Mallory Zabor
NURS60015
SOAP NOTE: Brian Foster
10/28/2022
Episodic Visit
Your Name: Brian Foster
Source and Reliability: Self, reliable as historian
SUBJECTIVE
Chief Complaint (CC): “I have been having some troubling Chest Pain (CP) now and then for the past
month”
History of Present Illness (HPI): Patient is a 58 y/o Caucasian male presenting with complaints of
intermittent chest pain that started about a month ago which has happened 3 times in the past month.
Patient has not sought emergency care for the chest pain as he states it is triggered by exertion and
resolves “after a few minutes” of rest. When chest pain occurs, he rates 5/10 but currently pain is 0/10 as
chest pain is not currently present on this visit. Denies pain radiating. No c/o of pain in arm, shoulder,
neck, back or jaw. The only trigger he can associate chest pain with is activity. Denies heartburn,
GERD/reflux, abdominal pain, bloating or any GI symptoms to correlate this pain with. He denies taking
any medication for chest pain as it resolves with rest, denies taking aspirin, takes Tylenol for minor aches
and pains unrelated to chest pain. Denies SOB. Denies stressors. Patient is only stressed about figuring
out source of chest pain.
Past Medical History (PMH):
HLD- Diagnosed about a year ago
HTN (Stage II)-Diagnosed about a year ago
Past Surgical History (PSH): None
Medications: Lisinopril 20 mg daily PO, atorvastatin 20 mg HS PO, Omega-3 Fish Oil 1200 mg PO BID
Tylenol for minor aches and pains (PRN and not daily)
Allergies: Codeine (Nausea and Vomiting)
Immunizations: Tdap 10/2014, Influenza this season
Family Hx:
Father: HTN, HLD, obesity, passed away from colon CA at age 75
Mother (80 y/o): Type 2 DM, HTN
Daughter (19 y/o): Asthma
Son (26 y/o): No current health problems
Brother: Fatal MVA 24 y/o
Sister(52 y/o): DM2, HTN
Maternal grandmother: passed away of pneumonia at age 78
Paternal grandfather: passed of “old age” at 85 y/o
Mallory Zabor
NURS60015
SOAP NOTE: Brian Foster
10/28/2022
Social Hx: Patient married for 27 years to wife, 2 grown children (19 and 26 y/o). Denies stressors at hoe
and at work. Only stress admitted to this visit of stress of this recurrent chest pain. Goes to annual
physicals which he had about 3 months ago where he did have an EKG and he stated that they said it was
normal. Also had a stress test about a year ago which he stated all the doctors ever tell him are
“everything looks good”. Drinks 2 cups of coffee per day. Denies current exercise however, he used to
regularly exercise before bike got stolen about two years ago and would like to get another bike to begin
again however, he wants to clear it with doctor due to current bouts of chest pain. Typical breakfast is
instant breakfast shake and granola, for lunch a turkey sub or an occasional Italian sub, and dinner is
typically grilled veggies and meat of some sort. For hobbies patient likes sports and to fish, he also
occasionally goes to his son’s body building camps when he can and repair small electronics.
Tobacco: Denies past or present cigarette smoking and denies second hand smoke.
Alcohol: Reports drinking 2-3 drinks in sitting on weekends.
Drugs: Denies drug use other then “what he is prescribed”
Review of Systems (ROS): Pertinent to CC
General/constitutional: Denies weight loss, fever, fatigue, chills, night sweats, dizziness, heart
palpitations, Denies trouble sleeping as he sleeps about 7-8 hours per night. Has gained about 20 pounds
in the last 2 years or so.
Cardiac: Patient states he has stage 2 HTN, does not take BP at home so unsure how it runs however, he
states he takes BP pill at home and MD never seemed to concern with his BP at office visits. Last ECG
few months ago at annual check-up and was told it was normal. Stress test also done about a year ago and
MD reported “everything looks good”.
Respiratory: Denies cough, SOB. Illicits chest pain which is CC of visit. Denies Hx of blood clots.
GI: Denies abdominal pain, bloating, heartburn, nausea, vomiting, diarrhea, constipation, GERD.
Peripheral Vascular: Denies circulatory issues and edema. Denies blood clots, denies rheumatic fever,
denies heart palpitations and heart murmur. Denies easy bruising/bleeding.
OBJECTIVE
Physical Exam:
Alert, oriented and appropriate. Patient appears well-kept and does not appear to be in any distress.
Cooperative and pleasant with pertinent episodic history taking, as well as, targeted assessment.
VS:
Height: 5’11”
Weight: 197 lbs
BMI – 27.5 (Overweight)
Temperature – 36.7 degrees Celsius
Mallory Zabor
NURS60015
SOAP NOTE: Brian Foster
10/28/2022
Blood Pressure –
Right Arm: 146/9
Left Arm: 146/88
Heart Rate – 104
Respiratory Rate – 19
Pulse Oxygenation – 98, RA
ASSESSMENT/IMPRESSION:
Skin: No moles, freckles, visible masses, skin tags, erythema, discoloration or birthmarks. No excessively
dry/flaky skin, scars, lesions wounds or bruising, purpura, lacerations, wounds, ecchymosis or rash. Skin
warm and dry without tenting.
HEENT: No JVD, height is 3 cm above the sternal angle. No facial bruising lesions, erythema or
flushing, scars or lacerations, bruising or evidence of trauma, no rashes, no pallor or cyanosis. Right
carotid artery has 3 + amplitude and thrill upon palpation. No bruit present on Left Carotid artery
auscultation., no thrill on palpation of left carotid artery, +2 (normal).
Cardiac: S1, S2, and S3 heart sounds audible with gallops present upon auscultation. No friction rubs,
murmurs or valve clicks audible. PMI is displaced laterally, is brisk and tapping and < 3 cm. ECG
results=regular sinus rhythm with no ST elevation.
Respiratory: Chest is symmetrical, AP diameter WNL, no signs of pectus excavatum or Barrell chest.
No excess use of accessory muscles during breathing cycle. Absence of intercostal retractions. No skin
growths, visible rashes, or lesions. No scars/lacerations, apparent bruising, or evidence of trauma. Breath
sounds present in all areas. Adventitious breath sounds found in bilateral posterior lower lobes of the
lungs exhibiting characteristics of fine crackles. All other lobes are clear and free of wheezing, fine
crackles, stridor, rhonchi, and rales.
Gastrointestinal: Abdomen non-distended, symmetrical with a rounded contour. Absence of rash, striae,
umbilicus bulging, visible masses, discoloration or excess hair. No wounds, scars, bruising or lacerations.
Absence of AA bruit and bilateral renal arteries absent of bruits upon auscultation. Normoactive bowels
in all quadrants. No masses, tenderness, guarding, or rigidity upon light abdominal palpation. No palpable
masses with deep palpation. All 4 quadrants are tympanic upon percussion. Liver is palpable and span is 7
cm in the mid-clavicular line. Spleen not palpable. Tympany upon percussion of spleen. Kidneys not
palpable.
Peripheral Vascular: Absence of pallor to fingernails and toes; no cyanosis, splinter hemorrhages or
clubbing. No thickening of skin, ulcerations, varicose veins, brownish pigmentation, medial ulcers or
swelling to BLLE. Absence of edema in BLLE. No bruits in bilateral femoral and bilateral iliac artery
auscultation. Finger and toe capillary refill is less than 3 seconds. No thrills and normal 2 + amplitude on
palpation of bilateral radial, brachial and femoral arteries. No thrill and 1 + amplitude, diminished
palpation to bilateral popliteal, tibial and dorsalis pedis arteries.
Diagnosis:
1) Angina Pectoris
Mallory Zabor
NURS60015
SOAP NOTE: Brian Foster
10/28/2022
Differential Diagnoses:
1) Stable Angina
2) Atherosclerosis
3) Heart failure
Problem List:
Chest Pain (intermittent, upon exertion)
Fine crackles in posterior lower lobes of bilateral lungs
Tachycardia and HTN
HLD
S3 heart sound and gallops
Overweight
Family history of DM2, HLD, HTN, MI (with fatality)
PLAN:
Labs: trops, BNP, D-dimer, BMP, CBC with diff, TSH, T3, T4, Lipid panel, HbA1C
R/O DM2 and continue to monitor, Rx 81 mg PO ASA daily, Rx nitroglycerin 0.3 mg
PRN chest pain, take Q 5 minutes, 3 doses maximum, If no relief call 9-1-1 or go to
emergency room, schedule stress test and ECHO, schedule coronary calcium score
imaging, educate on S/S of heart attack and angina (nitro) and when to go to ER
Chest X-ray, ECHO
Continue lisinopril 20 mg/day PO, consult cardiology to assess need for further testing
and/or dose increase, add metoprolol per Cardiology recs for tachycardia and HTN,
encourage patient to take BP’s at home in the morning and record results. If BP high
instruct patient to take later in afternoon after BP meds and educate on high BP and when
to go to the ED, encourage patient to take BP meds first thing in the morning
Continue atorvastatin 20 mg Daily at bedtime, coincide lipid levels to assess further need
to decrease lipids, educate on healthy lifestyle and eating, consult nutrition to further
educate on a low cholesterol diet
ECHO, stress test, Holter monitor, cardiac consult
Encourage healthy diet low in cholesterol, encourage decreased alcohol consumption,
encourage exercise as recommended by cardiology once cleared, discourage consumption
of red meats and processed foods as well as foods high in saturated fats, increase fruit and
vegetable intake and decrease foods high in added sugar. Educate on heart healthy diet
and provide handouts (whole grains, fruits, veggies, balanced meals)
Schedule follow-up to assess tests and consults and review progress
