SOAP Note Template

Chest pressure, left-sided, 3 weeks duration.

Patient reports dull, substernal chest pressure radiating to the left arm, onset approximately 3 weeks ago. Pressure is intermittent, worse with exertion, lasts 5-10 minutes, relieved by rest. Denies shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, palpitations, or syncope. No recent illness or fever.

Hypertension, diagnosed 8 years ago. Hyperlipidemia. No prior cardiac workup.

Lisinopril 10 mg daily (reports inconsistent adherence). Atorvastatin 20 mg at bedtime (recently started).

NKDA

Occasional ethanol use (2-3 drinks/week). Never smoker. Works as software engineer, sedentary occupation. Lives with spouse and two children.

Father: MI at age 58. Mother: HTN, T2DM. Brother: hyperlipidemia.

Constitutional: denies fever, chills, weight change. Cardiovascular: chest pressure as above, no edema, no claudication. Respiratory: negative. GI: negative. GU: negative. Neuro: negative. Endocrine: denies polyuria, polydipsia.

General: well-developed, NAD, no acute distress. Vitals: BP 148/92, HR 78, RR 16, Temp 98.6 F, SpO2 98% RA. CV: RRR, no murmurs, gallops, or rubs. JVP not elevated. No peripheral edema. Lungs: CTAB bilaterally. Abdomen: soft, NT/ND, no HSM.

1. Chest pain, likely atypical vs. early CAD given risk factors.

- ECG today: normal sinus rhythm, no ischemic changes

- Labs: BMP, lipid panel, HbA1c

- Stress test referral (exercise treadmill)

- Return in 1 week for results; counsel on medication adherence

- Low-sodium DASH diet, aerobic exercise 150 min/week