WU Focused SOAP for Stable Angina Case Study
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- Case Study:
- HI 70 y/o male. Pt. presented with chest pain
that alleviates with rest. Pt feels sharp pain while walking or when doing some
housework. Dx stable angina. Tx Sublingual nitro every time that chest
pain starts, dose every 5 min for a maximum of 3 pills. Referral to
cardiologist - Subjective: What details did the patient provide regarding his or her personal and medical history?
- Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities and psychosocial issues.
- Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 code for the diagnosis. What was your primary diagnosis and why?
- Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
- Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?
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