SOAP Note 1 Acute Coronary Syndrome Follow Soap Note Rubric as a guide Use 6th edition APA format and must include minimum of 2 Scholarly Citations. The use of tempates is ok with regards of Turn it in, but the Patient History, CC, HPI, The Assessment and Plan should be of your own work and individualized to your made up patient.

SOAP Note 1: Acute Coronary Syndrome

Patient History:
The patient is a 58-year-old male who presents to the emergency department with complaints of chest pain that began approximately one hour ago. The patient describes the pain as a crushing sensation in the center of his chest that radiates to his left arm. The pain is associated with shortness of breath and diaphoresis. The patient has a history of hypertension and hyperlipidemia. He takes medications for both conditions but reports occasionally forgetting to take them. He denies any previous episodes of chest pain or cardiac events. The patient has a family history of heart disease, with his father having a myocardial infarction at the age of 63. The patient is a current smoker and consumes alcohol occasionally.

Chief Complaint (CC):
Acute chest pain with associated shortness of breath and diaphoresis.

History of Present Illness (HPI):
The patient’s symptoms began approximately one hour ago with the sudden onset of chest pain. The pain is described as a crushing sensation that radiates to the left arm. The patient also reports feeling short of breath and experiencing sweating. The symptoms have persisted since their onset and have not improved with rest. The patient denies any associated symptoms such as nausea, vomiting, or palpitations.

Past Medical History (PMH):
– Hypertension: The patient was diagnosed with hypertension five years ago. He takes lisinopril 10 mg daily but reports occasionally forgetting to take it.
– Hyperlipidemia: The patient was diagnosed with hyperlipidemia two years ago. He takes atorvastatin 20 mg daily but also reports occasionally forgetting to take it.
– No history of diabetes mellitus or other chronic medical conditions.

Family History:
– Father: Myocardial infarction at the age of 63.
– Mother: Hypertension, no history of cardiac events.
– No siblings.

Social History:
– Smoking: The patient is a current smoker, averaging one pack per day for the past 30 years.
– Alcohol: The patient consumes alcohol occasionally, approximately one to two drinks per week.
– Illicit drug use: Denies any history of illicit drug use.

Review of Systems (ROS):
The review of systems was focused on symptoms relevant to acute coronary syndrome (ACS):
– Cardiovascular: The patient reports currently experiencing chest pain, shortness of breath, and diaphoresis. Denies palpitations, dizziness, or syncope.
– Respiratory: Denies cough, sputum production, or wheezing.
– Gastrointestinal: Denies nausea, vomiting, or abdominal pain.
– Genitourinary: Denies dysuria or changes in urinary frequency.
– Musculoskeletal: Denies joint pain or stiffness.
– Neurological: Denies headache, seizures, or weakness in the extremities.
– Hematologic: Denies bleeding or bruising tendency.
– Endocrine: Denies polydipsia, polyuria, or weight changes.
– Allergic/Immunologic: No known allergies.

Physical Examination:
– General: The patient appears in discomfort but is alert and oriented to person, place, and time. He is diaphoretic and demonstrates labored breathing.
– Vital Signs: Blood pressure 150/90 mmHg, heart rate 110 bpm, respiratory rate 22 breaths per minute, temperature 98.6°F, oxygen saturation 95% on room air.
– Cardiac: Regular rate and rhythm. No murmurs, rubs, or gallops heard. Capillary refill <2 seconds. No jugular venous distention. - Lungs: Clear to auscultation bilaterally, no wheezing or crackles. - Abdomen: Soft, non-tender, non-distended, no hepatosplenomegaly. - Extremities: No edema or varicosities. Pulses palpable and equal bilaterally. - Neurologic: Alert and oriented to person, place, and time. No focal deficits noted. Assessment: Based on the patient's presentation of acute chest pain, associated shortness of breath and diaphoresis, and risk factors such as hypertension, hyperlipidemia, and smoking, the primary concern is acute coronary syndrome (ACS), specifically an acute myocardial infarction (MI). Plan: 1. Monitor the patient's vital signs, paying special attention to changes in blood pressure, heart rate, and respiratory rate. 2. Administer oxygen via nasal cannula at 4 liters per minute to maintain oxygen saturation > 94%.
3. Initiate an intravenous line and obtain blood samples for a complete blood count, electrolytes, cardiac enzymes (troponin), and lipid profile.
4. Perform a 12-lead electrocardiogram (ECG) to evaluate for ST-segment changes suggestive of myocardial ischemia.
5. Administer sublingual nitroglycerin for immediate relief of chest pain, if the patient’s blood pressure remains stable (systolic blood pressure > 90 mmHg).
6. Administer aspirin 325 mg orally for antiplatelet therapy, if not contraindicated.
– End of SOAP note –

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