Generate Perfect SOAP Notes for Any Condition with Heidi's AI

Subjective:

• Medical: History of hypertension, high cholesterol. No previous cardiac events.

• Social: Smoker for 30 years, moderate alcohol use.

• Rx (Current Medications): Amlodipine 5mg daily, atorvastatin 20mg daily.

• Allergies: No known drug allergies.

Objective:

• Vital Signs: Blood pressure 150/90 mmHg, heart rate 102 bpm, respiratory rate 22 breaths/min, oxygen saturation 94% on room air.

• Physical Exam: Distressed appearance, diaphoretic, pallor noted. Chest auscultation reveals regular rate and rhythm, no murmurs.

• ECG Findings: ST elevation in leads II, III, and aVF.

• Lab Results: Troponin levels elevated.

Assessment:

• Primary Diagnosis: Acute Inferior Wall Myocardial Infarction.

• Differential Diagnoses: Angina, pericarditis, pulmonary embolism.

Plan:

• Immediate administration of aspirin, nitroglycerin, and morphine for pain relief.

• Start IV heparin infusion.

• Urgent cardiac catheterization planned.

• Admission to the Cardiac Care Unit for close monitoring and further management.