Case
Brian foster Chest Pain shadown health-soap note, Episodic Visit
- Course
- Nursing
- Institution
- Washington Hospital School Of Nursing
Brian foster Chest Pain shadown health-soap note, Episodic Visit
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BRIAN FOSTER SHADOWHEALTH-SOAP NOTE,
EPISODIC VISIT
www.pasinggrades.com
, NURS 60015
SOAP NOTE: Brian Foster
Year 2025
Brian foster shadow health-soap note, Episodic Visit
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
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