My first SOAP note

SOAP notes are summaries that doctors write up after seeing each patient. S stands for Subjective (what the patient tells you), O stands for Objective (what you observe-funny, huh?- and any lab and physical exam results), A is for Assessment and P is for Plan.

Though I've begun going to clinic where I get to see real patients, those interactions are (obviously) confidental. But in my doctoring class, we see "fake" patients, actors who are assigned roles and diseases and who we get to interview and attempt to diagnose. Since this is a "problem-based learning course", we never get to find out if we're right...

Here's my first SOAP note. Don't worry, I'm not going to post any more of these. (Explanations for all the abbreviations are at the bottom)

Subjective: Ms. B. is a 45 year-old, Caucasian, married female complaining of recurring retrosternal, left-sided chest pain, lightheadedness, dyspnea, and paresthesias around fingers and mouth. She reports the pain as being an 8 on a 1-10 scale, claims that it sometimes radiates towards her shoulders, and says that the pain will occasionally wake her up at night. She denies any correlation with eating or timing of day. The most recent episode was a week ago, and she visited the ED where she was evaluated for an MI; blood tests and ECG were negative. Pt’s father died of a MI at 39 and Pt is afraid that she may be having a heart attack. Mother is A&W at 80 yoa, brother is HTN. Pt is a 1 pack per day smoker for 30 years, does not exercise and claims to have a lot of stress at work. Coffee intake is about 3 cups a day, diet consists primarily of fast food, take-out and microwave meals, and alcohol consumption is negligible. Other than the dyspnea, patient does not claim any pulmonary or GERD Sx. No SOB in absence of pain episodes. Pt is aware of unhealthy lifestyle, apprehensive and fearful of serious disease, but hesitant to make any significant changes to lifestyle. Pt is strongly opposed to smoking cessation and claims that it is the only thing that helps her calm down.

Objective: Pt appears anxious and inclined to jump to most negative conclusion about her health. On several occasions, patient becomes excessively apprehensive and alarmed during the evaluation of her symptoms. Lab results: ECG normal. No elevation of cardiac enzymes (CK-MB, troponin T, troponin I). Cholesterol 225, Triglycerides 211. Chest x-ray is negative: lungs clear and heart and aorta are in normal size and shape. BP: 134/84. T: 98.7. P:82. R:18. Stress test on Bruce showed frequent PVCs/bigeminy at HR 120, that stopped at 131. Test stopped at HR 163 (98% MPHR) due to fatigue. No Sxs with exertion. ∅ ETT. No Meds reported.

Assessment: Negative ECG and negative cardiac enzymes indicate no recent hx of MI. X-ray negative for aortal disease. Heartburn as primary cause of CC is unlikely due to uncorrelated timing of attack. Pulmonary, neuromuscular and GI causes unlikely due to absence of supporting symptoms. Panic disorder possible, though not necessarily sole cause of pain events. However, Pt’s current cardiovascular health, including frequent PVCs and bigeminy in correlation with long-term cigarette smoking, high-fat diet, high cholesterol and triglycerides, stressful lifestyle, lack of regular exercise, and a family history of heart disease, also add clinical relevance to patient’s symptoms. . Pt is a serious candidate for heart disease; these concerns were raised during this meeting. Pt is opposed to significant changes of lifestyle, but has agreed to keep a food diary, practice suggested relaxation techniques, and attempt to introduce small amounts of activity into her lifestyle.

Plan: Pt requires further evaluation, possibly by a psychiatrist, for anxiety disorder. Will pursue differential diagnosis at next appointment and consider a referral. Will evaluate food diary with Pt at next appointment and make suggestions for healthier alternatives. Will evaluate lifestyle further and work with patient to make changes in activity and diet. Possibly recommend that patient begin daily intake of aspirin, as preventative therapy. Cholesterol and lipids will be tested again in 6 months. Continue to pursue patient to consider smoking cessation/reduction program.

MI- myocardial infarction (heart attack)
HTL- hypertensive/hypertension
GERD - gastroesophageal reflux disease
SOB -shortness of breath
ECG- electrocardiogram (measures the electrical impulses in the heart)
CC - chief complaint
PVC - premature ventricular contractions (everyone has some, but frequency and/or association with other symptoms can be significant)
Sx- symptom
Hx- history