A 58-year old male presents with a complaint of severe chest pain over the past hour. He did not call 911 “because I don’t have the money for an ambulance.
In SOAP format, list:
Subjective Data
Objective Data (Review of system assesment)
Assesment (Differential Diagnosis)
Pertinent positive and negative information
Differential and working diagnosis
Plan (Treatment plan, including: pharmacotherapy with complementary and OTC therapy, diagnostics (labs and testing), health education and lifestyle changes, age-appropriate preventive care, and follow-up to this visit
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