Explain how to revise the SOAP note to include the correct medical terms and an accurate documentation of the patient’s diagnosis:

SOAP NOTE:

CHIEF COMPLANT: 72 yr. old gentleman of Dr. K. Derby’s who presents with chest pain. HISTORY OF PRESENT ILNESS: Mr. Gibbon is a very cheery sort of fellow. He is very pleasant. He looks as though he probably should be running some sort of hardware store commercial. He states that today while he was preparing breakfast, in the restroom he suffered some chess discomfort. He is a little bit vague as to where his chest really is. He felt it in his back, he felt it in his jaw. He took a couple of Nitroglycerine in sequence three minutes apart and felt better. Apparently, this has been occurring a little more frequently recently. All these things are nebulous. If it wasn’t for his wife I think he would deny everything. According to his wife, he has been having more frequent episodes and has gained a fair amount of wait over the winter. He has had little physical activity. His pastor who is with him and often serves as his spokesman, stated that he had hunted this past fall without having to take any medication. However, he said the pace was quite controlled and he really didn’t do very much in the way of heavy exercise. The patient has a history of an mycocardial infraction in 1981. Underwent catheterisation. Apparently, no surgery was necessary. There is also some question about him having a lot of indijestion from time to time and it is not clear whether it is cardiac or GI. Because of his prior cardiac history, the progression of his chest pane, the uncertainty of its origin, he will be admitted for further evaluation and treatmant. PAST MEDICAL HISTORY: Is essentially that listed above. SOCIAL HISTORY & FAMILY HISTORY: The patient is married. Doesn’t smoke, although he had in the past. Doesn’t drink. There is no disease common in the family. Objective REVIEW OF SYSTEMS: Negative. VITAL SIGNS: Temperature of 97.6 (Normal = 96.6 – 100.6), pulse is 65 (Normal = 60 – 100), respirations 18 (Normal = 12 – 20), blood pressure 118/78 (Normal = 120/80 or below). HEAD: Normocephalic. ENT: Eyes -sclera and conjunctiva normal. PERRL, EOM’s intact. Fundi reveal arteriolar narrowing. ENT are unremarkable. NECK: Supple. No thyromegaly. Carotids are 2 out of 4. No bruits, no jugular venous distention. CHEST: Symmetrical. Clear to auscultation and percussion. HEART: Regular rhythm without any particular murmurs or gallops. ABDOMEN: Nontender. No organomegaly. Bowel sounds normal activity. No bruits or masses. BACK: No CVA tenderness nor tenderness to percussion over the spinous processes. GENITALIA: Normal male. RECTAL: Good sphincter tones. Stool is hemoccult negative. Prostate is normal in size. EXTREMITIES: No cyanosis, clubbing or edema. Pulses equal and full. NEUROLOGIC: Is physiologic. Assessment l) Chest pain, etiology to be determined 2) Hypertension 3) Tachypnea 4) Bradycardia Plan Schedule for stress test 4/28, 1230 if possible

ANSWER

Revising the SOAP Note with Accurate Medical Terms and Diagnosis Documentation

The SOAP note presented requires revision to include correct medical terminology and an accurate documentation of the patient’s diagnosis. The revised note should reflect professionalism, accuracy, and clarity in describing the patient’s condition and medical history.

Subjective

Mr. Gibbon, a 72-year-old gentleman under the care of Dr. K. Derby, presents with a chief complaint of chest pain.

History of Present Illness

Mr. Gibbon is a genial individual, exhibiting a pleasant demeanor. He reports experiencing discomfort in his chest while preparing breakfast today. The pain’s location seems nebulous, radiating to his back and jaw. He took two sequential doses of Nitroglycerine, three minutes apart, which alleviated the discomfort. Such episodes have become more frequent recently, as reported by his wife, who serves as a reliable source. Despite his tendency to downplay the symptoms, his wife’s observations suggest otherwise. Notably, he has gained weight during the winter, been sedentary, and his pastore also confirmed that he engaged in controlled activities during hunting season. Mr. Gibbon’s history includes a myocardial infarction in 1981, with catheterization but no surgical intervention. Occasional indigestion confounds the distinction between cardiac and gastrointestinal origins. Given his cardiac history, escalating chest pain, and diagnostic uncertainty, he will be admitted for comprehensive evaluation and treatment.

Past Medical History

Mr. Gibbon’s medical history primarily involves the aforementioned events.

Social and Family History

The patient is married, having quit smoking (prior history) and abstaining from alcohol. No familial disease trends are identified.

Objective

Review of Systems: No significant findings reported.
Vital Signs: Temperature 97.6°F, pulse 65 bpm, respirations 18 breaths/min, blood pressure 118/78 mmHg.
Head: Normocephalic.
Eyes, Ears, Nose, and Throat: Eyes exhibit normal sclera, conjunctiva, PERRL (pupils equal, round, reactive to light), and intact EOMs (extraocular movements). Fundus reveals arteriolar narrowing. ENT findings are unremarkable.
Neck: Supple, no thyromegaly. Carotid bruits graded 2 out of 4. No jugular venous distention.
Chest: Symmetrical, clear to auscultation and percussion.
Heart: Regular rhythm without murmurs or gallops.
Abdomen: Nontender, no organomegaly, normal bowel sounds.
Back:Absence of CVA (costovertebral angle) tenderness or tenderness over spinous processes.
Genitalia and Rectal: Normal male findings, good sphincter tones, hemoccult-negative stool, and normal prostate size.
Extremities: No cyanosis, clubbing, or edema. Pulses are equal and full.
Neurologic: Within normal limits.

Assessment

1. Chest pain with undetermined etiology.
2. Hypertension.
3. Tachypnea.
4. Bradycardia.

Plan

Scheduled for a stress test on 4/28 at 1230, if feasible.

Conclusion

By revising the SOAP note with accurate medical terminology and an appropriate documentation of the diagnosis, the healthcare team can ensure clear communication, precise assessment, and effective patient care.