Free Chest Pain Soap Note Template

Chest Pain Soap Note

Prepared by: [Your Name]

I. Subjective

A. Chief Complaint

The patient reports experiencing chest pain.

B. History of Present Illness (HPI)

  • Onset: Began 2 hours ago.

  • Location: Center of the chest, radiating to the left shoulder.

  • Duration: Continuous since onset.

  • Characteristics: Described as a heavy, squeezing sensation.

  • Aggravating Factors: Worse with physical exertion.

  • Relieving Factors: Slight relief with rest, none with antacids.

  • Associated Symptoms: Shortness of breath, nausea, and mild dizziness.

C. Past Medical History

  • Hypertension (diagnosed 5 years ago).

  • Hyperlipidemia.

  • No history of heart attacks or previous cardiac interventions.

D. Family History

  • Father: Died of a heart attack at age 58.

  • Mother: Diagnosed with type 2 diabetes.

F. Social History

  • Smoker: 10 cigarettes per day for 15 years.

  • Alcohol: Occasionally drinks on weekends.

  • Exercise: Sedentary lifestyle.

G. Review of Systems (ROS)

  • Cardiovascular: Reports chest tightness and palpitations.

  • Respiratory: No coughing or wheezing.

  • Gastrointestinal: No vomiting but has nausea.

II. Objective

A. Vital Signs

  • Blood Pressure: 150/92 mmHg.

  • Heart Rate: 98 bpm.

  • Respiratory Rate: 20 breaths/min.

  • Temperature: 98.6°F.

B. Physical Examination

  • General Appearance: The patient appears anxious and mildly diaphoretic.

  • Cardiovascular: No murmurs, gallops, or rubs; S1 and S2 audible.

  • Respiratory: Clear lung sounds bilaterally, no crackles or wheezes.

  • Abdomen: Soft, non-tender, no organomegaly.

  • Extremities: No edema; peripheral pulses intact.

C. Diagnostic Tests

  • ECG: ST-segment depression noted in leads II, III, and aVF.

  • Troponin: Pending.

  • Chest X-ray: No abnormalities.

III. Assessment

  • Primary Diagnosis: Unstable angina.

  • Differential Diagnoses:

    • Acute coronary syndrome (ACS).

    • Gastroesophageal reflux disease (GERD).

    • Costochondritis.

IV. Plan

A. Immediate Interventions

  • Administered aspirin 325 mg and sublingual nitroglycerin.

  • Oxygen therapy was initiated at 2 L/min via nasal cannula.

B. Diagnostics

  • Repeat troponin levels in 6 hours.

  • Order echocardiogram.

  • Schedule a stress test if symptoms stabilize.

C. Medications

  • Prescribed beta-blocker (metoprolol 25 mg twice daily).

  • Statin therapy to manage hyperlipidemia (atorvastatin 40 mg daily).

D. Referrals

  • Refer to cardiology for further evaluation.

E. Follow-Up

  • Reassess in 24 hours or sooner if symptoms worsen.

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