Chest Pain- SOAP – HA W2D1 R2
Type of document Essay 1 Page Subject area Nursing Academic Level Master
Style APA references 2
Order description:
Allison Skilton, Main Post Unit 2 DT 1
Chest Pain- SOAP
S: Mr. Tom Jones, is a 45 year old male, who has come to the office today with complaints of chest pain. He is a full -time air traffic controller for a large airport. He is married, and has 8 year old twin girls. His maternal grandfather had a heart attack at age 50. His family history is otherwise unremarkable. He describes the pain as chest tightness that does not radiate to his shoulder or jaw. He also states that sometimes he gets sweaty, rapid heart rate, with no shortness of breath. They symptoms occur frequently while at work, but if he takes a break it will lessen. He denies having the pain on his days off. He states that he is worried that he will have a heart attack just like his grandfather and leave his family behind.
O: Vital signs- HR 88, R 20, BP 140/85, T 98.9 Height- 6’ 1”, Weight 220lbs. The patients HR is within normal limits, an EKG show no ST elevations or other abnormal findings, his lungs were clear, normal reflexes in all 4 extremities.
A: This patient is most likely experiencing anxiety attacks from his high stress job. This would be why when he takes a break from work or his days off that the symptoms lessen or are not present.
P: Starting with reassurance for this patient, that most likely he is experiencing anxiety attacks that are related to his job combined with the added stress of leaving his family at an early age. It would be my recommendation that he see a cardiologist to establish a baseline stress test given his family history of heart attack at a relatively young age. For the anxiety attacks, he could consider a less stressful job, if this is not an option, learning coping skills such as regular breaks to walk around and relax. Prescribing anti-anxiety medications: Xanax, Klonipin, Ativan or Valium. Follow-up should be within in one month to re-evaluate the medications and their effects.
Questions to ask the patient
What are you doing when the pain occurs? Asking this question will determine if the pain is sudden when they are at rest, during exercise or during a stressful situation.
Does anything alleviate or make the pain worse? This allows us to see what the patient does to help the pain, or does he just endure without trying to help it go away.
On a scale of 1-10, 10 being the worst how would you rate your pain? This asks is the pain the same each time or does it change from time to time.
Where is the pain? Location of the pain is significant to defining if it is a cardiac event or not.
Do you have shortness of breath? Generally, anxiety attacks do not include shortness of breath, unless there is added panic related to the pain.
How would you describe the pain (stabbing, throbbing, crushing, sharp, etc). Radiating and crushing pain is more specific to a cardiac event.
Findings
Normal: It would be normal if the pain was related to stress/anxiety that when the patient is removed from the situation that the pain would get better. It would also be normal if the patient hasa panic feeling with the pain from the fear of leaving his family.
Abnormal: If the pain did not go away when stepping away from a potential situation. Abnormal if the pain happened if the patient was at rest when the pain came.
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