Free 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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