Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Evaluation of chest pain.
SOAP
Subjective (S):
History of Present Illness:
Describe the character of the chest pain (e.g., sharp, stabbing, dull, aching, crushing).
Inquire about the onset, duration, and frequency of the pain.
Ask about aggravating and alleviating factors (e.g., exertion, rest, deep inspiration, specific positions).
Investigate associated symptoms (e.g., shortness of breath, cough, palpitations, sweating, nausea, jaw pain, arm pain).
Review any recent activities or exposures that might be relevant (e.g., trauma, strenuous exercise, emotional stress).
Past Medical History:
Briefly summarize relevant past medical history, including:
Previous episodes of chest pain
Underlying medical conditions (e.g., coronary artery disease, angina pectoris, heart failure, pulmonary disease, gastroesophageal reflux disease – GERD)
Risk factors for cardiovascular disease (e.g., hypertension, diabetes, hyperlipidemia, smoking history)
Social History:
Briefly inquire about smoking history, alcohol intake, and illicit drug use.
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation.
Physical Exam:
Perform a focused physical exam to assess:
General appearance (respiratory distress, signs of sweating)
Vital signs (looking for abnormalities like tachycardia, tachypnea, hypotension)
Cardiovascular exam (listening for heart murmurs, abnormal heart sounds)
Pulmonary exam (assessing for lung sounds, signs of respiratory distress)
Neck vein distention (suggestive of heart failure)
Peripheral edema (swelling in legs)
Assessment (A):
Differential Diagnosis:
Based on the clinical presentation, consider a broad differential diagnosis for chest pain, including:
Cardiac causes (e.g., myocardial infarction, angina pectoris, pericarditis, myocarditis)
Pulmonary causes (e.g., pleurisy, pneumothorax, pulmonary embolism)
Gastrointestinal causes (e.g., GERD, peptic ulcer disease)
Musculoskeletal causes (e.g., costochondritis, muscle strain)
Psychiatric causes (e. g., panic attack)
Risk Stratification:
Use a validated risk stratification tool (e.g., HEART score, Revised Cardiac Risk Index) to assess the likelihood of acute coronary syndrome (ACS) based on clinical features and ECG findings.
Plan (P):
Diagnostic Testing (as indicated based on assessment):
Electrocardiogram (ECG) to assess for signs of ischemia or arrhythmias.
Chest X-ray to evaluate for lung abnormalities (e.g., pneumothorax, pneumonia).
Cardiac enzymes (troponin) to help diagnose myocardial injury.
D-dimer test to assess the risk of pulmonary embolism.
Echocardiogram (ultrasound of the heart) to evaluate heart function and rule out structural abnormalities.
Further investigations based on specific concerns (e.g., upper endoscopy for GERD, CT scan for aortic dissection).
Treatment:
Initiate treatment based on the underlying cause of chest pain. This may involve medications for pain management, specific therapies for cardiac or pulmonary conditions, lifestyle modifications (e.g., smoking cessation, dietary changes).
Disposition:
Depending on the severity of chest pain, risk stratification, and diagnostic test results, determine the disposition:
Admission to the hospital for further monitoring, treatment, and possible cardiac workup (e.g., coronary angiography).
Discharge home with close follow-up and specific treatment plan.
Patient Education:
Educate the patient about the potential causes of chest pain, the importance of following the treatment plan, and signs and symptoms that warrant immediate medical attention.
Discuss risk factor modification strategies for cardiovascular disease prevention (if applicable).
Additional Notes:
Document any other relevant information, such as:
Communication with consulting physicians (e.g., cardiologist, pulmonologist, gastroenterologist)
Need for urgent referral or activation of a specific care pathway (e.g., ACS protocol)
Importance of returning for follow-up appointments as scheduled.