SOAP Note for Episodic Visit: 15-Year-Old with Cardiac Condition

QUESTION

Need Full SOAP note on 15-year-old boy coming to doctor’s office for the episodic visit of any Cardiac Condition:

Final Diagnosis: Must need any diagnosis of a Cardiac condition

Please include Subjective, Objective data, an assessment with three differential diagnoses, one final diagnosis (Must be cardiac Conditions), Plan: including diagnostic, treatment, education, referrals, and follow-up.

ANSWER

SOAP Note for Episodic Visit: 15-Year-Old with Cardiac Condition

Subjective

A 15-year-old boy presents to the doctor’s office with complaints of chest pain and palpitations. He reports experiencing episodes of chest discomfort, which he describes as a sharp, stabbing pain that occurs randomly and lasts for a few minutes. The pain is not associated with exertion or activity. He also mentions feeling his heart racing or pounding during these episodes. The patient denies any shortness of breath, dizziness, or loss of consciousness. He has no significant medical history and takes no medications.

Objective

Vital signs: Blood pressure 120/80 mmHg, heart rate 90 bpm, respiratory rate 16 breaths per minute, temperature 98.6°F (37°C).
General appearance: The patient appears well-nourished and in no acute distress.
Cardiovascular examination: Regular rhythm, normal S1 and S2 heart sounds, no murmurs, rubs, or gallops. No signs of jugular venous distention or peripheral edema. Capillary refill time is less than 2 seconds.
Lung examination: Clear breath sounds bilaterally, no crackles or wheezing.
No peripheral cyanosis or clubbing observed.

Assessment

Differential Diagnosis:

Cardiac arrhythmia: The patient’s palpitations and chest pain suggest the possibility of cardiac arrhythmias, such as supraventricular tachycardia (SVT) or ventricular tachycardia (VT).
Mitral valve prolapse (MVP): MVP can cause chest pain and palpitations, especially in young individuals. It is characterized by the displacement of the mitral valve leaflets into the left atrium during systole.
Non-cardiac chest pain: Other non-cardiac causes, such as musculoskeletal pain or anxiety, should also be considered in the differential diagnosis.

Final Diagnosis: Supraventricular tachycardia (SVT)

Based on the patient’s symptoms of chest pain and palpitations, the absence of abnormal heart sounds or murmurs, and the absence of other concerning features, SVT is the most likely cardiac condition causing his symptoms.

Plan

Diagnostic:

Electrocardiogram (ECG): To evaluate the patient’s heart rhythm and identify any abnormalities suggestive of SVT.
Holter monitor: To record the patient’s heart rhythm over a 24-hour period and capture any transient arrhythmias that may occur.
Echocardiogram: To assess cardiac structure and function, ruling out any structural abnormalities contributing to the SVT.

 Treatment:

Vagal maneuvers: The patient will be educated on various vagal maneuvers, such as the Valsalva maneuver or carotid sinus massage, to attempt to terminate SVT episodes.
Medication: If vagal maneuvers are ineffective, the patient may be prescribed oral antiarrhythmic medication, such as beta-blockers or calcium channel blockers, to prevent SVT episodes.
Referral: The patient will be referred to a pediatric cardiologist for further evaluation and management of the SVT.

Education:

The patient and his family will receive education about SVT, including triggers to avoid and the importance of adherence to medication.
Instructions on how to perform vagal maneuvers correctly will be provided.
Information about lifestyle modifications, such as avoiding excessive caffeine or stimulant intake, will be discussed.

Referrals:

The patient will be referred to a pediatric cardiologist for further evaluation and management of SVT.

Follow-up:

The patient will schedule a follow-up visit with the pediatric cardiologist to assess the effectiveness of the treatment plan, monitor symptoms, and adjust medication if necessary.