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
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