SOAP Note for Angina Pectoris: Pharmacotherapeutics Practical
1. SOAP notes for Hypertension 2. SOAP notes for Angina Pectoris 3. SOAP notes for Myocardial Infarction 4. SOAP notes for Hyperlipidaemia 5. SOAP notes for Rheumatoid arthritis 6. SOAP notes for Asthma 7. SOAP notes for COPD 8. SOAP notes for Diabetes 9. SOAP notes for Epilepsy 10. SOAP notes for Stroke 11. SOAP notes for Depression 12. SOAP notes for Tuberculosis 13. SOAP notes for Anaemia 14. SOAP notes for Viral infection 15. SOAP notes for Dermatological conditions
Patient Information
Name: Nilesh Raut
Age: 58 Years
Height: 6 Feet 2 Inches
Weight: 90 Kg
S: Subjective
My chief complaint “Pain in my chest” on and off for the past six months.
When asked about how he feels about these episodes, he admits to being concerned about his health and longevity, considering his father died at age 52 of “heart problems.” He says, business is poor, and my kid is always in trouble. “Who’s going to take care of things?”
He describes the pain as being more of a discomfort or heaviness. It is localized to “my breast bone” and does not radiate. Today, following a brief rest, the pain subsided and he returned to his golf game. Previous episodes of the heavy feeling tended to occur following large meals and one occasion while dancing at a wedding. None of the episodes lasted more than “several minutes.”
O: Objective Findings
CBC: WBC = 5,600/mm3,
hemoglobin = 15.2g/dL,
hematocrit = 45%,
platelet count = 320,000/mm3
Chemistries: Glucose 110mg/dL,
Blood Urea Nitrogen (BUN) 11mg/dL,
Creatinine 0.9mg/dL
Urinalysis: Specific gravity: 1.016;
Protein, Glucose, Ketones = negative.
Chest X-ray: normal
A: Assessment
• Diagnosis of disease.
• Differential of diagnosis.
P: Plan
Diagnosis is based on clinical evaluation through history, physical examination, and routine laboratory tests to assess risk factors, reveal identifiable causes and detect target-organ damage, including evidence of cardiovascular disease.
• Testing
• Medication prescribed
• Psychoeducation if needed
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