Complete Notes and SOAP notes

Abdominal Pain

ROS:

GENERAL: Complains of decreased appetite. Denies fever, chills, night sweats.
GI: Complains of bloating and right-sided abdominal pain that is worse when laying down. Complains of nausea. States that BMs have been normal. Denies vomiting, diarrhea, abdominal pain.
GU: Denies dysuria, burning, urgency, and frequency.
MSK: Denies flank pain.
NEURO: Denies HA.
DERM: Denies rashes
All other systems were reviewed and are negative.

Physical Exam:

GENERAL: NAD, speaking full sentences
VSS, afebrile
GI: Pt is tender over McBurney's point, right adnexal tenderness, AND a positive Murphy's sign. No HSM. No suprapubic tenderness or distention. No CVAT. Flat without distention. No surface trauma, scars, incisions or rash. +BS.
SKIN: PWD, no diaphoresis, cyanosis or pallor
EYES: pupils PERRL and EOMI
PULM: CTA bilaterally, no rales, rhonchi or wheezing
CV: RRR, no MGR
NEURO: A&O x 4, good insight and judgement

THE REST IS JUST REMNANTS FROM THE CHEST PAIN NOTE

IGNORE THE FOLLOWING:

DDx: Myocardial infarction, Unstable angina, Tension pneumothorax, Pericarditis with tamponade, Pulmonary embolism, Thoracic Aortic dissection (TAD), myocarditis, costochondritis, pleurisy, gastritis.

ASSESSMENT:

Coronary artery disease risk factors include:
The patient's chest pain and pressure, left arm pain are/are not sufficiently worrisome for cardiac-associated symptoms to warrant EKGs as needed. The patient's EKG showed no diagnostic acute ischemic changes. Patient referred to ED for further testing to rule out myocardial infarction
**The patient's EKG does not show changes consistent with malignant underlying process.
Chest pain and shoulder pain were reproducible with palpation.
The patient was hemodynamically stable throughout course.


The patient's (specific symptoms, and character, i.e. chest pain SOB etc)*** are sufficiently worrisome for cardiac-associated symptoms to warrant admission for serial cardiac enzymes and EKGs as needed. The patient's initial ( enter cardiac enzyme testing)*** was negative, and the patient's EKG showed no diagnostic acute ischemic changes.
Wells criteria was considered in the evaluation of this patient. The patient did not have a Wells score indicating an emergent workup is necessary. The patient's EKG does not show changes consistent with pericarditis or other malignant underlying process. The patient's symptomatology and physical exam are not completely consistent with myocarditis, costochondritis, pleurisy, aortic pathology or pulmonary embolus. (if CXR or EKG is not normal, edit appropriate findings)***
The patient was administered aspirin upon arrival.(edit-- must account for where/when aspirin was given i.e. in ED, ambulance, home, or if not--why not)***
Coronary artery disease risk factors include: (HTN, high cholesterol, early fam fx, diabetes, smoking)***
The patient was hemodynamically stable throughout course (if patient had low or high blood pressue in course, this should be changed and treatment, if any explained/outlined).
Consultation: I discussed this case with Dr. ***, who agreed with assessment and plan.
CHEST PAIN
All patients with CP over 12 yo should have:

All patients with CP over 40 yo should have: