SOAP Note Template

Specialty: Acute Medicine Specialist SOAP Note Template Subjective Patient is a 68-year-old male presenting to the emergency department with a chief complaint of sudden onset, severe, crushing chest pain radiating to his left arm and jaw. The pain started approximately 2 hours prior to arrival, is rated 9/10 in severity, and is associated with shortness of breath, diaphoresis, and nausea. He denies any precipitating factors. He has a history of hypertension and hyperlipidaemia. Review of systems: * Cardiovascular: Chest pain, shortness of breath, diaphoresis. * Gastrointestinal: Nausea, no vomiting. * Respiratory: Dyspnoea on exertion, no cough or wheeze. Past medical history: Hypertension, Hyperlipidaemia. Surgical history: Appendectomy (childhood). Medications: Amlodipine 5mg OD, Atorvastatin 20mg OD. Allergies: Penicillin (rash). Family history: Father had a myocardial infarction at age 62. Social history: Smokes 10 cigarettes/day for 40 years, occasional alcohol use. Lives alone. Objective Vital signs: * Temperature: 37.2°C * Blood Pressure: 168/98 mmHg * Heart Rate: 110 bpm, regular * Respiratory Rate: 22 breaths/min * Oxygen Saturation: 92% on room air Physical examination findings organized by body system: Cardiovascular: Tachycardic, S1S2 present, no murmurs, gallops, or rubs. Peripheral pulses 2+ and symmetrical. Respiratory: Mildly tachypnoeic, clear to auscultation bilaterally, no crackles or wheezes. Gastrointestinal: Abdomen soft, non-tender, no organomegaly. Neurological: Alert and oriented x3, no focal neurological deficits. Laboratory results, imaging studies, and other diagnostic test results: * ECG: ST elevation in leads II, III, aVF. * Troponin T: 0.8 ng/mL (elevated). * Chest X-ray: No acute pulmonary pathology or cardiomegaly. Assessment Primary diagnosis or clinical impression: Acute Inferior Myocardial Infarction. Differential diagnoses being considered: * Aortic Dissection * Pulmonary Embolism * Pericarditis * Gastroesophageal Reflux Disease Clinical reasoning and interpretation of findings: The patient's presentation with classic anginal symptoms, elevated cardiac biomarkers (Troponin T), and ECG changes (ST elevation in inferior leads) strongly points towards an acute inferior myocardial infarction. The severe, crushing pain, radiation, and associated symptoms are highly consistent with ischaemic heart disease. Other acute cardiac and pulmonary pathologies have been considered and are less likely given the specific ECG findings and Troponin elevation. Plan Treatment plan including medications, procedures, and interventions: * Administer Aspirin 300mg orally. * Administer Ticagrelor 180mg loading dose orally. * Administer Morphine 2-4mg IV for pain relief. * Administer Oxygen via nasal cannula to maintain SpO2 >94%. * Initiate Heparin infusion. * Prepare for urgent percutaneous coronary intervention (PCI). Follow-up instructions and timeline: Patient will be admitted to the Coronary Care Unit (CCU) immediately following PCI. Close monitoring of vital signs, cardiac rhythm, and pain levels. Cardiology review post-procedure. Expected hospital stay 3-5 days, followed by outpatient cardiac rehabilitation. Patient education and counseling provided: Explained the diagnosis of heart attack, the need for urgent intervention (PCI), and the medications being administered. Discussed potential risks and benefits of treatment. Counselled on lifestyle modifications including smoking cessation, diet, and exercise post-discharge. Additional testing or referrals ordered: * Urgent Cardiology Consult for PCI. * Cardiac Rehabilitation referral post-discharge. * Dietitian consult for dietary advice.