Chest Pain: Lub dub and more
This is one of the most feared chief complaints by patients and providers alike. The differential diagnosis for this complaint includes myocardial infarction, aortic dissection and cardiac tamponade, to name a few. The initial encounter is often geared toward ruling out these feared diagnoses. Rightfully so. The gravity of this complaint requires that nothing is missed. We recommend using an online medical template as a guard against omissions.
We have created a curated template that allows you to streamline your documentation. Not only that, it also provides helpful prompts during the patient interview to help reduce the likelihood of missing a diagnosis. While this template by no means captures every question, test and treatment that should be considered, it does provide a good starting point. Let’s talk about what went into making this template.
During the initial encounter, history is extremely important. Assessing the chronicity of the pain will help the provider determine its acuity. A sudden onset of pain with significant risk factors is certainly concerning. Insidious chest pain in a young and otherwise healthy patient is less concerning. Particular questions should be asked as well. These include location of the pain as well as its character. Understanding factors that improve and relieve the pain are also helpful. In fact, these factors help categorize the pain as typical, atypical, and non-specific. Understanding if the pain is positional can clue the provider into the diagnosis of pericarditis.
A lengthy differential means numerous questions for the patient. Having an Online Medical SOAP Note template to ensure nothing is missed can be extremely helpful. SOAPassist’s curated template for chest pain has many details that providers frequently intend to ask. This can help the provider arrive at the diagnosis sooner.
Most providers know what should be done for the patient with acute chest pain. The frightening diagnoses loom large. Providers know exactly what needs to be done to work up the more frightening diagnoses. EKGs, troponins, telemetry monitoring, CT imaging, and other testing is performed. What happens when these tests come back negative? Patients and providers often have a sense of relief that the more concerning diagnoses have been ruled out. However, the etiology remains unknown. Providers are typically less quick to recall the many causes of chest pain that are not life-threatening. Using a medical SOAP note template helps providers consider these diagnoses so that the underlying etiology is identified sooner.
We recommend using online medical SOAP notes and templates. This ensures you have access to the templates you need wherever you practice. Patients with ST-segment myocardial infarction do not always first present to the emergency department. Online medical templates, such as the ones provided by SOAPassist, are available everywhere you have internet access. This allows you to practice your best medicine anywhere.
As we’ve discussed, building well-constructed templates can not only streamline the documentation process, but can provide reminders during the patient interview to ask important questions and discuss things that can change management. We recommend building and using templates that provide prompts to ask such questions. Additionally, considering a broad differential at the initial encounter can help ensure the appropriate workup and treatment are initiated as soon as possible. As mentioned previously, this template by no means captures every question, test and treatment that should be considered, but it does provide a good starting point. In fact, SOAPassist allows you to load any SOAPassist curated template into the template creator page so it can then be modified and saved as your own. You read that correctly. SOAPassist is here to help make your documentation reflect your practice and curated templates is the first step in that process.
Disclaimer: SOAPassist curated templates are created for use by licensed medical providers. While they are examples of what a provider might document, their intended purpose is to provide a starting point for documentation and do not constitute medical recommendations.
Content:
During the initial encounter, history is extremely important. Assessing the chronicity of the pain will help provider to determine its acuity. a sudden onset of pain with significant risk factors is certainly concerning. Particular questions should be asked as well. These include location of the pain as well as its character. Understanding factors that improve and relieve the pain are also helpful.in fact, these factors help categorize the pain as typical, atypical, and non-specific. understanding if the pain is positional conclude the provider into the diagnosis of pericarditis.
The differential diagnosis and their associated symptoms is much more expensive than what is detailed above. Having a template to ensure nothing is missed can be extremely helpful. The soap assist. The template for chest pain has many details that providers frequently intend to ask. This can help the provider arrive at the diagnosis sooner.
The objective portion of the assessment it’s driven by both the chief complaint the history elicited from the patient.
We recommend using an online medical soap note so that it is available wherever you practice. Patience with shemmy don’t always first present to the emergency department. An online medical template, such as the ones provided by soap assist, are available everywhere you have internet. This allows you to practice your best medicine anywhere.