Outpatient Chest Pain SOAP Note

SUBJECTIVE:
[text]yo [select value="M|F"] presents with chest pain.

Onset [text] prior to evaluation
Onset while: [text]
[select value="no|YES"] <-- Past Cardiac Events
[select value="no|YES"] <-- Similar to prior anginal pain

Associated Pain
Location: [text]
Radiation: [text]
Severity now: [text]
Duration: [text]
Characterized as: [text].

The pain is relieved with [text]
[select value="no|YES"] <-- OTC NSAID's
[select value="no|YES"] <-- Rest
[select value="no|YES"] <-- Nitroglycerin

The pain is worse with [text]
[select value="no|YES"] <-- supine or leaning forward ( concern for pericarditis)
[select value="no|YES"] <-- Rest
[select value="no|YES"] <-- exertional pain
[select value="no|YES"] <-- pleuritic pain


Associated Symptoms:
[select value="no|YES"] <-- nausea/vomiting
[select value="no|YES"] <-- diaphoresis
[select value="no|YES"] <-- shortness of breath
[select value="no|YES"] <-- Increase in SOB from baseline
[select value="no|YES"] <-- Preyncope


Pertinent PMH
[select value="no|YES"] <-- Coronary Disease
[select value="no|YES"] <-- Cerebrovascular disease
[select value="no|YES"] <-- Diabetes Mellitus
[select value="no|YES"] <-- Peptic Ulcer or GERD
[select value="no|YES"] <-- Chest injury or overuse
[select value="no|YES"] <-- ETOH use
[select value="no|YES"] <-- FH of Heart Dz
[select value="no|YES"] <-- Tobacco Use [text name="variable_1" default="sample text"]
[select value="no|YES"] <-- CKD

Pt does not have recent prolonged travel, recent trauma, hypercoagulable state, hormonal therapy or hx of blood clots in the family.

Pt denies fever, diaphoresis, rash, palpitations, dyspnea, orthopnea, PND, cough, sputum, hemoptysis, abdominal pain, nausea, vomiting, dysphagia, syncope, lower extremity pain.

Assessment/Plan:
Differential: Heart/ vascular: Angina MI Acute pericarditis Aortic dissection Lungs: Pneumonia PE Pneumothorax. GI: GERD Peptic ulcer disease Pancreatitis Diffuse esophageal spasm. Other: Costochondritis Rib fracture Anxiety Herpes zoster Skin lacerations Muscle strain.

IF Intermediate/High Risk:
<65yo:Order Coronary CT Angiogram (CCTA) to r/o ACS (Good for 2 years)
65+yo: Conduct Stress Test (Treadmill > Pharmacologic)
-If baseline ECG normal then stress w/ ECG
--If baseline ECG abnormal then stress with echo
---If baseline ECG and Echo abnormal then stress with nuclear test

Anything above abnormal → Invasive Coronary Angiography (ICA)
Look For: # of obstructive lesions (AKA >50%), Size/Caliber, and Location/Accessibility
•>=3 vessels, L mainstem OR difficult anatomy → CABG + DAPT
•<3vessels/small/reachable → PCI (DES) + DAPT

Medical Therapy for STABLE Ischemic ♥ Dz:
Aspirin 81mg
Statin: Atorvastatin 40/80mg OR Rosuvastatin 20/40mg
BB: HR Metoprolol, BP: Carvedilol
ACE/ARB
2PY12 Inhibitor: Clopidogrel, Prasugrel, Ticagrelor
+ Possible Anti-Anginal med
SUBJECTIVE:
yo presents with chest pain.

Onset prior to evaluation
Onset while:
<-- Past Cardiac Events
<-- Similar to prior anginal pain

Associated Pain
Location:
Radiation:
Severity now:
Duration:
Characterized as: .

The pain is relieved with
<-- OTC NSAID's
<-- Rest
<-- Nitroglycerin

The pain is worse with
<-- supine or leaning forward ( concern for pericarditis)
<-- Rest
<-- exertional pain
<-- pleuritic pain


Associated Symptoms:
<-- nausea/vomiting
<-- diaphoresis
<-- shortness of breath
<-- Increase in SOB from baseline
<-- Preyncope


Pertinent PMH
<-- Coronary Disease
<-- Cerebrovascular disease
<-- Diabetes Mellitus
<-- Peptic Ulcer or GERD
<-- Chest injury or overuse
<-- ETOH use
<-- FH of Heart Dz
<-- Tobacco Use
<-- CKD

Pt does not have recent prolonged travel, recent trauma, hypercoagulable state, hormonal therapy or hx of blood clots in the family.

Pt denies fever, diaphoresis, rash, palpitations, dyspnea, orthopnea, PND, cough, sputum, hemoptysis, abdominal pain, nausea, vomiting, dysphagia, syncope, lower extremity pain.

Assessment/Plan:
Differential: Heart/ vascular: Angina MI Acute pericarditis Aortic dissection Lungs: Pneumonia PE Pneumothorax. GI: GERD Peptic ulcer disease Pancreatitis Diffuse esophageal spasm. Other: Costochondritis Rib fracture Anxiety Herpes zoster Skin lacerations Muscle strain.

IF Intermediate/High Risk:
<65yo:Order Coronary CT Angiogram (CCTA) to r/o ACS (Good for 2 years)
65+yo: Conduct Stress Test (Treadmill > Pharmacologic)
-If baseline ECG normal then stress w/ ECG
--If baseline ECG abnormal then stress with echo
---If baseline ECG and Echo abnormal then stress with nuclear test

Anything above abnormal → Invasive Coronary Angiography (ICA)
Look For: # of obstructive lesions (AKA >50%), Size/Caliber, and Location/Accessibility
•>=3 vessels, L mainstem OR difficult anatomy → CABG + DAPT
•<3vessels/small/reachable → PCI (DES) + DAPT

Medical Therapy for STABLE Ischemic ♥ Dz:
Aspirin 81mg
Statin: Atorvastatin 40/80mg OR Rosuvastatin 20/40mg
BB: HR Metoprolol, BP: Carvedilol
ACE/ARB
2PY12 Inhibitor: Clopidogrel, Prasugrel, Ticagrelor
+ Possible Anti-Anginal med

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.69, 35 form elements, 333 boilerplate words, 11 text boxes, 24 drop downs, 35 total clicks
Questions/General site feedback

Send Feedback for this SOAPnote

This site uses Akismet to reduce spam. Learn how your comment data is processed.

More SOAPnotes by this Author: