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Mr 2 soaps **files (1)** – ## 2SOAPNoteTemplate-Final1_12417645412.pdf **## 2SOAPNoteTemplate-Final1_12417645412.pdf** SOAP Note NU : Herzing University Name: Typhon Encounter #: Comprehensive: Focused: S: SUBJECTIVE DATA CC: I experience chest pressure on walking or by physical activity. HPI: Ons…
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Mr 2 soaps
**files (1)**
– ## 2SOAPNoteTemplate-Final1_12417645412.pdf
**## 2SOAPNoteTemplate-Final1_12417645412.pdf**
SOAP Note
NU :
Herzing University
Name:
Typhon Encounter #:
Comprehensive: Focused:
S: SUBJECTIVE DATA
CC: I experience chest pressure on walking or by physical activity.
HPI: Onset: Several weeks ago, the patient started having symptoms.
Location: Central chest area.
Duration: Happens occasionally when exercising.
Characteristics: is characterized by pressure or tightness.
related Factors: Episodes of mild shortness of breath.
Relievers: Factors Factors are relieved by a Rest.
Treatment: No known past medications before visit.
History: 74-year-old man with pressure in the chest on exertion alleviated by rest.
PMH: Hyperlipidemia and hypertension.
ALLERGIES NKDA.
MEDICATIONS Nitroglycerin PRN sublingual in case of discomfort in the chest.
SH Former smoker (quit 10 years ago). Occasional alcohol use. Retired mechanic.
FH Father was 70 years of age and died due to coronary artery disease. Mother with
hypertension.
HEALTH
PROMOTION &
MAINTENANCE
Patient denies excessive activity but has been limited in the recent past because of
the symptoms. Diet moderate in fat.
ROS
(put N/A in sections
not completed day of
exam)
Constitutional Denies fever.
Head N/A.
Eyes N/A.
Ears, Nose, Mouth, Throat N/A.
Neck N/A.
Cardiovascular/Peripheral
Vascular
Denies dyspnea.
Respiratory Mild dyspnea on episodes.
Breast
Gastrointestinal Negative of nausea/vomiting.
SOAP Note
NU :
Herzing University
Name:
Typhon Encounter #:
Comprehensive: Focused:
Genitourinary N/A.
Musculoskeletal N/A.
Integumentary N/A.
Neurological No syncope and dizziness.
Psychiatric (screening tools: Ex:
PHQ-9, MMSE, GAD-7)
N/A.
Endocrine N/A.
Hematologic/Lymphatic N/A.
Allergic/Immunologic N/A.
Other N/A.
O: OBJECTIVE DATA
VITALS: HR: 82 RR:18 BP: 140/84 Temp: 98.2°F
SpO2%: 97% Ht: 5’9’ Wt: 185 lb BMI: 27.3
Age: 74 LMP: PAIN: 3/10
during exertion
PHYSICAL
EXAM
(Pertinent data
related to
presenting
problem or
visit type. Put
N/A in sections
not completed
day of exam)
General Appearance Security, obedient.
Head Normocephalic.
Eyes PERRLA.
ENT, Mouth N/A
Neck No JVD.
Cardiovascular/Peripheral Vascular Normally timed heartbeat, no murmur.
Respiratory lungs clear bilaterally.
Breast N/A
Gastrointestinal Soft abdomen
Genitourinary Male
• External Exam N/A
• Internal Exam N/A
Genitourinary Female
• External Exam N/A
• Internal Exam N/A
Musculoskeletal Range of motion normal.
Integumentary N/A
Neurological Aware and oriented.
Psychiatric Appropriate mood.
Endocrine N/A
Hematologic/Lymphatic N/A
SOAP Note
NU :
Herzing University
Name:
Typhon Encounter #:
Comprehensive: Focused:
Allergic/Immunologic N/A
Other N/A
A: ASSESSMENT AND DIAGNOSIS
DIAGNOSIS ICD-10 CODES
PRIORITIZE
DIAGNOSIS
1. Angina pectoris ICD-10: I20.9
2.
3.
VISIT CODES CPT BILLING CODES CPT-9: 99214
CPT-10: 99204
DIAGNOSTICS POC TESTING ECG, cardiac stress test ordered.
TESTS REVIEWED
P: PLAN
ACTIONS 1.
Diagnosis: Stable Angina
Diagnostics Order:
Cardiac stress test and electrocardiogram.
Therapeutic:
Nifedipine 0.4 mg SL tablet-at-onset of-chest-pain, #25 pills, 1 renewal.
Education:
Patient instructed to take a rest in between periods and take medicine as
advised. Directed to get emergency treatment in case of continuing chest
pain despite taking medication. Change in lifestyle was talked about such as
diet and exercise.
Consultation/Collaboration:
Further examination in cardiology.
SOAP Note
NU :
Herzing University
Name:
Typhon Encounter #:
Comprehensive: Focused:
2. Diagnosis:
Diagnostics Order:
Therapeutic:
Education:
Consultation/Collaboration:
3. Diagnosis:
Diagnostics Order:
Therapeutic:
Education:
Consultation/Collaboration:
PREVENTITIVE
(Used for
comprehensive exams)
FOLLOW UP In 1-2 weeks, cardiology appointment. Emergency treatment in case of
aggravation of symptoms.
**## 2SOAPNoteTemplate-Final1_12417645412.pdf**
SOAP Note
NU :
Herzing University
Name:
Typhon Encounter #:
Comprehensive: Focused:
S: SUBJECTIVE DATA
CC: I experience chest pressure on walking or by physical activity.
HPI: Onset: Several weeks ago, the patient started having symptoms.
Location: Central chest area.
Duration: Happens occasionally when exercising.
Characteristics: is characterized by pressure or tightness.
related Factors: Episodes of mild shortness of breath.
Relievers: Factors Factors are relieved by a Rest.
Treatment: No known past medications before visit.
History: 74-year-old man with pressure in the chest on exertion alleviated by rest.
PMH: Hyperlipidemia and hypertension.
ALLERGIES NKDA.
MEDICATIONS Nitroglycerin PRN sublingual in case of discomfort in the chest.
SH Former smoker (quit 10 years ago). Occasional alcohol use. Retired mechanic.
FH Father was 70 years of age and died due to coronary artery disease. Mother with
hypertension.
HEALTH
PROMOTION &
MAINTENANCE
Patient denies excessive activity but has been limited in the recent past because of
the symptoms. Diet moderate in fat.
ROS
(put N/A in sections
not completed day of
exam)
Constitutional Denies fever.
Head N/A.
Eyes N/A.
Ears, Nose, Mouth, Throat N/A.
Neck N/A.
Cardiovascular/Peripheral
Vascular
Denies dyspnea.
Respiratory Mild dyspnea on episodes.
Breast
Gastrointestinal Negative of nausea/vomiting.
SOAP Note
NU :
Herzing University
Name:
Typhon Encounter #:
Comprehensive: Focused:
Genitourinary N/A.
Musculoskeletal N/A.
Integumentary N/A.
Neurological No syncope and dizziness.
Psychiatric (screening tools: Ex:
PHQ-9, MMSE, GAD-7)
N/A.
Endocrine N/A.
Hematologic/Lymphatic N/A.
Allergic/Immunologic N/A.
Other N/A.
O: OBJECTIVE DATA
VITALS: HR: 82 RR:18 BP: 140/84 Temp: 98.2°F
SpO2%: 97% Ht: 5’9’ Wt: 185 lb BMI: 27.3
Age: 74 LMP: PAIN: 3/10
during exertion
PHYSICAL
EXAM
(Pertinent data
related to
presenting
problem or
visit type. Put
N/A in sections
not completed
day of exam)
General Appearance Security, obedient.
Head Normocephalic.
Eyes PERRLA.
ENT, Mouth N/A
Neck No JVD.
Cardiovascular/Peripheral Vascular Normally timed heartbeat, no murmur.
Respiratory lungs clear bilaterally.
Breast N/A
Gastrointestinal Soft abdomen
Genitourinary Male
• External Exam N/A
• Internal Exam N/A
Genitourinary Female
• External Exam N/A
• Internal Exam N/A
Musculoskeletal Range of motion normal.
Integumentary N/A
Neurological Aware and oriented.
Psychiatric Appropriate mood.
Endocrine N/A
Hematologic/Lymphatic N/A
SOAP Note
NU :
Herzing University
Name:
Typhon Encounter #:
Comprehensive: Focused:
Allergic/Immunologic N/A
Other N/A
A: ASSESSMENT AND DIAGNOSIS
DIAGNOSIS ICD-10 CODES
PRIORITIZE
DIAGNOSIS
1. Angina pectoris ICD-10: I20.9
2.
3.
VISIT CODES CPT BILLING CODES CPT-9: 99214
CPT-10: 99204
DIAGNOSTICS POC TESTING ECG, cardiac stress test ordered.
TESTS REVIEWED
P: PLAN
ACTIONS 1.
Diagnosis: Stable Angina
Diagnostics Order:
Cardiac stress test and electrocardiogram.
Therapeutic:
Nifedipine 0.4 mg SL tablet-at-onset of-chest-pain, #25 pills, 1 renewal.
Education:
Patient instructed to take a rest in between periods and take medicine as
advised. Directed to get emergency treatment in case of continuing chest
pain despite taking medication. Change in lifestyle was talked about such as
diet and exercise.
Consultation/Collaboration:
Further examination in cardiology.
SOAP Note
NU :
Herzing University
Name:
Typhon Encounter #:
Comprehensive: Focused:
2. Diagnosis:
Diagnostics Order:
Therapeutic:
Education:
Consultation/Collaboration:
3. Diagnosis:
Diagnostics Order:
Therapeutic:
Education:
Consultation/Collaboration:
PREVENTITIVE
(Used for
comprehensive exams)
FOLLOW UP In 1-2 weeks, cardiology appointment. Emergency treatment in case of
aggravation of symptoms.
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