The following represents the typical discussion on a 2nd opinion call and the format of how we document the visit. The call, if requested, may be recorded and sent to you. 

The time is yours but the doctor has specific goals to learn as much about you as possible to then develop a comprehensive treatment plan. 

Welcome to Your 100 Year Heart

SOAP Note – Second Opinion Consultation

Patient Name: [Patient Name]
Date of Visit: [Date]
DOB: [Patient’s Date of Birth]
Sex: [Male/Female]
Referring Physician (if applicable): [Referring Physician’s Name]

Subjective (S)

Chief Complaint:

• Patient presents for a second opinion regarding [primary diagnosis or concern], previously diagnosed by [previous provider].
• Seeking a more natural and holistic approach to heart health.

Current Symptoms:

• Reports [e.g., chest discomfort, palpitations, shortness of breath, fatigue, dizziness, swelling in legs].
• Symptoms began [timeframe] and have been [stable/progressing].
• Triggers include [e.g., exertion, stress, specific foods, poor sleep].
• Relieved by [e.g., rest, hydration, breathing exercises].

Past Medical History (PMH):

• Cardiovascular: [e.g., Hypertension, Hyperlipidemia, Atrial Fibrillation, CAD, Heart Failure]
• Metabolic: [e.g., Diabetes, Insulin Resistance, Thyroid Disorder]
• Inflammatory/Autoimmune: [e.g., Rheumatoid Arthritis, Lupus]
• Other: [e.g., Osteoporosis, Chronic Fatigue, Lyme Disease]
• Previous cardiac interventions: [e.g., Stents, Bypass, Ablation, None]
• Previous cardiac testing: [e.g., ECG, Echocardiogram, Stress Test, Calcium Score]

Medications & Supplements:

• Prescription Medications: [List medications, dosage, and duration]
• Nutritional Supplements: [List vitamins, minerals, herbal formulas]
• Allergies: [List any known allergies]

Family History (when applicable):

• Heart disease: [Yes/No – specify relation]
• Stroke: [Yes/No – specify relation]
• Diabetes: [Yes/No – specify relation]
• Cancer: [Yes/No – specify relation]

Social History & Lifestyle Factors:

• Marital Status: [Single/Married/Divorced/Widowed]
• Children: [Yes/No, how many]
• Stress Level: [Low/Moderate/High] – Contributing factors: [e.g., Work, Family, Finances, Chronic Illness]
• Tobacco Use: [Yes/No, former smoker? How long?]
• Alcohol Use: [Yes/No, frequency, type]
• Caffeine Intake: [Yes/No, source and amount]
• Childhood Trauma (ACE Score): [Discuss if relevant]
• Environmental Exposures:
  • Toxin Exposure: [e.g., Mold, Heavy Metals, EMF exposure, Pesticides, Plastics]
  • Age of Home: [Year built, History of water damage, Mold exposure assessment]

Dietary History:

• Current Diet: [e.g., Standard American Diet, Paleo, Carnivore, Keto, Mediterranean, Whole Foods]
• Meat Intake: [Grass-fed, Pasture-raised, Factory-farmed]
• Seafood Consumption: [Wild-caught, Farm-raised]
• Dairy Consumption: [Raw, Pasture-raised, Conventional]
• Grains & Legumes: [Yes/No, Type, Frequency]
• Seed Oils & Processed Foods: [Yes/No, Frequency]
• Sugar & Refined Carbohydrates: [Yes/No, Frequency]
• Food Sensitivities: [Gluten, Dairy, Eggs, Nightshades]
• Fasting Practices: [Yes/No, Type, Frequency]

Exercise History:

• Current Routine: [e.g., Walking, Strength Training, Yoga, None]
• Frequency: [Daily, 3-5x/week, Sporadic]
• Intensity: [Low/Moderate/High]
• Past Athletic Background: [Yes/No, Type]

Sleep History:

• Sleep Duration: [# hours per night]
• Sleep Quality: [Good/Poor, describe]
• Bedtime Routine: [Consistent/Inconsistent]
• History of Sleep Apnea, Snoring, or Restless Sleep? [Yes/No]

Sunshine Exposure:

• Daily Sun Exposure: [Yes/No, estimated duration]
• Time of Day for Exposure: [Morning/Midday/Afternoon]
• Sunscreen Use: [Yes/No]
• History of Vitamin D Deficiency? [Yes/No]

Dental History:

• Mercury Amalgams: [Yes/No, # of fillings]
• Root Canals: [Yes/No, Location]
• Cavitation Surgery: [Yes/No]
• Gum Health: [Good/Fair/Poor]
• Fluoride Use: [Yes/No]

Objective (O)- for in-person visit

Vitals:

• BP: [#/# mmHg] (Seated & Standing)
• HR: [# bpm]
• RR: [# breaths/min]
• Oxygen Saturation: [#%]
• Weight: [# lbs/kg]
• Height: [# in/cm]
• BMI: [#]

Physical Exam:

• General: [Well-nourished, No acute distress, Appears fatigued]
• Cardiovascular: [Regular rhythm, No murmurs/rubs, Peripheral pulses intact]
• Respiratory: [Lungs clear bilaterally, No wheezing/crackles]
• Abdomen: [Non-tender, No hepatosplenomegaly]
• Extremities: [No edema, No cyanosis]

Assessment (A)

• Primary Concern: [e.g., Hypertension, Coronary Artery Disease, Atrial Fibrillation, Insulin Resistance]
• Contributing Factors: [e.g., Inflammation, Nutrient Deficiencies, Poor Sleep, Toxic Load]
• Risk Stratification: [Low/Moderate/High risk for cardiovascular events]
• Differential Diagnosis: [e.g., Dysautonomia, Microvascular Dysfunction, Chronic Inflammation]

Plan (P)

1. Dietary Recommendations:

• Transition to whole food, anti-inflammatory diet
• Increase intake of omega-3s, magnesium, potassium, grass-fed meats, wild-caught seafood
• Eliminate processed foods, industrial seed oils, refined sugar, and excess alcohol

2. Lifestyle Adjustments:

• Sunshine: Daily morning sunlight exposure
• Sleep Optimization: Improve sleep hygiene
• Exercise: [Personalized based on fitness level]

3. Targeted Supplementation:

• Heart & Vascular Support: [e.g., CoQ10, Magnesium, L-Arginine, Nattokinase]
• Mitochondrial Support: [e.g., Ubiquinol, D-ribose]

4. Advanced Testing Considerations:

• Advanced Cardiac Panel
• Heart Attack Risk Test
• Level 1
• CHAT testing
• #8 swiffer test

5. Follow-up Plan:

• Follow up call in 3-4 weeks to review progress, adjust protocol, and discuss lab findings.
• Look out for a follow-up call / email to discuss next steps