrants; no abdominal bruits. No tenderness to light or deep palpation. Tympanic throughout. Liver is 7 cm at the MCL and 1 cm below the right costal margin. Spleen and bilateral kidneys are not palpable. • Neuro: Alert and oriented x 3, follows commands, moves all extremities. Gross cranial nerves 2-12 bilaterally and grossly intact. • Skin: Warm, dry, pink, and intact. No tenting and no sweating. • Musculoskeletal: Moves all extremities. • Psych: Normal affect, cooperative, good eye contact. • EKG (interpretation): Regular sinus rhythm. No ST changes. • Gastrointestinal: Round, soft, non-tender with normoactive bowel sounds in 4 quadrants; no abdominal bruits. No tenderness to light or deep palpation. Tympanic throughout. Liver is 7 cm at the MCL and 1 cm below the right costal margin. Spleen and bilateral kidneys are not palpable. • Neuro: Alert and oriented x 3, follows commands, moves all extremities. • Skin: Warm, dry, pink, and intact. No tenting. • EKG (interpretation): Regular sinus rhythm. No ST changes.


Based on the abnormal findings during cardiovascular and respiratory auscultation, my differentials include coronary artery disease with stable angina; congestive heart failure; carotid disease; aortic aneurysm; pericarditis; or GERD.


Mr. Foster should receive a 12-lead ECG, chest x-ray, and lab workup (cardiac enzymes, electrolytes, CBC, BNP, CMP, Hgb A1C, lipid profile, and liver function tests) to confirm a diagnosis. He should be referred for an echocardiogram, exercise stress test, and carotid dopplers as well as a consult with a vascular surgeon for carotid evaluation. Mr. Foster should be prescribed diltiazem and a diuretic in addition to his daily lisinopril and atorvastatin. If needed, add an ACE inhibitor to manage his hypertension and PRN nitroglycerin for chest pain that does not subside with rest.



Calculate The Price Of Your Paper

{{total || ""}}

Why Choose Us

Top Quality and Well-Researched Papers

We always make sure that writers follow all your instructions precisely. You can choose your academic level: high school, college/university or professional, and we will assign a writer who has a respective degree.

Professional and Experienced Academic Writers

We have a team of professional writers with experience in academic and business writing. Many are native speakers and able to perform any task for which you need help.

Free Unlimited Revisions

If you think we missed something, send your order for a free revision. You have 10 days to submit the order for review after you have received the final document. You can do this yourself after logging into your personal account or by contacting our support.

Prompt Delivery and 100% Money-Back-Guarantee

All papers are always delivered on time. In case we need more time to master your paper, we may contact you regarding the deadline extension. In case you cannot provide us with more time, a 100% refund is guaranteed.

Original & Confidential

We use several writing tools checks to ensure that all documents you receive are free from plagiarism. Our editors carefully review all quotations in the text. We also promise maximum confidentiality in all of our services.

Customer Support 24/7

Our support agents are available 24 hours a day 7 days a week and committed to providing you with the best customer experience. Get in touch whenever you need any assistance.

Our FREE services
Every order comes with these awesome features.
Order Now
Money Back Guarantee
FREE Best essay writer across your subject
FREE Cover page and bibliography
FREE APA/MLA/Chicago formatting
FREE Free Revisions
FREE 24/7 customer support hotline and chat


Essay Writing Services

No matter what kind of academic paper you need and how urgent you need it, you are welcome to choose your academic level and the type of your paper at an affordable price. We take care of all your paper needs and give a 24/7 customer care support system.


Admission and Business Papers

An admission essay is an essay or other written statement by a candidate, often a potential student enrolling in a college, university, or graduate school. You can be rest assurred that through our service we will write the best admission essay for you.


Editing and Proofreading

Our academic writers and editors make the necessary changes to your paper so that it is polished. We also format your document by correctly quoting the sources and creating reference lists in the formats APA, Harvard, MLA, Chicago / Turabian.


Revision Support

If you think your paper could be improved, you can request a review. In this case, your paper will be checked by the writer or assigned to an editor. You can use this option as many times as you see fit. This is free because we want you to be completely satisfied with the service offered.