SOAP Note Exercise Name Mackenzie Godoy
Case 1
CC: Sudden onset substernal chest pain that “woke me up “and lasted until now (about 45 mins)
HPI: 70 y/o man with h/o hypertension, hyperlipidemia, 40 pack-years smoking history, and brother who
died of MI at 60y/o brought in by ambulance to the ED with c/o substernal chest pain. The pain is
described as pressure-like and radiating to the left arm and jaw, accompanied by nausea, diaphoresis, and
shortness of breath. Nitroglycerin was administered sublingually, but only provided temporary relief.
Aspirin was given to the patient to chew in the ambulance.
PE:
VS: BP 150/70, HR 110, Temp 37.1 ͦC, R 30 Pulse oximetry: 96% on room air
Gen: obese, pale, diaphoretic patient
Lungs: clear to Auscultation and Percussion
Heart: RRR, S4 gallop noted
Ext: No cyanosis or edema
Labs:
CBC: Hemoglobin & hematocrit normal, WBC 11,000 (slightly high)
Electrolytes: Normal
Troponins: Troponin T and I are elevated
CK-MB: normal
EKG: sinus tachycardia, elevated ST segments in leads II, III, and AVF
Assessment: Acute Inferior wall MI
Plan: Start Morphine drip IV, O2 via nasal cannula, Metoprolol, urgent transfer to interventional cardiology
lab
The patient has a balloon angioplasty and stent placement and is transferred to the telemetry unit for
monitoring. You see the patient the next day and need to document your visit in a progress note in the
SOAP format. [See next page for information you need to write it]
The next day you visit the patient and must write a progress note to include the following:
A very brief synopsis of what occurred the day previously (including the treatment given in interventional
cardiology)
His current medications:
Aspirin 81 mg orally, once a day
Plavix 75 mg orally, once a day
Lopressor 25 mg orally every 12 hours
His report of his condition today: much more comfortable. No pain, no shortness of breath. Some mild
fatigue when walking from room to nursing station
The EKG this morning shows normal sinus rhythm with no ST elevations and no Q waves
The physical exam which includes: HR 72, BP 130/70, R 24, Temp 37.4 ͦC
General: appears comfortable.
Extremities: peripheral pulses are slightly diminished and 1+
Heart: Regular rate and rhythm, no gallops or murmurs
Lungs: clear
Groin: femoral and pedal pulses intact and 2+ . No hematoma
You believe he is doing well and that the same plan should be continued for now. You would like the nurse
to check his vital signs every 4 hours for one more day and then every 8 hours.
If all goes well, he can be discharged in 3 days.
Please write a SOAP note for your visit:
S: 70 y/o man being followed up in in-patient setting post-acute inferior wall MI. Patient is now status post
1 day balloon angioplasty and stent placement. Currently on Aspirin 81 mg PO once a day, Plavix 75 mg PO
once a day, and Lopressor 25 mg PO every 12 hours. Today patient is much more comfortable and stable
with no pain or shortness of breath. Notes some mild fatigue when walking from room to nursing station.
O: V: HR 72, BP 130/70, R 24, Temp 37.4 ͦC
General: appears comfortable.
Extremities: peripheral pulses are slightly diminished and 1+
Heart: Regular rate and rhythm, no gallops or murmurs
Lungs: clear
Groin: femoral and pedal pulses intact and 2+ . No hematoma
EKG also with normal sinus rhythm with no ST elevations and no Q waves.
A: 70 y/o man status post 1 day balloon angioplasty and stent placement for acute inferior wall MI.
Responding well to treatment.
P: Continue administering Aspirin 81 mg PO once a day, Plavix 75 mg PO once a day, and Lopressor 25 mg
PO every 12 hours. Check vital signs every 4 hours for one more day and then every 8 hours.
If continues to do well on current treatment, patient can be discharged in 3 days