NURS 6512 Advanced Health Assessment Soap Note - 49-year-old female patient with mid-chest pain

SOAP This pleasant 49-year-old female patient presents with a two-week new onset exertion-related "squeezing" mid-chest pain radiating to the left arm that's relieved with rest and is worsened with cold temperatures. The patient states dyspnea occurs with these episodes as well. The patient has a history of hyperlipidemia and hypertension, is currently in an overweight status, and has a stressful work situation. She has a 5-pack-year previous smoking history and a family history of heart disease. Physical assessment revealed warm and dry skin, normal skin turgor, and well-hydration status: no bruises or petechia. No cough, fever, or nasal discharge is present. No hoarseness is present, the mucosa is clear, and the tonsils do not have exudate. The tongue is a normal color and is symmetrical, with no swelling/ulcerations. Respiratory rate is WNL, with no sob and normal respiratory effort and excursion. Breath sounds equal, with no wheezing or crackles. Normal jugular venous pressure. PMI nondisplaced RR and R, without murmur or gallop. No peripheral edema, Normal peripheral pulses. No carotid bruit. Soft; nontender to upper quadrant and epigastric palpation; no hepatosplenomegaly. Normal bowel sounds X4 quadrants. The patient's symptoms are not reproducible to palpation. Hematologic laboratory diagnostics are unremarkable, EKG unremarkable, echocardiogram unremarkable, and stress test results indicate stable angina.